INPATIENT GROUP FACILITATION GUIDE: STAFF DEVELOPMENT AND PROCESSING, CONNECTING BODY AND BRAIN by Susan D. Lee B.A., University of British Columbia, 1997 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF EDUCATION IN COUNSELLING UNIVERSITY OF NORTHERN BRITISH COLUMBIA April 2017 © Susan D. Lee, 2017 INPATIENT GROUP FACILITATION GUIDE ii Abstract The purpose of this project is to provide resources for staff development and inpatient group facilitation. The project begins with a literature review on the history and evolution of inpatient group therapy, therapeutic goals and expectations. The effects of patient transference, facilitator countertransference, attachment theory, and social engagement is examined with a focus on the body and brain connection and what it means to be traumainformed. Evidence-based theoretical approaches that provide safety and stabilization are described and integrated for group members and practitioners alike. Included is a description of the format of the guide, target audience, goals, and resources. Lastly, the resource guide itself contains a list of specialized staff training, short staff development sessions, and safety and stabilization techniques for acute care group therapy. INPATIENT GROUP FACILITATION GUIDE iii TABLE OF CONTENTS Abstract ii Table of Contents iii List of Table and Figures vii Acknowledgement viii Chapter 1: Introduction Purpose and Rationale Differences between inpatient and outpatient groups Ongoing training and self-awareness for facilitators Clarification of Terms Personal Location UHNBC: Adult psychiatric unit Staffing, programming, and group structure My facilitation experience Complications Summary of Chapter One 1 2 3 5 6 11 11 12 15 16 19 Chapter 2: Literature Review History Clinical efficacy Outpatient Group Setting Screening Inpatient Group Setting Goals of Inpatient Therapy Safety and stabilization Significance of cohesion Facilitator self-disclosure and transparency Transference and countertransference Attachment Theory and Social Engagement Secure Preoccupied Dismissive-avoidant Fearful-avoidant The Brain: Bottom-up or Top-down Autonomic nervous system and polyvagal hierarchy Window of tolerance Corrective experiences Trauma Informed Practice Trauma and psychiatric patients Three pillars of trauma-informed care Problem of cohesion and single sessions 20 20 21 22 23 25 26 27 28 29 30 32 32 33 33 33 36 38 39 41 42 43 43 45 INPATIENT GROUP FACILITATION GUIDE Theoretical Approaches and Interventions Here-and-now Sensorimotor psychotherapy Psychoeducational groups Interpersonal approach Process-oriented psychoeducational model (POP) Training, Support, Personal Reflection and Awareness Co-facilitation Self-care Summary of Chapter Two Implications for groups Implications for facilitators iv 45 46 48 49 50 51 53 54 55 57 57 58 Chapter 3: Project Description Target Audience Resource Guide Goals Expectations of Group Summary of Chapter Three 59 59 59 60 61 Chapter 4: Resource Guide Part A: Twelve 30 Minute Sessions for Staff Development The Power of Vulnerability What’s your attachment style? Balanced life: POD Understanding self-disclosure, ambiguity and blind spots through the Johari Window Six core strengths for healthy development Awareness, expression and location Listening to Shame TIP Personal preparation plan Addressing countertransference self-assessment Hazards self-assessment Building and maintaining support Safety in groups Issues of special concern Part B: Safety and Stabilization Techniques Do’s and don’ts of trauma-informed inpatient group work How to facilitate a large group daily check-in How to facilitate a somatic and process-oriented psychoeducational (POP) group How to facilitate a reintegration (higher level) process group How to facilitate a relaxation group Part C: Training and Networking Continuing Education and networking opportunities Online Resources 62 62 63 64 68 69 74 75 78 79 80 81 82 83 84 85 86 87 89 92 95 97 97 98 INPATIENT GROUP FACILITATION GUIDE v References 100 Appendix A: Belly Breathing 111 Appendix B: Mindful Breathing & Various Breathing Techniques 112 Appendix C: 33 Quick Ways to Ground 114 Appendix D: Learning the Language of the Body—Sensations 116 Appendix E: Movement and Connection with the Body 117 Appendix F: Movement and Checking-in with the Body 118 Appendix G: Redirecting onto a Positive or Productive Pathway 120 Appendix H: Containment Imagery Exercise 121 Appendix I: Visualization of a Safe Place 124 Appendix J: 4 Elements Exercise 125 Appendix K: S.M.A.R.T. Goals 128 Appendix L: Food and Anxiety 129 Appendix M: Sleep Hygiene 131 Appendix N: Skills and Strategies for Teaching Self-care 134 Appendix O: Feeling Cards 136 Appendix P: Feeling Wheel 137 Appendix Q: Self-care Wheel 138 Appendix R: The Grieving Wheel 139 Appendix S: The Medicine Wheel 140 Appendix T: Attachment Styles 141 Appendix U: Relationship Questionnaire (RQ) 143 Appendix V: Johari Window 145 INPATIENT GROUP FACILITATION GUIDE vi Appendix W: TIP Preparation Plan for Facilitators 150 Appendix X: Addressing Countertransference Self-assessment 151 Appendix Y: Hazards Self-assessment 153 Appendix Z: Building and Maintaining Support Self-assessment 155 INPATIENT GROUP FACILITATION GUIDE vii Table and Figures List Table 1: Factors that affect group psychotherapy in outpatient and inpatient settings 23 Figure 1: Dimensional model of adult attachment 34 Figure 2: Bottom-up: Development of brain states 37 Figure 3: Brain development stages and corresponding capabilities 37 Figure 4: Porges’ view of the ANS 38 Figure 5: Three zones of arousal: A simple model for understanding regulation of automatic arousal 40 Figure 6: Three pillars of trauma-informed care 44 INPATIENT GROUP FACILITATION GUIDE viii Acknowledgements Sincere thanks to my committee members for their guidance and contribution to this project. A special thank you goes to my supervisor Dr. John Sherry, I am very grateful for his direction, reassurance and challenge, and especially for shared laughter along the way. Thanks to the remarkable psychiatrists, staff and patients at University Hospital of Northern British Columbia (UHNBC) whom I have had the pleasure to work closely with over the years and who inspired me to develop this resource guide. Thank you to my boys Ayden and Adam and my husband Troy for loving me and giving me their gifts of time, space and encouragement to finish my Master’s degree, and finally complete this project! And thank you to the special ladies who endeavor to keep me sane by supplying support and laughter, chocolate, wine or coffee as required. I am indeed blessed with precious people who share my pain, remind me I am not alone, and more importantly, that we all have something to offer; individuals that when together bear witness to the power of hope. When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand. ~ Henri Nouwen INPATIENT GROUP FACILITATION GUIDE 1 Chapter 1: Introduction Groups are like a microcosm of life, a community unfolding, and represent a great possibility of what we can be. ~Avraham Cohen A group is a gathering of individuals that offers a place for support, newfound awareness, challenge and growth. Since groups are often considered a microcosm for life, it is suggested that the way an individual presents themselves within a group may also provide a hint on how they are in their private life, outside of group. A healthy group therapy experience is an opportunity for personal growth, a place to experiment with new ways of being, and a time where feedback is given and reflected on and possibly integrated into one’s life. Especially noteworthy is the gift group members receive from one another; within a group, individuals often realize that they are not alone in their experiences and that they have something to offer others (Weiss, 2010; Yalom, 1983; Yalom & Leszcz, 2005). In this project I intend to clarify why specialized training and self-awareness, along with confidence, flexibility, support and resources are necessary for successful group facilitation experiences. Additionally, I offer a user-friendly resource guide for those professionals leading and co-facilitating group therapy on acute care psychiatric wards. The first chapter outlines the purpose and rationale for developing this resource guide. In doing so it addresses why typical outpatient models of group therapy are inadequate. The major differences between inpatient and outpatient groups are examined as well as the need for ongoing staff training in facilitation, self-awareness and support. The chapter concludes with a list of terms for clarification and the description of my personal location. INPATIENT GROUP FACILITATION GUIDE 2 Chapter 2 is the literature review that begins with the history and context of group therapy: outpatient and inpatient, and the goals of inpatient therapy. I then provide background information on attachment theory, how the brain processes trauma and why trauma-informed practice is necessary when working with psychiatric patients. Evidencebased theoretical models are reviewed, along with recommendations for ongoing facilitator training with an emphasis on introspection, confidence building and adaptability of skill set. Chapter 3 is an outline of what to expect in this resource guide through a project description, explanation of who the target audience may include and the goals of the project. Chapter 4 is the resource guide, including in-house training and development amongst staff, trauma-informed safety and stabilization resources for inpatient groups, and finally listings of where to access continuing education and online supports. Purpose and Rationale One of the major goals of this project is to provide guidance to those facilitating groups for clients on inpatient psychiatric wards. Yalom (1983) notes: However effective for outpatients, traditional group therapy is not effective for inpatients: the contemporary acute psychiatric ward is a radically different clinical setting and demands a radical modification of group therapy technique. (p. 50) As Yalom notes above in this powerful quote, traditional group therapy models do not translate well to acute care psychiatric settings. Specialized training for group therapists working in psychiatric facilities across North America is sorely lacking, possibly due to availability of training, funding, limited supervision, varying education requirements and differences in interdisciplinary scopes of practice (Lloyd & Maas, 1997). Models of INPATIENT GROUP FACILITATION GUIDE 3 theoretical orientation are often varied and inconsistent among staff. Co-therapists may include mental health clinicians, nurses, social workers, occupational therapists, psychiatrists and/or psych residents. Practitioners are operating from different scopes of practice, are often unsupervised or working alone and uncoordinated in their programming efforts. It is typical for North American staff to work off-the-cuff, gather resources online, and use communitybased group therapy modules/content to adapt on an ad hoc basis (Farley, 1997). Resources may be outdated, not trauma-informed or inconsistent with best practices for inpatient care. On a busy psychiatric ward there is also precious little opportunity for debriefing or collaborating with colleagues (Farley, 1997; Llyod & Maas, 1997; Parkinson, 1999; Yalom, 1983). There are many differences between inpatient and outpatient group work that are expounded upon later, but the purpose and rationale behind this project is two-fold, 1) to address the need for specialized training, personal awareness and staff support for inpatient group therapists, and 2) to provide trauma-informed, evidence-based programming and resources in one manual. I also point out the benefits of integrating somatic and processoriented-psychoeducational (POP) interventions into all group programming; competent practitioners maximizing the interpersonal benefits of groups while adapting specific therapeutic goals in practice. Differences between inpatient and outpatient groups. There are many significant distinctions between traditional outpatient and inpatient group settings. As noted by several authors (Hajek, 2006; Razaghi, Tabatabaee, Pouramzani, Mohammadpour, Maghaddam & Yahyavi, 2015; Vinogradov & Yalom, 1989; Yalom, 1983), the experience of acute care psychiatric patients is typically characterized by: INPATIENT GROUP FACILITATION GUIDE  4 Staff with limited [acute care] group training. Facilitators that have only outpatient models/resources to utilize.  High patient turn over. While in hospital, daily changes to group composition, frequent group meetings throughout the day, new patients continually joining groups throughout the week.  Brief hospitalization. Length of stay is often 1-4 weeks. Limited therapist stability with rotating staff/shift work.  Ward milieu. Patients sharing space 24/7 in a locked unit with strangers, a very unique ecosystem with group dynamics affected by roommate disparity, comorbid diagnoses, safety concerns, sleep issues.  Through inpatient group experiences, people may experience friendship, solidarity, camaraderie and community because of their unique living situation. This is an opportunity to develop interpersonal skills. Whereas outpatient groups are often discouraged from socializing outside of group time, there are benefits of extra-group socializing for inpatients who often feel ostracized, stigmatized, isolated and lonely.  There is no formal screening or group preparation. Group composition is based on availability and scheduling around appointments with other treatment providers. Participation is subject to a clients’ ability to participate and they could be disorganized, disorientated, heavily medicated, uncooperative, mandated to attend, or attendance encouraged by psychiatrists and/or nursing staff as part of their treatment plan. INPATIENT GROUP FACILITATION GUIDE  5 Daily meetings, single session/altered time frame. Without operational and structural requirement for appropriate space, there is little time for group cohesion/trust and working through patterns and no time to work on termination. There is a preference to work on here-and-now experiences rather than the past (using problem spotting and positive reinforcement).  Heterogeneity of psychopathology. Group members differ in co-morbidity (i.e. psychosis, suicidal ideation, anxiety, substance misuse, grief and loss), diagnosis, despair, and motivation. Simultaneously, facilitators endeavor to provide a positive group experience for all, which increases the likelihood of group members continuing treatment as outpatients.  