Group work for psychosis

Mental Health Nursing,  Nov/Dec 2002  by Coupland, Keith,  Macdougall, Vicky,  Davis, Eric

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Care study

This article by Keith Coupland, Vicky Macdougall and Eric Davis, summarises the work of the Gloucestershire Hearing Voices groups. It briefly outlines the structure and experience of group work for psychosis and how the work was developed from the value and evidence base. Evidence for a recovering process taking place was found but was hard to measure using conventional scales. So a longer term project was developed to look at the experience of group work for psychosis with the intention of understanding the process of recovering for individuals in the group

The hearing of malevolent voices (audio hallucinations) is a major symptom of psychosis and the conventional treatment for voice hearing in psychosis is medication. However, this is not fully successful as a treatment for at least 30 per cent of sufferers. We could clearly see that many members of Milsom Street day centre, Cheltenham, continued to suffer from voices despite, sometimes, enormous amounts of medication. This, the author's project grew out of the need to seek new ways of working with people with psychosis and it was designed to be part of a long-term project to integrate social, medical and psychological approaches to improving recovery in psychosis.

Theoretical model

The stress vulnerability model (Zubin and Spring, 1977) was the theoretical underpinning of the work. This relates the causes and course of psychosis to biological, social and psychological domains. Stress and trauma can both precipitate the onset and provoke relapses. This model predicts that reducing stress, including using medication as a buffer to stress, improving coping mechanisms and having faith in one's own ability to work through and control psychosis can be protective against relapse and helps the process of recovering (Nuechterlein and Dawson, 1984).

Value base

The group work was formed from the values the authors held as practitioners about being positive in helping people with psychosis in the process of recovering. The approach was then refined according to the best evidence that could be found. Keith Coupland and Eric Davis attended the Manchester Thorn course for psychosocial interventions for psychosis (Jackson, 1998) in 1995.

Several trainers from the course influenced the project through their values: Stuart Lancashire, because of his belief in the thoroughness of assessment of the experience of psychosis from the patient's view, (Lancashire, 1994), Gillian Haddock because of her emphasis on structure and evidence (Haddock and Slade, 1996), Ian Baguley because of his modelling of how to provide a structured therapy that was humanistic and down to earth (Baguley, 1995) and Ron Coleman who showed that the person with psychosis is the expert in the experience of their condition.

The Hearing Voices Network (HVN) based in Manchester, an organisation dedicated to self-help approaches, also inspired the project by showing the value of a group approach (Baker, 1995). A group work format for psychosis had been successfully started by a colleague, Julia Caley CPN at Coleford, who was also influenced by Thorn training, this time at London (Caley, 1996).

The value of having a belief in recovering from hopelessness and despair was also very important for both practitioners and voice hearers. This was influenced by the work and philosophy of Phil Barker (1995) and Patricia Deegan (1997). The value of normalising psychotic experience was gained from the article by Romme and Escher (1989).

Evidence base

The evidence base drew on two areas: cognitive behavioural therapy for psychosis for individuals and interactive group work for psychosis.

The individual work for psychosis was summarised in three publications: Kingdon and Turkington (1994); Haddock and Slade (1996); Chadwick, Birchwood and Trower (1996).

The evidence seemed overwhelming that psychotic symptoms are understandable, meaningful and amenable to therapy. The use of a simple ABC model of A for activating event (including a voice), B for beliefs (including thoughts, images) about that event and C for consequences (emotional and behavioural) has been immensely helpful in the group to understand and unravel complex voice-belief-emotion triads (Chadwick, Birchwood and Trower, 1996, p 2). The fact that these experiences were amenable to being made sense of, was, itself, a breakthrough for group members, The normalisation ideas of Kingdon and Turkington (1991) were the next most important element of the individual therapy applied to the group work. This greatly reduced the sense of alienation.

Lastly the stress vulnerability model helped make the normalisation process understandable and brought about radical reframing. One group member said: "Well, if people like Churchill heard voices at stressful times, then maybe I need not be ashamed of my voices. In fact, we could be part of a positive elite."

The group work evidence was based on the major reviews of the efficacy of group work for psychosis (specifically schizophrenia) provided by Nick Kanas (1988, 1996). He discovered considerable evidence for the use of group work and summarised his findings from 46 controlled studies. Seventy per cent showed a significant improvement, 26 per cent no change and four per cent significant worsening of condition.