2. How do we deliver & measure the impact of Recovery based services? Working with the individual – today Suzanne Sambrook – Improving confidence in mental health & recovery Isabel Clarke – The impact of CBT group work on stigma reduction Andrew Gumley – The impact of attachment based CBT on recovery Working with staff & teams – tomorrow Katherine Newman Taylor – Formulating teams to improve recovery Tess Maguire – How recovery based are our in-patient services? Sarah Wood – The impact of recovery training on attitudes & behaviours

3. Recovery Based Group Work: Building confidence in recovery Dr Suzanne Sambrook Consultant Clinical Psychologist Southfield Low Secure Unit Wessex Adult Forensic Service

4. The challenge Traditional bio-medical approach Demands of Forensic Services –Containment vs mental health needs Move towards ‘ rehabilitation ’ Passivity within the service user group

5. Wellness Group Programme Aims: oTo actively involve service users oTo move away from the ‘ all-or-nothing ’ view of illness oEmphasise the uniqueness of each individual ’ s journey of recovery oTo enhance motivation oTo provide a springboard for further interventions and work

6. Themes of the group Themes based on the principles of Recovery: oMoving from symptoms & pathology towards health, strengths & wellness oDeveloping a sense of agency oChanging relationship between professional & service user (coaches/partners) oDeveloping meaningful lives & roles oSelf management oDeveloping a sense of hope oGiving choices

7. Process o Incorporating service users words and ideas o Use of story and analogy o Sharing and commonality o Normalising o Goal setting o Focus on strengths o Enjoyment

8. Group design o Attendance of 3 week goal setting group before attending o Visual aids / Colourful handouts o Interactive exercises o Facilitator involvement o Wellness folders

9. Wellness Scale

10. Outcomes (Mental health confidence scale) Sambrook & Dixon. Motivation and Recovery in a Low Secure Unit: the Wellness Group. (in preparation)

11. Group Feedback - What did you enjoy about the group / what was good? “Gave me ambition” “I found the folder good so that we can look back on what we have done” “Understanding what illness means” “Helped put my symptoms and experiences into words” “Identifying what is going to help and what will make things worse” “Hard work but worth it” “Looking at well & unwell Jack & Jill was good fun & very helpful” “I was able to recap on skills / knowledge from psychology sessions”

12. Group feedback - Recommendations What suggestions do you have for a future group? “More weeks going into the subjects in more depth” “Learn how to deal with problems” “Do a group where we discuss & learn what to do with our early warning signs” “I would like the group to go on longer to make sure we carried on with our goals. To get together & discus how we got on” “Keep the group small it was a nice number”

13. Conclusions & way forward oThe Wellness Group has now become the cornerstone of introducing Recovery to the service users oOf those that attend the group, 75% go on to attend other groups within the unit oThe majority of service users are offered WRAP prior to discharge, with a 100% take up rate to date

14. Thank you oTo the service users at Southfield for all the comments about how to improve the group oLaura Dixon, Wendy Moody & Claire Field at Southfield for running and helping to develop the group

15. The impact of CBT group work on stigma reduction Isabel Clarke Consultant Clinical Psychologist Hampshire Partnership NHS Foundation Trust

16. The Context A 3 rd wave CBT for psychosis inpatient programme with a fresh perspective on psychosis Formal evaluation of the programme in its group form “Third Wave” – term coined by Hayes (Acceptance & Commitment Therapy) Kabat-Zinn – applied mindfulness to stress and pain Segal, Teasdale & Williams – Mindfulness Based Cognitive Therapy (relapse in depression) Linehan – Dialectical Behaviour Therapy (BPD) Chadwick – Mindfulness groups for voices Change lies not so much in altering thought to alter feeling, but in altering the person’s relationship to both thought and feeling Mindfulness is a key component Recognition of a split or incompleteness in human cognition – which mindfulness can bridge

17. The Holistic Revolution in Psychosis Recognising the role of arousal (Hemsley, Morrison) Importance of emotion (Gumley & Schwannauer; Chadwick) Attachment and interpersonal issues (“) Self acceptance and compassion (“ ; Gilbert) Self esteem (Harder) Recognition of the role of loss and trauma The Recovery approach All these lead to a blurring of diagnosis

18. Levels of Processing Theories First wave CBT comes unstuck over the gap between logical reasoning and strong emotion. This leads to the recognition of different types or levels of processing. e.g. Hot and Cold cognition (Ellis) – and many more! All these theories suggest 2 or more separate types of processing – the split in human cognition! There is one direct, sensory driven, type of processing and a more elaborate and conceptual one The same distinction can be found in the memory Direct processing is emotional and characterised by high arousal This is the one that causes problems – e.g. flashbacks in PTSD The two central meaning making systems of ICS provides a neat way of making sense of this