Inpatient group therapists must provide more structure, transparency, active support, and direction than long-term outpatient groups. Due to the limited time for treatment, severity of illness and vulnerability of patients, it is vital that the group facilitator is able to create and hold safe space for complex group members. (Hajek, 2006; Razaghi, Tabatabaee, Pouramzani, Mohammadpour, Maghaddam & Yahyavi, 2015; Vinogradov & Yalom, 1989; Yalom, 1983) Ongoing training and self-awareness for facilitators. Education, awareness and supportive environments that are trauma-informed, client-centered and evidence-based are contributors to ensuring the best possible quality of care offered. In order to do this, professionals must take time for reflective processing through regular events like peer supervision, group debriefing and team meetings addressing not only an awareness of skills, knowledge and performance, but also personal factors which might interfere with the ability INPATIENT GROUP FACILITATION GUIDE 6 to connect with a diverse range of clients (Pantuso, 2016; Shapiro, Brown & Biegel, 2007). Health care professionals must continually work towards fostering therapeutic relationships to treat clients with respect and dignity, provide a sense of safety, structure, support, offer choice, collaboration and empowerment. Understanding and attending to attachment styles, personality styles, areas of resistance, an ability to self-regulate, as well as level of comfort with ambiguity, self-disclosure, and attunement are all essential to the work of acute care group facilitators (AGPA, 2007; Herman, 1997; Montgomery, 2002; Vinogradov & Yalom, 1989; Wyatt, Yalom & Yalom, 2006; Yalom, 1983, Yalom & Leszcz, 2005). My intent for this project is to provide a developing framework to guide facilitator preparation and readiness. This will allow for flexibility when working with diverse, often severe psychopathologies and provide resources for self-reflection, guidance, instructions and integrative techniques. In doing this, there is a focus on the internal process of the clinician. This project also examines issues that arise for facilitators such as countertransference and self-care. Well balanced, self-reflective, confident and healthy practitioners are vital to quality acute care group therapy. Clarification of Terms Defining the following terms used throughout this manual assists the reader with familiarity and understanding, and provides an index for reference. Acute care: Used interchangeably with inpatient, psychiatric care is short-term, multidisciplinary treatment and recovery provided in hospital for severe injury to self and/or mental illness. Attachment: A developmental theory originally proposed by John Bowlby and Mary Ainsworth, whereby the closeness/attachment one has had to their primary or significant INPATIENT GROUP FACILITATION GUIDE 7 caregivers affects later perception of safety, security and confidence, which in turn affects how one responds to others. Adult attachment can be mapped out on dimensions of anxiety and avoidance that correspond with our level of security in relationship to others. Securely attached people are low in anxiety and avoidance, preoccupied people tend to be low on avoidance and high on anxiety, whereas fearful-avoidant people tend to be highly anxious and high on avoidance and dismissing-avoidant people have low anxiety but high avoidance patterns (Marmarosh, Markin & Spiegel, 2013). Countertransference: All the personal feelings a therapist has towards a client, or the reactions to a client’s transference, or the therapist’s own transferred feelings towards a client (Chan & Noone, 2000; Kottler, 2010). A group leader may respond to their discomfort with conflict or ambiguity to a particular group member by side-stepping further exploration and reverting to advice giving. Repetitive countertransference is when the leader unconsciously repeats or enacts his/her concerns within the group. The leader that encounters frustration by a group might react defensively to protect rather than probe the group (AGPA, 2004). Reparative work can happen within a group when the facilitator is able to remain neutral, grounded and focused rather than defensive, and continue the work of enquiring what is coming up for clients (and possibly the leader), providing space to process, expression of feelings and an opportunity to repair damage from past experiences. Group therapy: A form of psychotherapy where clients are treated together, rather than individually (CADTH, 2012). Formats vary from structured to unstructured, very few clients to a large group (20+), although studies suggest 6-12 persons is ideal for therapeutic groups (Farley, 1997; Chandler, 2016; Yalom, Wyatt & Yalom, 2006). Groups may be open with new people joining the group each session, often ongoing meetings with no end date, or INPATIENT GROUP FACILITATION GUIDE 8 closed when no new people are admitted to the group once it has started and it runs for a specific length of time in weeks or months. Group therapy has historically been shown to be an effective use of resources, cost effective as well as being a therapeutic tool itself, providing a microcosm in which group member’s interpersonal interactions assist their psychological development (Montgomery, 2002; Vinogradov & Yalom, 1989, Yalom, 1983).  Cognitive behavioral therapy (CBT): The most widely used evidence-based practice for treating mental conditions, main principles developed from behavioral and cognitive psychology. An action oriented model which addresses how our thoughts, feelings and behaviors influence one another. Treatment goals include identifying thought distortions and maladaptive behaviors for symptom reduction, identifying patterns, tracking in logs and teaching new coping skills.  Psycho-educational: Educating patients in ways that empower their self-worth, motivation, interpersonal problems, and symptom reduction. To equip and explore various topics related to improving their mental health through information, teaching coping skills, and experiential learning.  Process-oriented: A therapy method that is an interactive developmental process between the group and the individual, integrating doing and being, where feedback is encouraged and learning from one another is expected. Exploring, questioning and analysis of what is heard, seen and felt by the group members to reflect on their present state. For example asking, “How do you feel about what you just heard, what do you notice coming up for you as you share this, is this familiar or new?”  Sensorimotor psychotherapy: Body-oriented awareness to address what’s going on internally, to identify sensations and perceive physical states and movement. INPATIENT GROUP FACILITATION GUIDE 9 Awareness that orients a person to the present by attending to non-traumatic stimuli, discovering new ways to self-regulate and respond to internal sensations, gaining control over their physiological state. This approach “incorporates theory and technique from psychodynamic psychotherapy, cognitive-behavioral therapy, neuroscience and the theories of attachment and dissociation” (Ogden, Minton & Pain, 2006, p. xxviii). Grounding: The process of removing a charge from an object by means of transfer of electrons. Grounding as a coping skill effectively transfers your body’s energy the way a ground wire safely draws away electrical current. In the same way that a ground wire secures physical safety, grounding techniques can bring a sense of security to the body. One strategy consists of planting your feet firmly onto the earth while recognizing stability and security in that action (see Appendix C: 33 Quick ways to ground). Here-and-now: Focus is on present time, an essential aspect of interpersonal processing to allow group members to pay attention to what is currently happening, for themselves and others, how they feel, what they think, what they see in front of them. Inpatient: When a person has an acute psychiatric admission, remaining in hospital for treatment as a voluntary (at their request) or as a certified patient, when two doctors have established that they are at risk of harm to themselves or others due to their mental health status. Client is then admitted to hospital whether they are in agreement or not. Interpersonal: Relationships between persons, friends, family, groups. Interpersonal group therapy involves interacting, speaking, listening and connection among group members rather than a hierarchical learning experience of group facilitator (expert) and INPATIENT GROUP FACILITATION GUIDE 10 individual group members. It is inclusive and clients are seen as experts, each with something important to offer the group. Metaskills: The “ongoing, continuously unfolding and emerging in-the-moment feelings and attitudes” naturally accessed by the facilitator which brings the process-oriented experience to life in ways that the use of mechanical techniques do not (Cohen, 2004, p. 156). Mindfulness: Self-observation of present moment experience. For example, paying attention to the details of the breath, inhale, pause, and exhale, or holding a warm cup of tea in your hand; stimulating curiosity of present internal or external exploration (Ogden et al., 2006; Van der Kolk, 1994). Outpatient: When a person is being treated for mental health concerns in the community. Typically an outpatient group is composed of 6-8 clients that meet 1-2 times a week for 90+ minutes for several months or even years (Vinogradov & Yalom, 1989; Yalom, 1983, Yalom & Leszcz, 2005). Patient/client: Within hospital settings individuals admitted are referred to as either patients or clients of the health care system. The term patient and client will be used interchangeably in this project to refer to individuals accessing group therapy. Self-regulation: Using your body to self-soothe, to find ways of regulating physiological arousal and gain a sense of self-control. It is the body’s capacity to selfregulate the parasympathetic and sympathetic nervous systems: when arousal is too high, to calm down (down-regulate) and when arousal is low, to self-stimulate (up-regulate) as necessary. For example, an individual may be hyper-aroused and defensive needing to calm down or hypo-aroused and requiring increased alertness. Interactive regulation is then the INPATIENT GROUP FACILITATION GUIDE 11 same ability, but activated through interaction with others. These abilities are developed early on, prior to language acquisition during attachment relationships in infancy (Ogden et al., 2006). Somatic resourcing: Identifying physical experiences that engage a person’s capacities and beliefs with movement of their own body to self-regulate, to provide a sense of well-being and competence. Treatment begins by focusing on observation and control of the body to offer a sense of safety and self-care through movement, sensation and posture for stabilization (Herman, 1992; Ogden et al., 2006). Transference: When a client projects their unconscious feelings onto a therapist, according to Freud, our early experiences are often replayed, redirected and transferred onto others and that response continues to shape later life (Freud, 2012, as cited in Pantuso, 2016). Personal Location Over the past three years I have become particularly interested in group therapy in acute care facilities while working as a Mental Health and Addictions Clinician for Northern Health (NH) in the Adult Psychiatric Unit (3NE), Adolescent Psychiatric Assessment Unit (APAU) and Adult Withdrawal Management Unit (AWMU, also known as Detox). I started my career with NH as a casual clinician 4 years ago doing short and longer term relief positions on these wards before acquiring a permanent position with Adult Psychiatry in 2016. Adult psychiatric unit. University Hospital of Northern British Columbia (UHNBC) is located in Prince George, BC. The adult psychiatric unit is a secure, locked, 20 bed unit with four additional beds in the seclusion psychiatric intensive care unit (PICU) which is only available for those who are actively a danger to themselves or others. INPATIENT GROUP FACILITATION GUIDE 12 From January 1st, 2015 to January 1st, 2017 there were 773 admissions of persons over the age of 18, 49% were males, 51% females. Average length of stay was recorded at 21 days, admitting diagnoses include (but not limited to) Major Depression, Depression with Suicidal Ideation or Attempt, Eating Disorders, Anxiety Disorder, Bipolar, Psychotic, Schizophrenic, Schizoaffective Disorder, and Personality Disorders. Health Canada states that the co-occurrence of substance use and mental health issues is a growing concern for health care. The most common concurrent disorders are substance use and anxiety, followed by substance use disorder and mood disorders (2002). On the psychiatric unit there are two patients to a room, gender specific, and patients are not to enter another patient’s room. There is a large kitchen area with four round tables, sink, fridge and self-serve tea service with cold cereal, toast and fresh fruit. Clients are able to go outside for fifteen minute fresh air breaks approximately every two hours throughout the day and are assigned short passes (1-3 hours), day passes, and overnight passes by their psychiatrist as they prepare for discharge back to the community. Staffing, programming and group structure. There are 10 psychiatrists and two general practitioners currently on staff, one social worker, nine fulltime registered nurses (RN)/registered psychiatric nurses (RPN) as well as 4.5 licensed practical nurses (LPN), each nurse caring for six to seven patients. Mental health and addiction clinicians (MHAC) are not assigned a patient load but work primarily in planning and leading group programming, meeting with clients one-to-one and/or other specific tasks as requested. There is one occupational therapist (OT) who leads weekly activity groups and attends morning groups when scheduling allows. Nursing staff alternate joining therapeutic groups as needed to INPATIENT GROUP FACILITATION GUIDE 13 ensure there is always two staff with patients during groups. Occasionally nursing students also participate in group programming. The weekly programming schedule is posted in the main hallway and includes daily large group check-in at 9 a.m. where clients scale their current mood between 1-10, then describe how they are feeling, create S.M.A.R.T. goals (Specific, Measurable, Attainable, Realistic, and Timely, refer to Appendix K) and discuss personal coping skills. At 10 a.m. there are various psychoeducational small groups on self-esteem, anger management or coping skills. At 11 a.m. a guided relaxation group is held. In the afternoons there are different groups each day at 1 p.m. including a medication education group, peer support, recreation, or art activities. At 3:15 p.m. each day there is a larger health and wellness group offered in the OT room so clients can finish art projects, start new ones, play board games or use the Wii. Daily therapeutic programming is over at 4 p.m. when visiting hours begin. A final check-in group happens at 8 p.m. to share any positive moments from the day, review outcomes or revise S.M.A.R.T. goals and/or share any items they are grateful for. In addition, there is a short relaxation group offered at 9 p.m. for those interested in a relaxing transition to bed before evening medications. When a clinician such as myself, steps onto a ward, whether for casual relief (1 day) or a block of time in a regular rotation, there are posted expectations and a weekly schedule, as well as resource binders full of creative ideas, topics and skills to utilize. I often find myself spending time researching content, as almost always the materials I locate are intended for individual therapy or outpatient groups. Upon starting work on the unit, I quickly realized that outpatient groups are “radically different” than acute care groups for all the reasons listed previously (Yalom, 1983, p. 26). This experience has emphasized to me INPATIENT GROUP FACILITATION GUIDE 14 how critical it is as a facilitator to be aware of areas of expected countertransference, be emotionally and physically grounded, active, flexible, directive and process-oriented whenever possible. Also, depending on who shows up or stays for group, alternative strategies and back-up plans are essential to quickly adapt to the current group dynamic. Farley (1998) in his review of group therapy practices in six North American psychiatric hospitals, found that “there does not appear to be a consistent method of designing, implementing, and assessing inpatient group therapy programs” (p.1). My experience echoes this and is common among the research nationwide, suggesting that much of acute care group psychotherapy is conceptualized on-the-spot by hardworking, multitasking and intuitive staff (Gabrovsek, 2009; Hoge, Migdole, Cannata & Powell, 2013; Marcovitz & Smith, 1983; Yalom, 1983). Such on-the-job learning with little specialized training or supervision can make for a daunting, sometimes isolating, overwhelming and perhaps even unsafe environment for patients as well as staff. There are times when my assumptions or insecurities around my abilities to get the best of me, such that I either overcompensate by placating group members or ignore opportunities for further exploration. Sometimes my level of anxiety, fatigue or patience for others is lacking, and then there can be stressful situations where a “debrief” would be beneficial, but second guessing and ruminating may occur instead. Staffing of the acute care therapeutic groups on UHNBC Adult Psychiatric ward consists primarily of the clinician and the OT if scheduling allows, or someone from the nursing staff. Management is in line with the current research and prefers a co-facilitator be made available for all group meetings, but at times this is not possible. When a second facilitator is unavailable the location of the group is relocated to a more common area such as INPATIENT GROUP FACILITATION GUIDE 15 the main television lounge, or an open area on the psychiatric unit since the smaller group room is not equipped with cameras. Acute care group therapy requires co-facilitation, which necessitates securing the support and planning of staff. Two facilitators can model healthy interaction and it is always preferred to have a lead facilitator as well as another set of eyes and ears to assist if a patient needs help