With one voice contd ...
Training of facilitators
Within Gloucestershire most of the facilitators have undergone specialist training in psychosocial approaches to psychosis and are also skilled in group work. The facilitators are from the disciplines of nursing, psychology and social work and one is a service user who has co-facilitated a group in an inpatient setting.
The process of setting up a group
The setting up of a hearing voices group or other group for psychosis needs to be a decision taken by the whole team. It is important that the multi-disciplinary team, users and carers take part in the setting up of the group in order to ensure ownership, support and participation in the process. Once the decision is made to start the group then contact could be made with facilitators and members from other groups, who will then explain the process and resources available.
If women are present as group members then it is important that at least one facilitator is a woman (Macdougall 1998). Many people who experience voice hearing have suffered childhood trauma including bullying and sexual abuse (Read, Agar, Argyle, & Aderhold, 2003; Read, Perry, Moskowitz, & Connoly, 2001). There may be a need for a separate women's group as was the case when one of our groups grew too large as a mixed group. The women felt they had lost the ability to communicate effectively because of domination by the men. The women also felt there was too much of an emphasis on the cognitive aspects of voice hearing rather than how voice hearing impacted on family relationships.
After each group the facilitators (two for every group) write up the minutes and discussed the group. Every month the facilitators meet as a group for supervision, usually for two hours. The style is informal and sharing successful interventions is encouraged. Risk issues and other more immediate needs can be addressed by calling the supervisor or other facilitators as well as normal risk management processes within the care programme approach.
Inclusion criteria for group members
The group members:
• Are primarily distressed from hearing voices and may have other problems of psychosis;
• Want to work as a member of a Hearing Voices Group;
• Usually have a diagnosis of psychosis/severe mental illness such as schizophrenia or affective psychosis;
• Usually have tried a variety of anti-psychotic medication with little effect on the hallucinations/voices;
• May have a contact who will liaise with the group facilitators, such as a care co-ordinator or key worker.
Where possible they will already be attending at the centre where the hearing voices group or other group for psychosis is to be held as this helps the person feel comfortable in the group. For some people it is very stressful to enter a busy day centre for the first time without knowing the people there. If they are not attending the day centre already then a careful process of engagement may be needed, depending on the person.
Usually, the continued use of illegal substances such as amphetamines, heroin etc., or large quantities of alcohol excludes persons from making use of the group at this time.
Referrals can be accepted from members of the multi-disciplinary team who would normally be the key worker of the voice hearer or sufferer from psychosis. The importance of the rest of the team is recognised. Referrals should be in writing and include a brief psychiatric history. The voice hearer should see the referral letter or copy of full Care Programme Approach (CPA) and agree, before it is sent to the group facilitators. A voice hearer or sufferer from psychosis should be able to refer themselves to the group and the normal process reversed in order to ensure a keyworker and multidisciplinary (MDT) support. Several group members have prompted the referral of voice hearers they know need help. This has been a very successful method of introduction. Most new referrals see the group video made by group members (Coupland & Jones, 2002). They are encouraged to make an informal visit to the group before committing themselves.
If the referral is accepted the voice hearer may be asked to attend an individual assessment. The first strategy is to normalise the voice hearing experience and put the voice hearer at their ease. The assessment is quite lengthy and makes use of the Manchester Symptom Scale, also called the KGV after the authors (Krawiecka, Goldberg, & Vaughan, 1977). The scale is very helpful in finding out how the voice hearers experience their psychotic symptoms as well as the anxiety, depression and suicidality the symptoms may cause, especially in the later versions of the scale (Lancashire, 1994). We write back to the group member with the results of the assessment, including a history of the voice hearing, so that the member can correct mistakes and co-create the final version of the assessment, a process that seems to increase the ownership of the experiences (Coupland, Davis, & Gregory, 2001). Not being able to complete a KGV does not necessarily preclude the sufferer from attending a group. A very comprehensive assessment (the Maastricht Interview) is included in the book by Romme and Escher, 2000. After the assessment a letter is sent to the voice hearer, with a copy to the care co-ordinator, explaining the outcome of the assessment and whether the person has been accepted at this point to join a group. An important part of the letter is identifying and reflecting back the coping mechanisms that the person already has as well as a provisional formulation as to how the person is affected and a plan of how the groupwork might help. Where possible assessments are repeated every three to six months.
Structure of the group
The group would normally have six to eight participants and two facilitators. Initially, the group will meet weekly for 12 sessions, followed by a break for two weeks for evaluation. After a further 12 sessions there is another evaluation period of two weeks. The group meets at a set time each week. The time of the sessions need to be agreed by the group along with the ground rules. Although there is evidence of efficacy for short-term (six weeks) psycho-educational groupwork (Wykes et al., 1999) our own research suggests additional benefits of long term work. This gives the group a slow, open style, with additional members joining the group in time and members leaving the group when they have jobs or move on for other reasons. Group members may need gentle encouragement over a long period to keep coming to the group.
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