Group program

1. Group program An emotion based approach

2. Structure of program – who are we trying to help? • Core program for those staying approximately 12 weeks so groups need to be slow open in format. • Anticipating relatively few genuinely elective admissions – building trust key priority + long term relationship with team. • Program needs to address needs of first admission patients to those with multiple prior admissions.

3. Group program - mindfulness • Mindfulness practice group - aims a) to encourage curiosity/self observation/acceptance of difficult thoughts and feelings and bodily sensations b) develop skills in tolerating anxiety that can be practiced outside of the group e.g. observing breath, 3 min breathing space - potential difficulties/adaptations? a) suitable for patients who are severely depressed? b) ability to concentrate – shorter sessions more frequently? c) maintaining practice post discharge

4. mindfulness • Integrating mindfulness into the whole program? • Mindful movement: yoga or physio lead group which focuses on noticing the body’s limits etc. • Mindful use of the courtyard for “exercise” • Encouraging patients to use activity groups (e.g. craft, leisure) as opportunities to be mindfully engaged/in the present moment and for group leaders to be curious about how this has been for patients. • Mindful eating experiments?

5. Patients feedback • Helpful: • “I found mindfulness sessions very useful – helped me develop strategies I can use to help in times of increased anxiety” • “Yoga was the best group” • + 3 positive comments • Unhelpful: • “mindfulness, I’m fully aware of my own emotions – that’s the problem. Made me frustrated, as I wanted to resolve not discuss these problems again” • “Movement sessions were so low impact as to be embarrassing and humiliating”

6. Managing difficult feelings Combining elements from distress tolerance and emotional regulation DBT modules. Tool kit for self soothing that staff can encourage patients to use outside the group. Recognising and accepting basic emotions with a particular emphasis on validating emotions linked to unmet needs e.g. hurt, anger, shame, fear.

7. Relationships/communication • Semi structured group to focus on relationships in the here and now (home and hospital) which may be creating distress (by not meeting needs for acceptance and understanding?) • Active listening skills (empathic, accepting) that patients can practice with each other, expect from staff and perhaps work on with their families. • Support with expressing needs and feelings openly within the unit.

8. Patient feedback • Helpful • “Most helpful were the groups that adopted something called DBT. The groups on social skills, distress tolerance….i greatly benefited from especially when accompanied by notes/worksheets” + 2

9. Creative therapies • opportunities for creative expression/ exploration e.g. through art, writing, music. • aim to help patients recognise feelings, develop their curiosity regarding how they experience the world, potentially soothing. • do we need this to be a formal therapy? • potential advantages of having input from staff outside the core team?

10. Patient feedback • Helpful • “Art gave me a way to express my emotions” • “All art/movement etc. essential to give patients a break” + 5 • Unhelpful • “drama – was unable to express myself felt very self conscious” + 3 (all drama/music)

11. Bridging the Gap –( recovery a useful framework?) • Bridging the gap between hospital and home needs to be a priority throughout the admission and not just in the discharge phase. • Dietetic group – realistic planning preparing for eating at home + active, practical groups to support patients trialling this in hospital. • “Meaningful activity group” – supporting patients to maintain the social and occupational resources they already have. Identify ways to extend these starting from how they structure their day within hospital.

12. Patient feedback • “There was nothing to do in hospital ,boredom was as damaging as being made to eat” • Helpful • “Active recovery/life skills/maintenance – vital” • “The act of any group that allows doing something engaging and unrelated to issues is in itself therapuetic” + 6 • Unhelpful • “I consistently found dietetic groups a bit pointless as information about food was generally unnecessary/suspected by me I’m afraid”

13. Support and community groups • Daily (if possible) small groups which are unstructured and aim to support patients with the coming day. • This is a chance to reinforce work from all other groups e.g. use of toolkit, chance to identify emotions as they arise, facilitate open communication with team and other patients, plan meaningful activity etc. • Replace post meal support groups with daily these support groups and have individualised care plans for post meal times? • Weekly community meeting to address practical and procedural shared concerns + contribute ideas to the program and make requests.

14. Patient feedback • “A lot of groups were too large and easy to hide in. I also found myself giving a lot of support but not taking it” • “Unstructured support groups were helpful especially allowing time to talk to people at different stages of recovery” • “open structured….the problem with this is that they were patient led and inevitably led to one patient dominating…it is better to have groups that are well structured and led more by the therapist than purely patients alone” • “Open group was good – if you needed support it could be hard to feel able to upset the flow of a planned group” • Unhelpful “ After dinner support where everyone just moaned”

15. Leaving out? • formal CBT group • body image group • relaxation/anxiety management groups • motivational enhancement group • developmental/past focussed or formulation based groups

16. Patient feedback • CBT • 1 helpful – helped amongst other things to find new coping strategies • Unhelpful – • “CBT became too repetitive as I went through admissions. I could recite the booklet by heart. CBT doesn’t work for everyone” + 2 • Relaxation – 2 patients described as particularly helpful. • Uncertainty about body image groups + no reference to motivational groups or psychotherapy/formulation based groups.

17. Summary • Aim for an integrated program that prioritises validation and understanding • Change comes from increased self acceptance that allows patients to take risks so that core needs can be met in the outside world. • Validate the need to control weight whilst empathically asserting the prioritisation of meeting core physical needs.

18. Implications for Staffing Additional skills required: Creative therapy (art/writing) and/or project work Mindful movement Delivery and development of range of meaningful activities Pros and cons of sessional vs core team members AHP / nursing – skills balance – providing 1 activity based gp a day (?)