orientating, staying present or decompressing (Razaghi et al., 2015). The TV lounge and/or kitchen tables are less than ideal because of constant client and staff traffic flow. A high level of ambient noise is distracting and there are no alternatives (other than patient’s rooms) for clients who are not appropriate for group or those that choose not to attend. As a facilitator, I am often challenged by the distractions and uncertainty of location, often wishing for a designated space where members can choose to be open, vulnerable and focused, while feeling safe and protected from hospital commotion. There is one small group room usually available which is appropriate, quiet, private, and comfortably holds 6 to 8 clients for therapeutic groups. In order to provide safe and effective, evidence-based group therapy by wellinformed, knowledgeable and prepared staff, it is suggested that government funders and health authorities recognize that acute care group therapy is very different from outpatient therapy. Intentional floor plans, furnishings, spacing requirements, staffing and specific techniques must be adapted to patients’ therapeutic needs and require evidence-based training and supports necessary to deliver appropriate care for inpatient clients. My facilitation experience. I came into this work with many years of group work experience, leading and co-leading within the special education system (elementary and high school), church environment, university context, and community mental health. Over the INPATIENT GROUP FACILITATION GUIDE 16 years I have had the privilege to work with diverse groups of people: preschoolers, children, teens, university students, staff and faculty, as well as older adults. My facilitation of small to large groups involved teaching, coordinating social activities, experiential learning, and facilitating spiritual-growth groups to large and small clusters of people. I personally participated in a variety of groups that involved skills-building, education and therapy. Whether leading or participating in groups, often uncomfortable at first, I have always come away pleasantly surprised by what I’ve learned about a topic, myself and others. Occupational and academic group training also afforded me a good understanding of group dynamics with the ability to navigate and integrate personality types, conflict, attachment styles and especially trauma awareness (AGPA, 2007; Bath, 2008; Bowlby, 1988; Forsyth, 1998; Myers Briggs, 1980; Tuckman & Jensen, 1977). Yet, I was still unprepared for the complexities of group work on a psychiatric unit, the complications of patient comorbid diagnoses, fluidity of group composition, and the severity and diversity of illnesses. Obstacles like patient’s decreased cognizance and comprehension due to medication interventions, limited time and space necessary for therapeutic work, not to mention the daily busyness of an integrative workplace. Distractions are inherent with an open concept meeting area subject to ongoing activities of doctors, nurses, staff and patients coming and going. I found myself wanting to be more connected to my staff team, to learn from those with more experience, to build trust, and support one another. I desired time to communicate, to provide feedback, share ideas and planning to better serve our patients and advance the breadth of knowledge found in such a multidisciplinary environment. Complications. More recently, I experienced “post-concussion syndrome” from a fat-biking accident in which I landed firmly on my head. I was off work for ten weeks to INPATIENT GROUP FACILITATION GUIDE 17 recover, followed by a supportive back-to-work schedule. This experience intensified my appreciation of the specific skill set required when working with groups on a psychiatric ward. As a result of my head injury, my anxiety and depression increased, I found it more difficult to self-regulate my emotions and my memory, concentration, and focus was diminished. My ability to multi-task was significantly impacted and my reduced capacity acutely affected the very skills that are critical to my effectiveness as a group facilitator. In light of my recent situation and reflection on my group leadership skills, I reviewed and found Cohen’s (2004) approach to teaching process-oriented group facilitation an excellent reference to the significance of these basic facilitation skills: (a) the capacity to attend to another’s experience, (b) the ability to accept and convey that acceptance to another, (c) the awareness and sensitivity to demonstrate a range of metaskills (“the ongoing, continuously unfolding and emerging in-the-moment feelings and attitudes…”), and (d) the ability to facilitate the creation of a “group container” and safe interpersonal connections (p. 156). To therapeutically and effectively attend to what individuals are experiencing within group, facilitation requires leaders to convey acceptance, detect micro-expressions and maintain multilevel awareness. To simultaneously finesse at least four levels of awareness, leaders’ attention is “split” between foreground and background processing, for instance demonstrating a coping skill while checking-in on the group. Or “dual”, tracking external processes while staying tuned in to the internal processes of group members and self (countertransference) while noticing “roles” that emerge, the effects on the group, how and when there’s a shift to recognize. Also, facilitators need to continually notice, reflect, and INPATIENT GROUP FACILITATION GUIDE 18 undertake their own “inner work”, evaluating and articulating their experience to make use of teachable moments, on the spot (Cohen, 2004). For instance, a facilitator may address a participant that just sat straight up and is clenching their jaw by saying to them, “I am aware that when you lean back in your chair and get quiet, I feel a sense of apprehension. When my son gets quiet it often means somethings up, and I would like to check-in now and ask you if something has just shifted for you”. In addition to multilevel awareness, a facilitator is tasked with integrating coping skills for safety and stabilization and managing up to 20 patients who don’t necessarily want to be in hospital, are isolated from family and friends, are quite possibly feeling frustrated, fearful, disorganized, embarrassed, all the while undergoing medication changes. As a practitioner, I need to first recognize what I need to be fully present, so I can be equipped to be present to group members on a myriad of different levels. Multitasking on a psychiatric ward involves thinking on your feet, being incredibly flexible, confident, compassionate and consistent while simultaneously managing and balancing various agendas and crises. I learned quickly to take action with my health outside of work and enlist the support of peers to challenge my assumptions, reflect with me on my ways of being and encourage me to keep learning. A psychiatric ward is an absolutely amazing place to serve people, to promote healing through safe connections, stabilization of symptoms and witness substantial changes and growth in patients over a relatively short period of time. It is a place where I have had the privilege to learn from others, be encouraged, and experiment with new ways of being for myself. I have learned that there is always more to comprehend about group dynamics and that I’m affected in the process. Tailored treatment and management is essential; clients (and INPATIENT GROUP FACILITATION GUIDE 19 staff) are unique, resourceful and complex beings. It is clear that clinicians who facilitate groups require ongoing specialized training, resources and support. Summary of Chapter 1 In providing my professional experiences, I highlighted what I believe is necessary for evidence-based inpatient group therapy. I intend to provide a resource manual that is trauma-informed with an adaptable framework of body-oriented, interpersonal, psychoeducational group therapies. Key factors to success are sufficient time, structure and support. Staff facilitators need to have an understanding of their own vulnerabilities or perceptions of conflict, control, ambiguity, safety, and explore how these impact their leadership and interaction with clients in group. Appreciating their own vulnerabilities, trained facilitators may process here-and-now situations with clients, building a sense of safety and connection while developing a variety of coping skills within an acute care setting. I intend for this proposed resource to be informative, accessible (to relief/casual clinicians, as well as permanent staff) and straightforward to implement. It could enhance opportunities for ongoing staff support, collaboration, as well as improve and advance training while recommending evidence-based group therapy interventions for a very distinctive, yet diverse clientele of psychiatric inpatients. INPATIENT GROUP FACILITATION GUIDE 20 Chapter 2: Literature Review History Group psychotherapy has been a primary tool for treating psychiatric patients for over 100 years. It began with psychoanalytically-oriented approaches after the First World War that resembled talks/lectures and group exercises with inpatients, followed by subsequent implementation of cognitive, existential and interpersonal approaches (Burlingame, Fuhriman & Mosier, 2003). In the 1930’s community based aftercare was developed for those recently released patients handling the transition from mental hospital to post-hospital life. Former inpatients not sick enough to be re-institutionalized, but not well enough to survive in the community without professional support were the focus. After WWII community based psychiatry was gaining support to replace institutionalized care (Chan & Noone, 2000). It wasn’t until the late 1960’s and 70’s that authors began to differentiate between inpatient and outpatient group therapy (Fabian, 2003; Kibel, 1992; Kosters, Burlingame, Nachtigall & Strauss, 2006; Marcovitz & Smith, 1983; Montgomery, 2002; Razaghi, et. al., 2015; Yalom, 1983). In Canada, in the 1950s there was move to de-institutionalize and shift the focus of care from longer term mental hospitals to psychiatric units of general hospitals for briefer psychotherapies and treatment. Eventually, in the 1990s Canadian government planning included capacity for 25 adult psychiatric care beds per 100,000 for British Columbia (Chan & Noone, 2000). Many psychiatrists including Yalom credited improved communication throughout the hospital to group therapy. Length of admission dropped with the advent of neuroleptic medications; significant improvements were seen in patients who were otherwise INPATIENT GROUP FACILITATION GUIDE 21 unreachable. The benefits of interpersonal integration was realized in the early stages of acute care group psychotherapy models as staff described reduction of patient fear and increase in socialization. Therapists emphasized the client’s experiential aspect with group cohesion as an essential form of support. The goals of the acute inpatient group are not identical to those of acute inpatient hospitalization. The goal of the group is not to resolve a psychotic depression, not to decrease psychotic panic, not to slow down a manic patient, not to diminish hallucinations or delusions. Groups can do none of these things. That’s the job of other aspects of the ward treatment program - primarily of the psychopharmacological regimen. (Yalom, 1995, p. 459) By the 1980s researchers were looking for models that would frame patient improvement and fundamental elements of group treatment. The 1990s also included the development of protocols for specific diagnoses, settings and orientations arose in the literature (Burlingame et al., 2003). Inpatient group therapy is now considered an important introduction to (outpatient) therapy and a positive inpatient experience is correlated with better allocation of resources and increased follow-up with outpatient therapy (Yalom, 1983). Clinical efficacy. Group therapy is still considered a cost effective and beneficial treatment to reduce symptoms, modify behaviors and deal with interpersonal issues for those with (often co-morbid) severe mental illness. Yet it is difficult to measure exactly how because of numerous complexities and variables with group treatments and contextual factors in patient outcomes. Obviously there is an absence of controlled studies, due to ethical/moral reasons: researchers cannot ethically determine a randomized sample of psychiatric patients, INPATIENT GROUP FACILITATION GUIDE 22 place them in treatment groups, withhold treatment for a control group, and replicate the exact factors and environment (Burlingame et al., 2003; Farkas-Cameron, 1998; Kosters et al., 2006; Liebherz & Rahbung, 2014; Llyod & Maas, 1997; Lothstein, 2014; Montgomery, 2002; Phan, Rivera, Volker & Garret, 2004; Vinogradov & Yalom, 1989). While there is support for the “theoretical basis for short-term inpatient psychotherapy”, Marcovitz and Smith (1983) found that there is also “variability and ambiguity with respect to practical, concrete approaches to inpatient groups” (p. 375). Kibel (1992) concurs, citing great diversity in facilitator practice of inpatient groups, hence the need for simple, user-friendly, hands-on guidelines for effective evidence-based inpatient group therapy. Outpatient Group Setting Outpatient groups are often offered in community with types of therapy groups including, but not limited to: grief and loss, substance abuse, family support, anxiety and depression coping skills, mindfulness, meditation, and/or relaxation, anger management, parenting or interpersonal process groups. Typically 6-12 homogeneous (re: range of psychopathology) clients attend one or more times a week for 1-2 hours, with individuals committing to the group if it’s closed (not allowing new members to enter the group once the group starts), or if it’s an open group membership fluctuates with a longer term drop-in model. Confidentiality is encouraged and agreed to, trust and cohesiveness in group identity evolves over months or years and there is usually an obvious termination or good-bye process. Group facilitators are often much less active, groups tend to be more self-directed and clients are not necessarily meeting socially outside of group time (Corey & Corey, 1997; Rutan, Stone & Shay, 2015; Yalom & Leszcz, INPATIENT GROUP FACILITATION GUIDE 23 2005). See Table 1 below for comparisons between group psychotherapy in outpatient and inpatient settings (Miller & Matthews, 1988, p.22). Table 1. Factors that affect group psychotherapy in the outpatient and inpatient setting. Factor Turn-over of patients Turn-over of staff Range of psychopathology Confidentiality Time spent together outside of group session Length of time in treatment Outpatient Low Low Narrow Within group Limited Inpatient High High Wide Within ward/ team 24 hours 1-2 years 3-4 weeks Screening. Interested outpatient group members are carefully pre-screened for group therapy suitability (Fried-Ellen, 1999; Marmarosh et al., 2013; Yalom & Leszcz, 2005). The American Group Psychotherapy Association’s (AGPA) Practice Guidelines for Group Psychotherapy differentiate the issue of selection and recipient of the greatest benefit, with composition, to determine the blending of clients to produce an effective therapy group (2007). The AGPA suggests that the determination of who should be excluded from group is based on the possibility and availability of strong therapeutic alliance, which is by far the most significant predictor of positive outcomes for individual as well a group therapy (Yalom, 1983). If perhaps a patient is excluded through group screening, other therapy options are considered. Vinogradov and Yalom list the following reasons for possibly excluding a group member: previous failure in group therapy, hostile to the idea of group work, uses group to seek social contacts, client has unrealistic expectations for outcome of treatment, and shows manic, agitated or paranoid behavior, or is unable to participate in group task (1989). Research suggests that the composition of a group has direct impact on outcomes, and interactions within the group determine the group dynamics, which in turn affect therapeutic INPATIENT GROUP FACILITATION GUIDE 24 factors. Ideally, a group experience will promote change and members will find it beneficial. Paradoxical to this are detrimental factors that can alter treatment outcomes like when a person’s experience is not managed for safety, if they feel alone and not understood, if there is no sense of togetherness, acceptance, or of being of any help to other clients, the individual will not likely engage in further group treatment (Phan et al., 2004). Practitioners must determine if the potential group member is incompatible with participation goals for group process. Seasoned clinicians recognize the importance of group dynamics on the therapeutic experience. The group itself is the “client” (similar to couple’s therapy, where the couple is the client), made up of unpredictable, complex individuals; therefore it can be detrimental to the group’s effectiveness as a whole, or harmful to individuals, if a particular person is unfit or incapable of benefiting from the group experience (Corey & Corey, 1997; Dirmaier, Harfst, Koch & Schulz, 2006; Rutan et al., 2014). For inpatient groups, if a patient is actively psychotic, disorganized, violent or threatening, obviously they would not be appropriate for participation in a group (de Chavez, Gutierrez, Ducaju & Fraile, 2000). Important to note, a person’s readiness for group may be fluid and needs to be reassessed by staff throughout the day depending on the patient’s actions, state of mind and willingness to contribute (Cowls & Hale, 2005; Marcovitz & Smith, 1983; Paley, 2013). Though the attending psychiatrist will initially create an inpatient’s treatment plan, determining appropriate groups for participation, an interdisciplinary staff team will communicate and share information throughout the day and use their clinical judgement to collaboratively and continually construct the best possible therapeutic environment for all patients (Farely, 1997; Khorasani & Campbell, 2013). INPATIENT GROUP FACILITATION GUIDE 25 Inpatient Group Setting Persons entering a psychiatric unit tend to be disorganized in their behavior, and experience a higher sense of anxiety upon admittance to hospital. Clear explanations, expectations and options for treatment need to be offered repeatedly to lower patients’ stress levels (Khorasani & Campbell, 2013; Lloyd & Maas, 1997). The clinical group setting typically offers a combination of large (up to 20+ patients) and small (2-12 patients) diagnostically heterogeneous groups throughout a day. The need to provide distinct levels of care inherently presents challenges in obtaining therapeutic factors which are characteristically borne out of the common experience of a diagnostically homogenous group (Cook, Arechiga, Dobson & Boyd, 2014). Adler (1995) noted that heterogeneity can actually enhance the therapeutic environment chiefly due to diversity of members with mutually complementary traits that function as complementary roles within the group dynamic. Clients are in and out of groups, typically rapid turnover with admissions and discharges throughout the week making cohesion difficult and engagement with patients is an art (Parkinson, 1999). Structure, boundaries, creativity and active facilitation are imperative in heterogeneous multileveled inpatient groups. Typically, in most mental health settings, larger groups lean towards more simplistic approaches to review ward expectations and schedules, as well as daily morning and evening check-ins. Art therapy, health and wellness or community groups are also offered. These groups tend to be open—clients choose when to participate, come and go, and have reduced structure. Smaller therapeutic groups lend themselves to increased focus, intentionality and require higher functioning patients who may be expected to arrive on time and to minimize disruption to the group if they choose to leave (Emond & Rasmussen, 2012; Parkinson, 1999; INPATIENT GROUP FACILITATION GUIDE 26 Wyatt, Yalom & Yalom, 2006; Yalom, 1983). Patients that attend groups may leave for various reasons, to see their psychiatrist or physician, if feeling unwell or overwhelmed with frustration that needs to be dealt with by another staff member. These conditions not only affect the facilitation of group, but can also alter and disrupt the intended group format and cause dysregulation for other patients (or facilitator). Nursing staff and/or psychiatrists generally determine what types of groups are appropriate given the clientele. Collaboration between staff, group facilitators and patients is beneficial for designing a treatment plan. Research recommends voluntary attendance. This is ultimately dependent upon the patient’s readiness of how well s/he feels, possible side effects from medication changes, conflicting appointments and openness to change (Cowls & Hale, 2005; Khorasani & Campbell, 2013; Parkinson, 1999). Goals of Inpatient Therapy Historically, inpatient psychotherapy sought to treat mental illness through curative goals, strengthening ego development and relational functioning. The goal was not to remove all symptoms but to help patients shift to more adaptive ways of thinking and behaving (Marcovitz & Smith, 1983). Further changes in treatment models to pharmacotherapy and away from inpatient psychotherapy followed the mid nineteenth century with improvements in the development and research of psychotropic treatments. Later, there was yet another shift towards brief hospitalization, pharmacology and specific therapeutic goals, originally led by Dr. Yalom (1983). Responding to the changing therapeutic environment, Yalom suggested that there are four interpersonal goals of acute care therapeutic interventions: 1) to engage the participant in immediate and future therapy, 2) to demonstrate that talking helps, 3) to identify and work on interpersonal problems, and 4) decrease hospital-related anxiety. INPATIENT GROUP FACILITATION GUIDE 27 Yalom and Leszcz (2005) subsequently added two more goals of “decreasing isolation” and “being helpful to others” (Emond & Rasmussen, 2011, p. 70). Hajek also endorsed Yalom’s interpersonal model of inpatient therapy goals as “engaging the patient in the therapeutic process”, “reducing isolation” and anxiety connected with hospitalization, and “providing experience of universality and of being helpful to others” (2007, p. 11). Lloyd and Maas (1997) surveyed inpatients on Yalom’s therapeutic constructs and found they appreciated having things in common, sharing problems, feeling supported, being able to talk more freely, staying in touch with feelings, giving and receiving feedback and increasing their confidence, from comments on post-group therapy questionnaires. These felt benefits were found to be interdependent with shared experience or group cohesiveness, confirming the underlying therapeutic value of group therapy. They concluded that it is imperative that proficient group leaders know how to make use of inpatient group structure and process to enhance social interaction and a sense of cohesion/shared experience with coclients. It was clear that a client’s sense of interpersonal connectedness and safety is vital to receiving benefit from group experience. Safety and stabilization. Emond and Rasmussen (2012) cite ward stability as a goal of psychiatric units. This refers to a multitude of research findings that has shown inpatient group therapy improves staff-patient relationships, decreases violent behavior, empowers patients, and creates a therapeutic ward milieu. These researchers found that measureable cognitive and behavior outcomes for highly acute populations focused on improving interpersonal skills and decreasing symptoms. The outcomes expedited patient recovery and preparation for discharge. INPATIENT GROUP FACILITATION GUIDE 28 It is essential for staff to provide a safe trauma-informed environment within group therapy where clients are assisted with tools to ground themselves in the present, to regulate their emotions, and better attend to interpersonal relationships with co-clients, staff and supporting family members or friends. Safety and stabilization is a prerequisite to other therapeutic collaborations including psychoeducational groups where patients develop new coping skills, or interpersonal experiential learning, or higher level processing. Therefore, since strengthening interpersonal capacity while attending to safety and stabilization techniques is necessary for optimal mental health outcomes, the goals of inpatient therapy (to improve interpersonal capacity) need to be offered in an enriched environment with selfregulated, grounded, trained facilitators, who then determine adaptable strategies and techniques (Cowls & Hale, 2005; Kottler, 2012; Ogden & Fisher, 2015; Yalom, 1983). Significance of cohesion. It is imperative that group cohesion is developed quickly, as acute care group work is brief; composition is constantly changing with people being admitted and discharged daily (Cook et al., 2014; Dinger & Schauenburg, 2010; Muskett, 2014; Stone, Clendenin, Zapata & Gonzales, 2012). At the very least, members may only ever attend one group session, or engage in sporadic attendance over many weeks. Progress occurs over a relatively short time span, therefore it is necessary for facilitators be much more directive and somewhat embedded in the group to create that sense of safety and shared experience (Weiss, 2009). Farkas-Cameron (1998) combined Gunderson’s (1978) and Yalom’s (1985) therapeutic processes for their work with psychiatric nurses and found that containment, support, structure, involvement, validation and education were paramount to effective leadership of inpatient groups. INPATIENT GROUP FACILITATION GUIDE 29 Well over 100 research studies have since assessed Yalom’s (1983) therapeutic factors, believed to promote change and contribute to the benefits of group therapy which include “installation of hope, universality, imparting of information, altruism, corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, catharsis, existential factors, cohesiveness and interpersonal learning” (p. 41). Maxmen (1978) identified the top four therapeutic factors that patients found to be most helpful from inpatient psychotherapy to be installation of hope, cohesiveness, altruism and universality. Similarly after comparing eight other studies, Kahn (1986) concluded that regardless of diagnosis, the primary therapeutic benefits for inpatients are installation of hope, interpersonal connections, universality and self-understanding. Facilitator transparency and self-disclosure. To develop rapport and connect with clients in an acute care setting, facilitator self-disclosure or personal transparency is indispensable. Yalom (2002) self describes his own relationship with patients as “fellow travelers”, allowing for ways to “dismantle the distinctions between ‘them’ (the afflicted) and ‘us’ the healers” (p. 6). When a patient witnesses another individual, especially the group leader, indicating similar thoughts or experiences, a sense of universality expands and they feel less alone in their illness. Of course there may be others who wish to hold the fantasy that the clinician is set apart to heal with wisdom and authority, but Yalom’s response to those patients is to explain that having a human encounter with a real person is vital to their healing process. Obviously transparency must be balanced with responsibility, what’s best or instrumental for the group as a whole (Yalom, 1983). Rutan et al. (2014) suggest that group leaders consider and commit to two things: to understand more clearly what they are INPATIENT GROUP FACILITATION GUIDE 30 attempting to accomplish from disclosure and be ready to attend to anticipated or unexpected reactions from the group. Transference and countertransference. Facilitators that participate in sharedlearning experiences through modelling in a process group, reduce client transference by clarifying behaviors in the here-and-now (Montgomery, 2002). For example, the facilitator can make good use of client transference as a tool to address maladaptive beliefs, resistance or stuck-ness when members are given the opportunity to address patterns, make connections or corrections in their present experience (AGPA, 2004; Yalom, 2002). Processing here-andnow emotions safely as a group is a wonderful way to authentically connect as humans for a communal transformative experience. Countertransference refers to the emotions a staff member feels towards clients and may be reactive, induced, displaced or projected (AGPA, 2004; Kottler, 2010). It is present in all therapies and is a predictable side effect of interpersonal encounters and should be anticipated, not overlooked or discounted. In Group Interventions for Treatment of Psychological Trauma the AGPA describes common group phenomena to watch for including group defenses of denial, splitting, dissociation, projection (patient transference), and projective identification (another patient enacting projected identity). If a facilitator is not well grounded, confident, self-aware or cognizant to such client defenses, they may not recognize what’s going on. The Crisis and Trauma Resource Institute (CTRI, 2014) suggests that once professionals can ensure self-regulation of their own body, voice, posture and thoughts they themselves will be grounded, and better able to support clients. Facilitators who are attuned to their group members, connecting their conscious awareness with physical INPATIENT GROUP FACILITATION GUIDE 31 and emotional states, strengthen the regulatory capacity in both body and brain to coregulate. According to the AGPA (2004) common responses to countertransference in terms of working with clients who have experienced trauma include feeling overwhelmed (anxiety, rumination, dissociation) or wanting to distance oneself from feeling overwhelmed (avoidance, rigid neutrality, intellectualizing). Facilitators may experience feelings of depression, despair, sadness, anger, inadequacy, shame, blame, or guilt. They may fear anger, conflict, triggering clients, or connecting with loss. Having an opportunity to address these fears outside of group session is important for staff to understand the complexities of countertransference, how it affects their leadership style, choice of treatment modalities or even their self-care (Chan & Noone, 2000). An example of countertransference is when a facilitator avoids certain material or experiences, for example, experiences of walking on egg shells with group members, sleepiness, or shame, guilt, hypervigilance and rescue fantasies. Kottler (2010) suggests therapist countertransference feelings may not be undesirable complications, but “real assets in the promotion of a true human encounter” (p. 147). He states that intense personal reactions can be turning points, “entanglements that often form the nucleus of therapeutic work” (Kottler, 2010, p. 146). A few questions a group leader should consider: “Are the feelings that come up conscious or unconscious?”, and “are they familiar, unusual, appropriate, defensive?” The caution and skill for an inpatient group facilitator is to be comfortable enough with him or herself to identify the source, function and impact of countertransference while monitoring the group-as-a-whole and the individuals, at the same time assess whether disclosure will INPATIENT GROUP FACILITATION GUIDE 32 facilitate therapeutic attunement or if it underscores the need for further personal processing in supervision. Attachment Theory and Social Engagement Attachment theory was developed by John Bowlby who believed that most psychopathology has its origins in problems that occur in early development when children’s basic needs for safety and felt security are not met (1988). The ability to emotionally regulate or self soothe is believed to be shaped by that implicit learning from our early attachment experiences with caregivers. According to Ogden et al. (2006) disruptions to that foundational social engagement system effect people’s ability to modulate their arousal, develop healthy relationships and cope with stress. Those primary relationships help form the ways in which we understand our self and others (Beihl, 2012). Yalom and Leszcz (2005) have confirmed correlations between persons who are treated for mental health issues and significant interpersonal challenges. Brennan, Clark and Shaver (1998) came up with a dimensional model of adult attachment. This model identifies dimensions such as anxiety (how fearful one is in relationships) and avoidance (how emotionally avoidant a person is). An individual’s high or low levels of anxiety and avoidance determines their placement in one of four quadrants based on levels of security (see Figure 1). For example, an insecurely attached person’s “selfprotective way of relating to the world” is counterintuitive to a person’s basic need for closeness and attachment (Beihl, 2012, p. 18). Brennan et al.’s four quadrants include the following: Secure. Caregivers were good enough, mostly available and responsive. Adults low on both dimensions of avoidance and anxiety are people that do not avoid intimacy or fear INPATIENT GROUP FACILITATION GUIDE 33 rejection or abandonment. Secure individuals are more likely to seek help, self-disclose, be emotionally committed and make better use of treatment opportunities within group therapy. Preoccupied. Caregivers may have been inconsistently available or poorly responsive to the child’s needs. Adults exhibiting high levels of anxiety and low avoidance are sometimes described as clingy or needy; they may be hypersensitive to rejection and try hard to maintain intimate contact, demonstrating fear of being alone. In groups, these individuals may fear rejection and become disappointed with the group leader, have difficulty forming alliances and experience more misunderstandings within group sessions (Marmarosh et al., 2013). Dismissing-avoidant. Caregivers were consistently unavailable and poorly responsive to the child’s needs. Adults presenting with low anxiety but highly avoidant seem self-reliant and keep to themselves, they don’t seek out others and may actually push them away. Dismissing members tend to be less emotionally connected to the group and prefer simple companionship over group interactions (Marmarosh, et al., 2013). Fearful-avoidant. Primary caregivers were likely frightening or were very frightened themselves. Adults displaying high anxiety and high avoidance alternate between fear of rejection (deactivate) and fear of abandonment (hyper-activation), they seem inconsistent or disorganized because of their conflict as they avoid intimacy but long for connection. Along with dismissing members, fearful-avoidant group members self-disclose the least and are more likely to require crisis intervention (Brennan et al., 1998; Ogden et al., 2006; Marmarosh et al., 2013). INPATIENT GROUP FACILITATION GUIDE 34 Figure 1. Dimensional Model of Adult Attachment Kirchmann et al. (2012) confirmed associations between psychiatric diagnoses and insecure attachment and cited several studies revealing that insecure attachment limits cohesion within group psychotherapy. Adult attachment patterns can change over time, play a role in symptoms, and can also have a powerful influence on group process. When individuals are stressed, past attachment experiences are played out implicitly between all group participants, members and facilitators. Attachment relationships between group members and facilitators are complex, there’s often transference and countertransference. Early caregivers shape a group member’s perception of another’s behavior. Leading groups is challenging at the best of times, but particularly so if members (or facilitators) are trying to mitigate fears, look for reassurance, defend themselves by trying to seem superior, or withdraw but simultaneously long for connection. Understanding how attachment styles affect patterns of behavior for clients and facilitators, is central to providing reparative or corrective interpersonal experiences within the group context. In order for that to happen, INPATIENT GROUP FACILITATION GUIDE 35 group leaders need time to explore how unpredictable group situations affect their sense of self, their response to ambiguity, flexibility, comfort level with disclosure, or be aware of their own triggers and blind spots. Health care professionals require a safe place for guidance, challenge and support for reflection and encouragement to continue developing. A group leader can have a profound effect on the group process, positively or negatively. How facilitators handle emotions, express or appreciate conflict, their ability to empathize, nurture or facilitate a safe group interaction either leads to corrective emotional experiences or it can destabilize group members (Cabecinha, 2017; Marmarosh et al., 2013). Understanding the role of attachment can be a wonderful tool for a facilitator. If a facilitator is familiar with their own style and can make use of transference/countertransference in the here-and-now processing within the group, this skill is especially powerful. For instance, when an insecurely attached (preoccupied) facilitator interacts with dismissing-avoidant group members s/he could disclose and address his/her own sensitivity to the pushback/withdraw and enquire what group members noticed, what has shifted or what’s needed to restore a sense of security? As previously stated throughout this paper, it is important to build interpersonal capacity and coping skills which regulate emotions. The more open individuals are to relational intimacy and emotional experiences, the more integral an understanding of attachment styles is to effective group experience, inside and outside of group. To integrate and engage group members Marmarosh et al. (2013) suggest that group facilitators should emphasize here-and-now. To avoid flooding and reenactments in group process, keep preoccupied members in the here-and-now, and encourage identification of internal experiences for dismissing-avoidant members to minimize dissociation. Ask clients, “What’s INPATIENT GROUP FACILITATION GUIDE 36 coming up for you right now?” Reflect on feelings. Insecure members may be quick to shut down mentally and emotionally. Help people to explore and identify sensations and feelings to better understand their emotions that trigger reactions. Ask, “How is it for you to share that with us?” Structure and integrate group format to teach skills that encourage emotion regulation and improve attachment through mindfulness. For example, in group you may want to check-in with the clients to have them notice how they are breathing (or sitting, sensing body temperature, tension, etc.), or to notice and respond to the tension in their body, “How about we pause and address that tension in our bodies right now?” The Brain: Bottom-Up or Top-down The brain develops from the bottom up, see Figure 2 for illustration. The reptilian brain or the brain stem develops earliest in the womb and organizes automatic, basic life sustaining activities of heart rate, blood pressure, body temperature, arousal, sleep, hunger and chemical balance. The brain stem is highly responsive to threat throughout our entire lifetime (Van der Kolk, 2014). The old mammalian brain or the limbic system develops over the first six years of life and continues to evolve in a use-dependent manner (use-it or lose-it). It stores memory of emotional relevance, attachment, responsiveness, categorization, perception and affiliation. The limbic system decides what is safe or dangerous. The prefrontal cortex develops last and can go offline in response to a threat. It is used for executive planning, anticipation, holding a sense of time and context, empathic understanding, concrete thinking and abstract or reflective thought (Ogden et al., 2013; Ogden & Fisher, 2015; Perry, 2013). INPATIENT GROUP FACILITATION GUIDE 37 Figure 2. Bottom Up: Development of Brain States. www.childtrauma.org Mindfulness or being present is motivated by curiosity and we can use our “topdown” capacities to observe ourselves and surroundings, make conscious choices to inhibit, organize or modulate automatic responses or to monitor sensations through activities such as meditation and yoga. We can also use “bottom-up” approaches to recalibrate our autonomic nervous system (ANS) through breath, movement or touch (Odgen & Fisher, 2015; Perry, 2013; Van der Kolk, 2014). Figure 3. Brain Developmental Stages and Corresponding Capabilities INPATIENT GROUP FACILITATION GUIDE 38 The Occupational Therapy Group’s 2017 website Inside Out recommends that when planning therapeutic group activities, one must consider normal brain development and what stage an individual (or group) is capable of operating from because if a patient can not regulate their physical, sensory and emotional states (bottom-up) then conventional cognitive therapies (top-down) will be much less effective. As shown in Figure 3 above, group therapy and activities need to be tailored to the patient/group’s developmental stage in order for them to access their resources. Autonomic nervous system and polyvagal hierarchy. Stephen Porge’s polyvagal theory of neurobiology provides a framework for understanding the interactions between the autonomic nervous system (ANS), parasympathetic and sympathetic nervous system. Refer to Figure 4 for diagram. His theory describes a hierarchical response and describes how our ANS is governed by neurobiological responses to environmental stimuli. Figure 4. Stephen Porges’ View of the Autonomic Nervous System INPATIENT GROUP FACILITATION GUIDE 39 The parasympathetic branch of our vagus nerve responds to social engagement by rapidly engaging or disengaging (optimal engagement when we feel safe). This system can be overridden under stress. The sympathetic branch mobilizes us when we need to adapt to danger (fight or flight) and is evolutionarily more primitive and less flexible that our social engagement system. If the parasympathetic and sympathetic systems are unsuccessful at guaranteeing safety, the most primitive and instinctive system of the dorsal parasympathetic branch immobilizes us (freeze). Immobilization can assure survival or it can be lethal if maintained over long periods of time (Ogden et al., 2006; Rothschild, 2000; Van der Kolk, 2014). As we subconsciously and consciously absorb information, our bodies react in a split second according to information stored, making the most adaptive (involuntary) survival response for each circumstance. In light of this information, the clinician’s role is to help group members self-regulate, attune to healthy relationships, and tolerate and continue to integrate bodily sensations, feelings, and thoughts into current situations. Window of tolerance. To keep group members safe and maintain optimal affect, facilitators need to be watch closely and be aware of somatic signs of arousal when clients receive information from their internal and external environment and integrate that sensory information (micro-expressions may include change in skin color, rate of breathing, posture). If someone is hyper-aroused they will likely look defensive (body tension, shortness of breath, rapid heart rate) or correspondingly if a person is hypo-aroused or dissociative they disengage with group (posture may shift, pale skin tone, fixed stare or glazed eyes). See Figure 5 below. As individuals begin to recognize and take note of their sensory experiences they are able to make necessary adjustments to their level of arousal, maintain dual INPATIENT GROUP FACILITATION GUIDE 40 awareness (simultaneous attention to perception and sensation states) and utilize somatic interventions to challenge and repair attachment disturbances. Calm breathing is foundational for clients and facilitators alike, to mindfully notice the breathe (hands on chest and abdomen to feel the inhale and exhale), or explore different ways of breathing and how it affects their experience. For example, an individual can up-regulate by increasing oxygen intake which brings about alertness, or down-regulate through nasal inhale, pause, and long slow exhale which optimizes oxygen and carbon dioxide balance to bring a sense of calm and control (Ogden & Fisher, 2015). Figure 5. Three Zones of Arousal: A Simple Model for Understanding the Regulation of Autonomic Arousal. Psychoeducational groups offer clients experiential learning opportunities to explore the interaction between their body and brain, develop coping skills to shift their internal physiological and emotional states through grounding exercises, while building interpersonal skills through the group process. If group members are outside of their optimal window of INPATIENT GROUP FACILITATION GUIDE 41 tolerance they will be unable to contain or tolerate their affect, which in turns effects their ability to participate, process or protect themselves. Group leaders need to be able to teach, equip and empower patients to self-regulate their autonomic nervous system for management of symptoms and benefit from group interventions. Corrective experiences. Recurrent depression may be found in clients with a history of feeling isolated and disconnected creating downward cycles of mood and increasing anxiety (Beihl, 2012). Researchers Gene-Cois, Fisher, Ogden and Cantrel (2016) recently reported that sensorimotor group psychotherapy has shown statistically significant positive results in chronic and severely ill populations. Clinicians demonstrate in the group how to become aware of body sensations by asking questions about what they are sensing (hot, cold, tight, soft, tingly, sharp, pounding, dizzy, tight, butterflies), where are they sensing (head, hands, back, stomach, feet, etc.), regulation of emotions, or identify cognitive processes that maintain symptoms and relationship difficulties (Ogden et al., 2006). Co-regulating emotions in group can be a very fruitful way to enhance trust, foster a sense of self control and build resources. With the help of strong a therapeutic alliance, facilitators can prudently challenge behaviors and process outcomes with patients to gain insight into motivations or interpersonal conflicts affecting their mental health. Camu (2013) describes mirroring as a corrective process in which the attuned facilitator, through verbal communication and purposeful inclusion of nonverbal gestures (animation/expression), repeats, reflects, and represents a members remembered experience with great accuracy and correct reflection of the real (subjective), remembered experience. Providing corrective secure attachment both INPATIENT GROUP FACILITATION GUIDE 42 psychologically and physically seems to be the best defense against trauma-induced psychopathology (Gene-Cois et. el., 2016; Van der Kolk, 2014). Trauma Informed Practice (TIP) BC Mental Health and Substance Use Planning Council (2013) defines trauma as any “experience that overwhelms an individual’s capacity to cope” (p.5). A single incident or Type I acute trauma is an unexpected and overwhelming event that is time limited (sudden loss of loved one, natural disaster, car accident). Complex trauma or Type II may occur when physical, sexual or emotional abuse, violence, neglect or betrayal is ongoing occurring at important developmental times or when a person is emotionally or physically trapped. Trauma survivors commonly report feeling unsafe, have a pervasive mistrust of others and/or a sense of hypervigilance. Some individuals develop symptoms of posttraumatic stress disorder (PTSD) which involves repeated involuntary, triggered, reexperiencing of helplessness (i.e. flashbacks), avoidance of cues, reminders of trauma, hyperarousal and hypervigilance, problems with concentration, strong emotions and exaggerated startle response. Bessel van der Kolk (2014) explains the development of complex trauma as, “the experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature…and early life onset” (p. 402). Historic trauma includes emotional/psychological wounding over a lifespan for generations following a massive group traumatic experience (i.e. wars, slavery, residential schools). Intergenerational trauma may be the after effect for people living with trauma survivors and is an aspect of historic trauma (TIP Guide, May 2013). INPATIENT GROUP FACILITATION GUIDE 43 Trauma-informed group therapy is an opportunity for clients to learn, develop, express and manage emotions, but it must emerge out of a structured environment where clients can safely connect with others, especially within the context of a strong therapeutic alliance with staff. Effective programming requires experiential learning of basic interpersonal skills such as active listening, self-reflection, problem-spotting, labelling, processing impulses and feelings that equip clients to self-regulate (Bath, 2008). Trauma and psychiatric patients. Statistics reveal 76% of adult Canadians experience at least one trauma exposure in their lifetime and 9.2% meet the criteria for PTSD (TIP Guide, May 2013). Trauma-informed practice (TIP) recognizes the patient’s (or group member’s) need for physical and emotional safety, as well as choice and control in decisionmaking regarding their treatment. Judith Herman in her now classic book Trauma and Recovery encourages TIP care providers to ere on the side of providing a sense of safety, empowerment and client collaboration with all clients, regardless of whether or not a clinician is aware of a trauma history. Harm reduction, choice and working at the client’s pace so to mitigate further trauma or re-traumatizing patients in the process of treatment is essential (1997). Three pillars of trauma-informed care. Trauma can cause physical stress symptoms which effect developmental attachment, biology, affect regulation, dissociation, behavioral control, cognition, and self-concept (Herman, 1997; Ogden et al., 2006; Rothschild, 2000; Van der Kolk, 2014). Howard Bath (2008) suggests that three critical factors are necessary to create a trauma-informed space where one can begin to experience healing: 1) development of safety, 2) promotion of healing relationships through connection, and 3) teaching self-management of emotions and coping skills. Thus, these are essential INPATIENT GROUP FACILITATION GUIDE 44 foundations to be developed, taught, supported and experienced in group therapy while treated on an acute care psychiatric ward. See Figure 6 below. Figure 6. Three Pillars of Trauma-informed Care. Herman (1997) states that 50-60% of all psychiatric inpatients have experienced childhood physical or sexual abuse, with 70% of emergency room patients reporting abuse histories. Muskett (2014) has more recently confirmed that a trauma lens is essential to inpatient group therapy as we may now assume that: Up to 90% of people seeking treatment for serious and enduring personality disorders, substance abuse, and mental illnesses, such as eating disorders, anxiety, and depressive disorders, and those in contact with the criminal justice systems, were exposed to significant emotional, physical and or sexual abuse in childhood. (p. 51) Childhood trauma is well documented and is linked to long term adverse mental health issues, therefore group therapy practices must take into account the probability of INPATIENT GROUP FACILITATION GUIDE 45 numerous acute care patients possibly lacking in the ability to have effective interpersonal relationships, regulate emotions and learn from their own and others experiences (Chandler, 2008; McDuff, Cohen, Blais, Stevenson & McWilliams, 2008; Muskett, 2014; Ogden et al., 2006). A welcoming and comfortable physical environment is vital, as are quiet rooms to destress or take a time-out. Ongoing orientation to the unit, regular review of expectations and boundaries and significant patience and compassion by staff, is essential to inpatients’ perception of effectiveness and quality of care. Any expressions of anger within a group should be reframed by the facilitator so as not to scapegoat members and let the group know early on that the leader will deal with and defuse any emotional intensity, providing a safe environment and modeling healthy ways to address emotional content (AGPA, 2004). Problem of cohesion and single sessions. According to Bessel van der Kolk (1987) it is the group’s cohesion that is most therapeutic for trauma survivors, not insights from the facilitators. Cohesion is the essence of meaningful relationship, it’s intrapersonal when members have a sense of belonging, acceptance and commitment to the group and interpersonal as members listen, learn from one another and offer feedback (Burlingam et al., 2006; Corey & Corey, 1999). Achieving cohesion is challenging in acute care therapy. Patients participate for relatively short stays, clients might only attend a single session and new patients may join therapy groups on a daily basis. Therefore, facilitators have to be active, personal, supportive, directive, and work quickly to create a cohesive environment for patients in each session (Yalom, 1983; Yalom et al., 2006). Theoretical Approaches and Interventions Yalom (1983) and others write about the vast array of inpatient psychotherapy groups that traditionally meet from 1-3 times per week. Due to variability in staffing, some groups INPATIENT GROUP FACILITATION GUIDE 46 are led by psychiatrists, occupational therapists, nurses, mental health clinicians, or part-time health care professionals brought in from outside the hospital. Examples of evidence-based inpatient groups that I reviewed for this paper include: interactional, analytic, goals, acceptance and commitment (ACT), mindfulness, time-limited dynamic, movement therapy, art, transition, relaxation, interpersonal, music, singing, pet, human sexuality, life skills, crafts, discharge planning, dialectical behavioral (DBT), problem-solving, psychodrama, self-awareness training, body awareness, psychodynamic, compassionate-focused therapy (CFT), men’s and women’s, exercise, activity/recreational, spirituality, horticulture, medication education, process, cognitive behavioral (CBT), coping skills, assertiveness, social skills, future planning, decision making, Gestalt, symptom management, solutionfocused, guided fantasy, stress management, and process-oriented psychoeducational (Barker & Dawson, 1998; Charters, 2013; DiGiacomo, Moll, MacDermid & Law, 2016; Emond & Ragmussen, 2013; Farley, 1997; Gudiano & Herbert, 2004; Hajek, 2007; Heriot-Maitland, Vidal, Ball & Irons, 2014; Khorasani & Campbell, 2013; Pollack, Harvin & Roxy, 2001; Raune & Daddi, 2001: Sullivan, 2003; Veltro, Vendittelli, Oricchio, Addona, Avino, Figliolia & Morosini, 2008; Weiss, 2010; White, Gumley, McTaggart, Rattrie, McConville, Cleare & Mitchell, 2011; Wyatt & Yalom, 2006; Yalom, 1983). There is significant overlap in form and content with the above group approaches and distinctions are dependent on who is designing, planning or implementing interventions in each particular hospital. Here-and-now. Patients tend to think they need to review/retell their past repeatedly, the details of who, what, when, where and how; however, this can be re-traumatizing. INPATIENT GROUP FACILITATION GUIDE 47 The beauty of the here-and-now conversation is that group members are directed to focus on what’s happening in the room, within themselves, how they are feeling about others, what they are hearing from others, primarily being aware of the present moment. It is new and frightening, especially for the many patients who have not previously had close and honest relationships, or who have spent their lives keeping certain thoughts and feelings – anger, pain and intimacy – covert. The therapist must offer much support, reinforcement, and explicit training. A first step is to help patients understand that the here-and-now focus is not synonymous with confrontation and conflict. In fact, many patients have problems not with anger or rage, but with closeness and the honest and non-demanding or non-manipulative expression of positive sentiments. (Vinogradov & Yalom, 1989, p.89) If group members get stuck problem solving, trying to help each other solve past issues, they are destined to not only disappoint, but get increasingly frustrated and discouraged by overwhelming circumstances (which is likely why they came into hospital in the first place). Effective and beneficial dynamics occur when group members can explore their immediate feelings, address personal boundaries, or offer feedback on the interactions happening in the here-and-now. Facilitators listen, observe and attend to the relational exchange of information occurring between clients while paying attention to horizontal disclosure (disclosure about disclosure). Facilitators must be active, diligent “shepherds” who keep the group work “grazing on current interactions. All strays into the past, into outside life, or into intellectualization, must be gently herded back into the present.” (Vinogradov & Yalom, 1989, p. 86) INPATIENT GROUP FACILITATION GUIDE 48 Leaders carefully enquire about feelings and encourage expression while being attentive to and registering incoming data from group members as well as their own reactions, thoughtfully using it all as material for further process. Redirecting the group back to the here-and-now provides patients with the opportunity to access and express feelings that might not otherwise be safely explored or validated (Corey & Corey, 1997; Yalom, 1983). Ask, “I noticed you seemed far away just now, what’s coming up for you as when X talks about her frustration?” Sensorimotor psychotherapy. The experience of safety is the core developmental need for secure attachment and is paramount in developing and maintaining healthy therapeutic alliance (Herman, 1997; Rothschild, 2000). The integration of sensorimotor psychotherapy in the form of somatic resourcing brings the whole person into group therapy by building awareness of body sensations and controlled movement, increasing observation skills and a sense of safety while experimenting with somatic interventions (refer to Appendices D – G). Somatic sensations may include: sound, touch, smell, sight, taste, movement, posture and instinctual reactions. If clients can initially become familiar with feeling and identifying sensations on a body level while safely contained (careful pacing, titration and/or use of container imagery), they are better able to name, describe and give meaning to what they are sensing (see Appendix H). Resource development is foundational to increasing safety and security for clients. This project will include instructions on building resources such as body awareness, containment imagery, calm/safe place, muscle toning, and healthy boundaries (Rothschild, 2000). Bessel Van der Kolk affirms body-oriented approaches, “Sensorimotor psychotherapy is sensitive to the fact that most trauma occurs in the context of interpersonal relationships” INPATIENT GROUP FACILITATION GUIDE 49 (as cited in Ogden et al., 2006, p. 23). Facilitators teach patients simple ways to observe the present moment, notice what they feel, where they feel it, create a vocabulary that helps them explain sensations, build confidence in their ability to self-regulate internal and external stimulation, and increase or decrease arousal as needed to manage symptoms (Ogden et al., 2006; Rothschild, 2000; Van der Kolk, 2014). A trauma-informed approach in psychiatric settings ensures a culture of safety, sensitivity and collaboration to reduce patient symptoms, increase acceptance, expression of emotions, and foster interpersonal connections with others. Best practices for continual staff development in education, training, role modelling and self-awareness must be continually encouraged and cultivated (Chandler, 2008; McDuff et al., 2008). Van der Kolk and Courtois (2005) noted how a trauma-informed approach is changing current practice, “clinicians have learned to focus on issues of safety, affect regulation, coping and self-management skills as well as on the therapeutic relationship itself” (as cited in Bath, 2008 p. 387). Psychoeducational groups. For years cognitive behavior therapy (CBT) was recommended for inpatients with anxiety and depression. Page and Hooke (2003) verified measured improvements in self-esteem, locus of control, depression, anxiety and stress. Another group of researchers completed a four year follow-up study that looked into the effectiveness and efficacy of CBT for inpatient groups and compared the impact on patients diagnosed with schizophrenia, major depression, bipolar disorder and personality disorders. Patients with co-morbid substance abuse were not included in the study. They found that readmission rates were reduced, patient satisfaction and ward atmosphere improved. However, CBT was found to be not very affective during the first week to 10 days of admission, particularly with depressed patients who are characteristically cognitively passive INPATIENT GROUP FACILITATION GUIDE 50 and uninvolved emotionally. As could be anticipated, when medications became effective these patients wanted to be discharged and underestimated the importance of issues discussed in group sessions (Veltro et al., 2008). Psychoeducational groups are opportunities for interpersonal learning, ego support and skill building. Along with CBT, are other interventions that work well for patients with depression, personality disorders and anxiety (Cowls, & Hale, 2005; Montgomery, 2002; Page, & Hooke, 2003; Veltro et al, 2008). Emond and Rasmussen (2012) list dialectical behavioral therapy (DBT) as effective for persons with emotional dysregulation and biological emotional vulnerability. While modules are modified for inpatient units, more research is needed to establish efficacy on psychiatric wards. Like medications, not all approaches will benefit every patient. Cowls and Hale’s (2005) qualitative research study found that patients value activities that put them at ease and facilitate connecting with other group members, but they also readily rely on group leaders to limit the intensity and emotional disclosure during psychoeducational groups. Clients appreciate when difficult experiences are safely shared and discussion follows to debrief and develop coping strategies for their feelings. Interpersonal approach. Hajek (2007) describes Yalom’s interpersonal model of inpatient group therapy and suggests that a “good group engages patients, reduces their sense of isolation, helps deal with anxiety caused by hospitalization and provides the experience of universality and being helpful to others” (p. 7). By primarily addressing interpersonal skills and developing structure for patients to engage with one another, clients are able to give and receive feedback, modify or change maladaptive patterns that affect their ability to manage mental health issues and connect with others in real time. Well-managed interactions within INPATIENT GROUP FACILITATION GUIDE 51 interpersonal group therapy can alleviate anxiety, shame, stigmatization, staff tensions, expectations, instability, unsettling events, and help with transition to discharge (Khorasani & Campbell, 2015; Lloyd & Maas, 1997; Yalom, 1983). Personal change happens in group therapy by processing the common human experience, intrapsychically (within oneself), interpersonally (between persons) or group-as-a-whole process. The group leader listens for shared experiences and themes and then structures the group to tailor discussions (treatment) to a variety of pertinent needs. Because inpatient treatment needs to be brief and efficient, psychoeducational models which teach and inform clients about symptom management frame the group structure. The facilitator then integrates ways to process the current intellectual and emotional needs of clients to further develop a personal, meaningful and transforming experience for group participants (Cook et al., 2014). Gonsalez de Chaves et al. (2000) compare Yalom’s therapeutic factors in schizophrenic inpatients and outpatients, concluding that interpersonal learning produced less anguish in patients when they are able to identify as part of the group, experience acceptance, togetherness, less isolation, support and reassurance. Cohesion is difficult to establish in short term heterogeneous groups with rapid turnover, but it is a very powerful condition for change and group effectiveness. For schizophrenic patients, the feeling of social acceptance is a critical factor to fight against demoralization and low self-esteem (Cook et al., 2014). Therefore, facilitators need to take advantage of teachable moments to address disruptions, confusion or distress in a compassionate, respectful and inclusive discussion. Process-oriented psychoeducational model (POP). Vannicelli (2014) suggests that group leaders encourage free flow discussion by being invitational, avoiding circular goarounds if possible, and help create space where members speak to one another and not INPATIENT GROUP FACILITATION GUIDE 52 solely to the facilitator. Rutan et al. (2014) explain the interplay between content and process, “The content (overt meaning) of any association cannot be divorced from the process (the covert meaning) because the two are connected. The content might be a symbolic representation of a group wide issue or an interpersonal transaction, or it might be a direct commentary on the process of the group” (p. 191). Teaching coping skills, relaxation techniques or body awareness in a psychoeducational setting opens up space for developing deeper process interactions that are simple and relatively content free. By tracking the emotional climate of the group, the leader addresses a shift in topic or emotional tone with questions like, “How are things going right now? or “What makes it hard to continue?”, or “What’s happening in the room right now?” The group facilitator makes every effort to foster reflective observation of how members are caring for themselves without criticizing or requiring change, while encouraging interpersonal engagement and containment for safe exploration during the process (Vannicelli, 2014). Communication is vital for any group interaction. Bringing up unconscious or internal sensations and addressing them together in the here-and-now is the privilege of group therapy. Yalom refers to this as “grist for the mill” (2002, p. 70). Gray-Deering (2014) noted that over the past 30 years there has been a trend away from process-oriented groups on inpatient units due to shorter admissions and increasing acuity levels of patients. Crisis stabilization and brief evidence-based psychoeducational and CBT approaches ensued. She currently co-leads groups in a 32 bed locked inpatient ward and makes a strong case for process groups for any patient who wishes to sit in a circle and participate. Her approach integrates Yalom’s single-session framework along with a focused approach to validate and respect where patients are at when approaching discharge. She emphasizes the need for a INPATIENT GROUP FACILITATION GUIDE 53 group where patients can engage and identify (not resolve) conflicts that brought them into hospital and have a positive experience of group therapy that will motivate them to continue with therapy after discharge. She listens for themes, helps the group grapple with stressors of chronic mental illness, relapse, loss of control, faith, hope and difficult decisions. GrayDeering also emphasizes an existential approach, acknowledging patient’s immense strengths in enduring chronic illness and finds that they are motivated to continue with treatment because of “inspiration, hope and greater appreciation of the human race” (p. 170). Integration of psychoeducation with process and somatic resourcing on various topics provides informative content, member-to-member feedback, and experiential learning in a safe place to try out something new. To be able to witness the process, creating time to slow things down, investigate, elaborate and integrate a meaningful experience in real time – is a profound gift. POP requires a flexible, self-assured, self-regulating, trained group facilitator who understands how to tailor treatment needs while allowing for individual capacity within the group milieu (Bernstein & Schultz Duquette, 1995; Cohen, 2004; Cook et al., 2014; Khorasani, 2013; Rutan et al., 2014). Training, Support, Personal Reflection and Awareness For years researchers have questioned the credentialing guidelines (or lack there-of) for inpatient group facilitation (Cook et al., 2014). Differentiating between group therapy and group programming is muddled in the literature and there is no consensus as to who should or should not lead groups. Researchers do agree on the fact that formal training is often limited to outpatient group work. The theoretical rationale of what is taught, why and by whom, is not standardized and ongoing education and/or supervision is required to address issues that are commonplace to psychiatric inpatient group work, be it technique, INPATIENT GROUP FACILITATION GUIDE 54 culture or self-awareness (Hoge et al., 2014; Khorasani & Campbell, 2013; Lothstein, 2014; Vannicelli, 2014). Others have noted how important facilitator self-care and awareness is to quality group experience. A leader’s own understanding of attachment styles, comfort with disclosure, conflict, control and ambiguity will have an effect on how they contribute or take away from the competency and safety of the group (Chan & Noone, 2000; Cohen, 2004; Marmarosh et al., 2013; Shapiro et al., 2007). Co-facilitation. The concept of co-facilitation is debated in the literature. The American Group Psychotherapy Association (AGPA, 2004) suggests that when treating individuals with trauma history, groups require co-leadership. This necessitates one person to work with the group on task, the other to observe and monitor group members for any increase in symptoms or dissociation, and then support or accompany those that may need to leave the session. Some people prefer leading groups on their own, with a myriad of reasons behind this (primary factors being staff allocation, training, or uncomfortable with coleaders). It remains best practice to have two clinicians for safety and support, not only for the client’s sake but also for facilitators. As group facilitators become more familiar and aware of their own countertransference and dysregulation due to difficult group scenarios (being triggered themselves by content, aggressive or disorganized clients, etc.), a partner in leadership is essential to share challenging responsibilities and support one another during preplanning, in-session, or debriefs. Debriefs can be a particular gold mine of gathered insights, micro-expressions, mannerisms and shared information that can aide the staff team in care planning and patient consults (Cohen, 2004; Stone et al., 2012). Peer supervision or learning communities for colleagues that meet periodically to discuss clinical practice, implementation of skills and sharing of best practices, provides INPATIENT GROUP FACILITATION GUIDE 55 guidance, constructive feedback and meaningful support where inpatient group facilitators can learn from one another and reduce feelings of isolation (Foy, Unger & Wattenberg, 2004; Hoge et al, 2014; Marmarosh et al., 2013). Hogge et al. offers substantial evidence that supervision impacts staff retention, skill levels, adherence to evidence-based practices, and improved quality of care. Qualitative studies indicate a positive effect of clinical supervision on staff, citing decreases in stress, burnout and professional isolation, and feelings of competency, efficacy and well-being are increased, as are attainment, retention and application of new learning. Self-care. Health care providers are notoriously poor with their own self-care and are at risk for occupationally related psychological problems. The helping profession attracts many people who put others first and enjoy being fixers. Yet working with highly distressed clients is often itself stressful, and the negative consequences to caregivers can include increased depression, emotional exhaustion and anxiety (Shapiro et al., 2007). Therefore, selfawareness of why and what is defined as a healthy, sustainable lifestyle will benefit not only clinicians and clients, but also the health and sustainability of staff teams. Empirically supported treatment (EST) and research of exemplary practices of staff supervision encourages explicit attention to self-care. Ensuring there is scheduled work time for staff teams to relax together, with a focus on strengths, provision of practical suggestions for time management and access to supports has been shown to reduce feelings of isolation and minimize burnout (Hog et al., 2014). Shapiro et al. (2007) researched the contemplative approach of cultivating mindfulness as a stress management intervention for therapists in training. Their findings suggest that mindfulness-based stress reduction (MBSR) lowered levels of perceived stress and distress, INPATIENT GROUP FACILITATION GUIDE 56 enhanced participant’s ability to regulate emotional states and increased positive affect and self-compassion. The increase in self-compassion is particularly noteworthy as research has shown that clinicians who lack self-compassion and are critical and controlling towards themselves tend to be more critical and controlling of their patients as well (Henry, Schacht & Strupp, 1990 as cited in Shapiro et al., 2007). Discovering attachment styles, blind spots, personal complications and triggers is also necessary self-work for practitioners. This helps to understand that health care professionals do not operate in a vacuum and mental, physical and emotional health impacts the effectiveness and outcomes of groups. When group leaders become aware of their own needs, have staff support and appropriate supervision, they are better equipped to interact, nurture, handle conflict, or offer corrective emotion experiences to vulnerable group members (Cabecinha, 2017). Reflection and action planning for life/work balance, self-regulation and grounding skills, therapy for vicarious trauma or stressors, being mindful of ways to reduce stress, engaging with community, healthy eating, exercise and sleep all have a strong effect on work satisfaction and sustainability of overall health (Cohen, 2004; CTRI, 2014, Shapiro et al., 2007). Marmarosh et al. also propose that facilitators’ attachment styles can significantly influence the process climate of a group. The authors caution that when group leaders are highly activated in stressful settings, even if they have done the work to become more securely attached, most will revert to earlier attachment models. Therefore, reflecting on where you have been and where you would like to be or how you currently function is subject to change due to demanding environments, even for highly trained professionals (2014). INPATIENT GROUP FACILITATION GUIDE 57 Summary of Chapter 2 The literature review was intended to be an overview of numerous variables tied into inpatient group therapy. The emphasis was on how inpatient group therapy differs from traditional outpatient models and what is needed for facilitators to offer best practices, including being trauma-informed practitioners with appropriate leadership skills, resources and self-awareness. Implications for groups. All group therapy should be trauma-informed, building capacity for clients to be present with their bodies, acquire the ability to self-regulate, and form personal goals. This can be attained in typical large group check-in sessions that ground clients, giving them a present awareness of where they are, how they currently feel and what they would like to accomplish throughout the day while listening, respecting and responding to others in the group. Research has suggested that as long as group members aren’t too disorganized or disruptive, are nonviolent, attentive to instructions and are able to perform the task at hand, most psychiatric inpatients will benefit from group participation (Adler, 1995; DiGiacomo et al., 2016; Yalom, 1983). Those who aren’t able to benefit from a particular group will receive periodic one to one attention from their nurse and psychiatrist. As patients become more settled and cognitively aware, daily process-oriented psychoeducational groups are great opportunities to increase interpersonal connectedness while working on managing symptoms. Topics to consider may include: coping skills, selfesteem, assertiveness (passive, assertive, aggressive differences), relaxation techniques and health and wellness. As patients prepare to be discharged, a more traditional, higher level process group may be appropriate for members to meet 1-2 times during the week. Patients that are feeling less vulnerable and more attuned to others, able to give and receive feedback INPATIENT GROUP FACILITATION GUIDE 58 about their current affect and/or behavior, can benefit from having an opportunity to discuss transitioning to home life, outpatient resources and follow-up. Implications for facilitators. Those that lead groups want not only to be prepared with programming of group therapy and activities, they need to be grounded, personally aware of their own limitations, yet confident in their abilities. Facilitators should be able to emotionally regulate themselves in stressful situations, be flexible with agendas and content, manifest excellent observation skills, understand, integrate and implement various evidencebased theoretical models as needs arise. In order to manifest all the above skills, one must take the time necessary to internally process through intentional self-reflection, awareness of strengths and weaknesses, blind spots, and identify areas to nurture. The following chapter will outline ways in which facilitators can enrich their leadership experience and provide quality group facilitation for psychiatric inpatients. Finally, let’s re-examine Yalom’s quote, “…the contemporary acute psychiatric ward is a radically different clinical setting and demands a radical modification of group therapy technique” (1983, p. 50). Technique is only part of this story. There has been limited examination and exploration into specialized training for facilitation; this too requires radical modification. Inpatient facilitators work in an often demanding, unpredictable atmosphere. They need to be resourced on how to mitigate stressors and stabilize themselves first, in order to mediate multileveled group work. Hence, facilitation is part science, part creative art. INPATIENT GROUP FACILITATION GUIDE 59 Chapter 3: Project Description This chapter will be divided into the following three parts: Part A: Twelve 30 minute sessions for developing self-awareness among staff. Attachment styles, level of comfort with disclosure and ambiguity, countertransference, selfcare and safety will be addressed. Part B: Safety and stabilization techniques for facilitators to use in inpatient groups. This will include somatic resources to ground clients (and facilitators), process-oriented psychoeducational topic ideas, outlines for groups including a higher level transition/discharge planning process group and relaxation suggestions. Part C: Training and networking opportunities for inpatient group facilitators. Professional associations, websites, and online resources are included. Target Audience This resource guide is aimed at accredited professionals and/or master level clinicians and their co-facilitators working on inpatient psychiatric wards. Facilitators will likely include mental health and addictions clinicians, social workers, or occupational therapists. Co-facilitators may include registered nurses, registered psychiatric nurses, licensed professional nurses, mental health and addictions clinicians, occupational therapists, mental health workers, nursing students, or psychiatric residents. Resource Guide Goals The goal of this resource guide is two-fold. It is to provide simple, accessible, training sessions that promote self-reflection and self-awareness for staff and offers traumainformed materials to use in acute care groups. Resources from Part A include twelve 30 minutes sessions designed to be implemented during monthly staff meetings (or modified for INPATIENT GROUP FACILITATION GUIDE 60 ½ day workshops or retreats for more in-depth staff team development). Resources in Part B consist of the trauma-informed “do’s and don’ts” in acute care groups, guidelines for leading various groups on how to use simple, accessible, quick activities and handouts for clients during daily check-ins or higher level process-oriented psychoeducational groups or reintegration (discharge readiness) process groups. Because the majority of inpatients will have some trauma history, it is imperative that facilitators be cognizant of group members who may be triggered, dysregulated or dissociative before, during or after a group session. Attuned staff can help patients co-regulate and ground themselves to avoid re-traumatization. Part C is intended as a referral list of outside training and networking opportunities for continuing education and professional development as well as online training resources. Expectation of Facilitators Professionals are expected to act ethically when engaging with clients as well as other staff members. Confidentiality is anticipated but can never be guaranteed, so utilization of this resource guide must be undertaken with informed consent. Participants (facilitator training or inpatient group members) are encouraged to respect one another, foster growth and provide space for themselves and others as they work towards enhancing their well-being in the company of others. Part A: Twelve 30 minute single sessions for staff development  The Power of Vulnerability  Know your attachment style  Balanced Life: POD  Six core strengths for healthy development  Listening to Shame INPATIENT GROUP FACILITATION GUIDE 61  Understanding self-disclosure, ambiguity and blind spots through the Johari Window  Awareness, expression and location of feelings  TIP Personal preparation plan for facilitators  Hazards Self-assessment  Addressing countertransference and other personal reactions  Building and maintaining support for self-care  Safety in Groups Part B: Safety and stabilization techniques  Do’s and don’ts of trauma-informed inpatient group work  How to facilitate a large group daily check-in  How to facilitate a somatic and process-oriented psychoeducational group  How to facilitate a re-integration (higher level) process group  How to facilitate a relaxation group  CBT manuals, worksheet and information for discharging clients Part C: Training and networking opportunities  Continuing Education and networking opportunities  Online resources Summary of Chapter 3 This chapter briefly outlines the manual to be presented in Chapter 4. Description of the professionals that might benefit from this resource guide, its goals, and the three separate parts for facilitators to access are also listed. The compilation of resources in the final chapter is designed to address facilitator preparation, staff development and techniques, strategies and tools for quick reference. INPATIENT GROUP FACILITATION GUIDE 62 Chapter Four: Resource Guide When you have means of reflecting on yourself, then you do not lose sight of the conditions and feelings of others. If you have no means of reflecting on yourself, then confusion comes into play when you act. ~Lo-tzu, Chinese philosopher This chapter provides twelve single-session resources for professional development as well as suggestions, directions and outlines for inpatient group therapy. Part A: Twelve 30 Minute Sessions for Staff Development The following section contains twelve 30 minute sessions for staff development which can be implemented during monthly staff meetings (with staff team leads, mental health clinicians, nurses, social workers, and occupational therapists) to engage clinicians and their co-facilitators in activities that promote self-awareness, reflection and self-care. These sessions are designed to be incorporated into an already functioning team meeting (no need for warm-up or ice breaker exercises) to inform, educate and offer an experiential learning experience to staff that will be co-leading inpatient groups. It may be helpful to get participants to identify a goal on an index card at the beginning of each exercise, what are they hoping to learn from the topic? Staff will then be better prepared to discuss their fears and concerns and how those link to leading inpatient groups. The exercises and activities can be experienced in pairs, small groups of 3-4, or easily modified for a larger group context. INPATIENT GROUP FACILITATION GUIDE 63 The Power of Vulnerability Materials needed: Computer/ipad and screen to play You Tube video. Index cards for each participant. Goal: Watch and then discuss together Brené Brown’s TED Talk 2010 The Power of Vulnerability (20:19 minutes) https://www.ted.com/talks/brene_brown_on_vulnerability Purpose: To explore the “power of vulnerability” and to understand the strength of connection. Brené Brown studies human connection — our ability to empathize, belong and love. In a poignant, funny talk, she shares a deep insight from her research, one that sent her on a personal quest to know herself better as well as to understand humanity. Leader presents: Before you view the YouTube video, take a moment to write out on your index card what you feel in your body when you think about topic of vulnerability. Also write down the first words you think about when you hear “vulnerability”. Watch the video together and then share your thoughts with the group. Some topics for discussion might include: 1) What makes it easy to be vulnerable, what makes it difficult? 2) What prevents you from being vulnerable in this group? 3) What would increase your sense of safety, connection or commitment to this group? INPATIENT GROUP FACILITATION GUIDE 64 What’s Your Attachment Style? Materials needed: Copy handouts for each participant (see Appendix T) and index cards. Goal: To identify and reflect on individuals early attachment style and if it has changed over the years. Purpose: To explore attachment style and its effect on current interactions with staff team members and/or clients in group sessions. Leader presents: Figuring out your attachment style may help, not only understand yourself better, but also to consider if there’s a pattern of how you react or respond to group members or your staff team. According to Cabecinha (2017), to know one’s original attachment style (impact of how they were parented and childhood experiences) and to understand if it has changed over time (with corrective experiences) is impactful. One can make better use of ways to self-regulate emotions, connect with others and comprehend why an individual may revert back to earlier insecure ways of being. Interestingly, when individuals are in highly stressful environments, most if not all of us, will react out of our earlier attachment style, even if we have had corrective experiences and are currently more securely attached as adults. What questions or thoughts come up so far? Please take a moment to write out on an index card what you are looking for from this session. Take a moment to listen to and review each of the four attachment style descriptions and see if you can figure out where you would place yourself on the graph below between 17. Consider the center to be 4, low anxiety is 1, high anxiety is 7, low avoidance is 1, high avoidance is 7. INPATIENT GROUP FACILITATION GUIDE 65 Fearful-avoidant individuals: Those high on both dimensions of avoidance and anxiety, experience attachment-related anxiety yet avoid intimate contact with others. In essence, these people alternate between deactivation (because of fear of rejection) and hyperactivation (because of fear of abandonment). Some theorists have referred to this style as disorganized because persons with this style engage in both activating and deactivating strategies. Indeed, these individuals are uniquely conflicted because they may withdraw and avoid intimacy with others in relationships while simultaneously longing for closeness and connection. Their inconsistent behaviors make it particularly hard for them to maintain healthy relationships and regulate emotions under duress (Mikulincer & Shaver, 2007b as cited in Marmarosh et. al., 2013). Dismissing-avoidant individuals: Those high on avoidance but low on anxiety, they often keep to themselves and can appear self-reliant. They deny fear of being alone or abandoned and do not generally seek out emotional support from others. They tend to use deactivating strategies—that is, they push others away—to deflect intimate contact, such as making a joke or changing the subject after someone shares something vulnerable. These individuals withdraw and minimalize attachment-based needs, and they deny anxiety about rejection and abandonment (Mikulincer & Shaver, 2007b as cited in Marmarosh et. al., 2013). Preoccupied individuals: Those low on avoidance but high on anxiety and are often described as clingy or needy. They report more anxiety about relationships and are hypersensitive to signs of rejection or abandonment. These individuals engage in hyperactivation strategies—that is, they exert intense efforts to achieve and maintain intimate contact—and they are preoccupied with fears of being alone. These individuals tend to seek INPATIENT GROUP FACILITATION GUIDE 66 out others for comfort but are often dissatisfied with the support they receive (Mikulincer & Shaver, 2007b, as cited in Marmarosh et. al., 2013). Secure individuals: Those low on both dimensions of avoidance and anxiety, neither avoid intimacy with others nor fear rejection or abandonment. They feel capable of seeking out support and trusting others, they tend to report caring connections with attachment figures and compassion and empathy for romantic partners and family members. Even when there are challenges within a relationship, these individuals tend to forgive others (Mikulincer & Shaver, 2007b as cited in Marmarosh et. al., 2013). INPATIENT GROUP FACILITATION GUIDE 67 Questions to discuss in pairs and/or in a group: (If you have the time, view a (4:39 minute) clip on You Tube explaining Attachment Theory and its Effect on Adult Relationships https://www.youtube.com/watch?v=uSAPfiSw_Ic) 1. What’s your attachment style? Or, what would those that know you well or live with you say? 2. Has is changed over time, if it has, how so? 3. How is your attachment style affected when you are highly stressed? (What’s your default style?) 4. How do you think your attachment style impacts the groups you facilitate? What attachment style do you have difficulty dealing with in other people? How do you usually react to those people? What would help you to respond differently? INPATIENT GROUP FACILITATION GUIDE 68 Balanced Life: POD Materials needed: Computer/ipad and screen to play You Tube video, index cards for each participant. Goal: Watch: Dr Shimi Kang, TEDxKelowna. Discuss as group. What One Skill = An Awesome Life? https://www.youtube.com/watch?v=IEHZAQmw2JA Purpose: To explore the idea of health and wellness, what are the basics? Dr. Shimi Kang is an award-winning, Harvard-trained doctor, researcher, media expert, and lecturer on human motivation. She is the author of the #1 Bestseller, The Dolphin Way: A Parent’s Guide to Raising Healthy, Happy, and Motivated Kids Without Turning Into A Tiger (Penguin Books 2014). Dr. Kang is the Medical Director for Child and Youth Mental Health for Vancouver community, a Clinical Associate Professor at the University of British Columbia, and the founder of the Provincial Youth Concurrent Mental Health and Addictions Program and BC Children’s Hospital. She has helped thousands of children, adolescents, and adults move toward positive behaviors and better health. Leader presents: Before we watch the video, write out on the index card what you are hoping to take away from this session. We will watch this TED Talk together and then discuss as a group. 1) What gets in the way of having a balanced life? 2) What change can you make this week to have more of what you need: PLAY, OTHERS, or DOWNTIME? INPATIENT GROUP FACILITATION GUIDE 69 Understanding Self-disclosure, Ambiguity and Blind Spots Through the Johari Window Materials needed: Copies of Johari Window handouts for participants to complete before meeting. Refer to Appendix V. Index cards for participants. Goal: To develop self-awareness and understanding of participant’s comfort level with ambiguity, disclosure and feedback. Purpose: To have a group experience with colleagues. To discover where an individual’s openness to others can grow and gain access to previously “unknown” potential through the giving and receiving of feedback. Leader presents: Using the index cards presented, take a moment to write out a couple of things you are concerned about regarding self-disclosure, ambiguity or blind spots. How do you feel about self-disclosure, ambiguity and blind spots? Yalom (2002) suggests that feedback can be a powerful gift of group experience. But how is one to lead others safely if one’s own blind spots are unexplored? This is an opportunity to explore, understand and practice using here-and-now comments (talking about what we see and hear of one another in the present moment, not venturing into the past or future, but remaining here-and-now). By listening and sharing your feelings and observations within a small group you can bear witness to and appreciate the impact of your own behavior on others. This is an experiential learning opportunity for you as a leader and as group member. Please refer to your questionnaire (completed ahead of meeting time) and discuss together the ways in which the results may influence your working relationships. 1) You have completed the questionnaire (handed out and completed ahead of time). 2) You will share your insights from this exercise with at least one other staff member. INPATIENT GROUP FACILITATION GUIDE 70 Johari window (Yalom, 2009) is a personality paradigm exercise. Individuals reflect on their relationship with them self and others, their comfort with self-disclosure, ambiguity and to take notice of blind spots. It was developed by psychologist Joseph Luft and Harrington Ingham in 1955 (Jo-Hari). There are 4 quadrants: public, blind, secret and unconscious which are either known or unknown to the individual and others and vary in size depending on person’s level of awareness. To develop healthy relationships with others Kottler (2010) encourages our secret self to shrink and public self to increase so we can see ourselves as others see us. Feedback is very important during this task, as people share, quadrants expand, what’s hidden becomes less and personal understanding grows. INPATIENT GROUP FACILITATION GUIDE 71 Johari Window The Johari Window is a disclosure/feedback model of awareness, first used in an information session at the Western Training Laboratory in Group Development in 1955. The four panes of the “window” represent the following: Open: The open area is that part of our conscious self - our attitudes, behavior, motivation, values, way of life - of which we are aware and which is known to others. We move within this area with freedom. We are "open books". It is through disclosure and feedback that our open pane is expanded and that we gain access to the potential within us represented by the unknown pane. Blind: There are things about ourselves which we do not know, but that others can see more clearly; or things we imagine to be true of ourselves for a variety of reasons but that others do not see at all. When others say what they see (feedback), in a supportive, responsible way, and we are able to hear it; in that way we are able to test the reality of who we are and are able to grow. Hidden: Our hidden area cannot be known to others unless we disclose it. There is that which we freely keep within ourselves, and that which we retain out of fear. The degree to which we share ourselves with others (disclosure) is the degree to which we can be known. Unknown: We are more rich and complex than that which we and others know, but from time to time something happens – is felt, read, heard, dreamed - something from our unconscious is revealed. Then we "know" what we have never "known" before. Take a few moments to review the 4 quadrants again. Johari Window Questionnaire Instructions: Instructions: • Carefully read each numbered item and its statements marked "A" and "B." • Assign a point value to the A and B statements as follows: • The total point value for A and B added together is five (5). • If statement A is most similar to what you would do, mark 5 for A and 0 for B (0, very unlikely, 5 very likely). • If A is not wholly satisfactory, but in your judgment better than B, mark 4 or 3 for 1) If a friend hadB. a "personality conflict" with a mutual acquaintance of ours with A andof1mine or 2 for whom it •was important for him/her get along, The converse is true: if B to is best, mark I5would: for B and 0 for A and so on (choose best fit/true for you between 0-5). INPATIENT GROUP FACILITATION GUIDE 72 Calculating Your Scores: Copy your point values from the questionnaire to the appropriate spaces below. Add up the total points for each column. Solicits Feedback: 2B_____ 3A_____ 5A ____ 7A ____ 8B ____ 10B____ 12B____ 14B____ 16A____ 20A____ Total _____ Willing to Give Feedback: 1A_____ 4B_____ 6B ____ 9B ____ 11B____ 13A____ 15A____ 17B____ 18B____ 19B____ Total _____ Charting Your Scores: • On the top line of the graph below, mark your score for Solicits Feedback, then draw a vertical line downward. • On the left line of the graph below, mark your score for Willingness to Self-Disclose/Gives Feedback, then draw a line across horizontally (left to right). INPATIENT GROUP FACILITATION GUIDE 73 In pairs or as a small group please discuss the following questions: 1) What did you learn about yourself from this questionnaire/graph? Were you surprised by anything? 2) Describe a previous experience with disclosure or feedback. 3) Take turns give and receiving feedback from your partner or group members on what you experienced of them while you each answered questions 1 and 2. 4) How do you think others are affected by your blind spots? 5) How will you use what you learned today in your professional practice? As people get more comfortable sharing information about them self their public quadrant grows and the hidden secret quadrant shrinks when communication and trust is built. Welcomed feedback grows one another’s blind quadrants and helps to decrease what is unknown to self and others. ,13$7,(17*5283)$&,/,7$7,21*8,'(  6L[&RUH6WUHQJWKVIRU+HDOWK\'HYHORSPHQW 7KHFRUHRIDOOYLROHQFHLVDODFNRIUHVSHFWIRURQHVHOIDQGIRURWKHUV a'U%UXFH3HUU\  0DWHULDOVQHHGHG&RPSXWHULSDGDQGVFUHHQWRYLHZ