19. Linehan’s States of Mind (DBT – maps onto Interacting Cognitive Subsystems) EMOTION MIND (implicational subsystem) REASONABLE MIND (propositional subsystem) WISE MIND IN THE PRESENT; IN CONTROL

20. Two Ways of Knowing Good everyday functioning = good communication between the two levels of processing (ie. implicational and propositional in ICS) At high and at low arousal, the implicational (more holistic) subsystem becomes dominant This gives us a different quality of experience – one that can be either valued and sought after, or shunned and feared

21. The Everyday The Transliminal Ordinary Clear limits Access to full memory and learning Precise meanings available Separation between people Clear sense of self Emotions moderated and grounded A logic of ‘either/or’ Numinous Unbounded Access to propositional knowledge / memory patchy Suffused with meaning / meaningless Self: lost in the whole / supremely important Emotions: swing between extremes or absent A logic of ‘both/and’

22. Taking Experience Seriously in Psychosis Acknowledging that psychosis feels different Normalising the difference in quality of experience as well as the continuity Positive side as well as vulnerability Helping people to manage the threshold –mindfulness is key Sensitivity and openness to anomalous experience – continuum with normality: Gordon Claridge’s Schizotypy research Understanding the role of emotion – where expression of emotion is not straightforward

23. Evidence for a New Normalisation Schizotypy – a dimension of experience: Gordon Claridge Mike Jackson’s research on the overlap between psychotic and spiritual experience Emmanuelle Peter’s research on New Religious Movements Caroline Brett’s research: having a context for anomalous experiences makes the difference between whether they become diagnosable mental health difficulties and whether the anomalies/symptoms are short lived or persist New chapters by Brett and Jackson in Psychosis and Spirituality: consolidating the new paradigm – along with new qualitative research Wider sources of evidence – e.g.Cross cultural perspectives; anthropology. Richard Warner: Recovery from Schizophrenia

24. Therapeutic Alliance As this approach represents a new normalisation, it can greatly aid the therapeutic alliance The individual’s experience is taken seriously and valued – at the same time as working on a better relationship to shared experience It is possible to get away from illness language – and arguments about diagnosis The schizotypy continuum is a good normaliser – association of high schizotypy with creativity etc

25. What is Real & What is Not? A 4 session group programme for acute inpatient settings Run by staff supervised by or co-facilitated with clinical psychologist (Mental Health Practitioners, nurses, AOT staff) Builds on the Romme and Escher ‘Voices Group’ tradition Is different from other CBT approaches in normalizing the difference in quality of experience in psychosis, as well as thinking style This normalization attacks stigma by associating psychosis with valued areas such as creativity and spirituality Attempts to mitigate the damage to self concept of the traditional, diagnosis, based approach

26. What is Real & What is Not? Signing up for the group Validate their reality Introduce the idea that their reality is only one way of looking at it: shared and unshared reality (negotiate the language) The individual’s experience is taken seriously and valued – at the same time as working on a better relationship to shared experience It is possible to get away from illness language – and arguments about diagnosis

27. The Group Programme: Session 1 Introduce Romme and Escher Extending from voices to other experiences that people in general do not share. Idea of openness to voices and strange experiences. Schizotypy spectrum. Artists etc. David Bowie example. Examples from the group – what do they want to get out of the sessions. Fill in goal form.

28. Characteristics of unshared reality. Idea of the line/ the threshold. Importance of being able to manage the line Motivational aspect – pros and cons. Coping skills to manage the line When is unshared reality most powerful; in charge? Arousal as a means of being in control; Stress management Being alert and concentrated – watch out for drifting states Grounding in the present Wise mind and mindfulness Focusing/mindfulness v. distraction

29. Session 2. The role of Arousal shaded area = anomalous experience/symptoms are more accessible. Level of Arousal Ordinary, alert, concentrated, state of arousal. Low arousal: hypnagogic; attention drifting etc. High Arousal - stress

31. Session 3: mindfulness & 4: making sense. Introducing Focussing. Haddock research on Focussing and Distraction. Mindfulness and focussing. Mindfulness exercise. ******************************************************How do people make sense of their experiences? Disussion of different ways of making sense of them. Clue: what was happening when they first started? Feedback, summing up and completing the goal sheet again.

32. The Challenge of Evaluation in the Inpatient Setting People in crisis are not keen to fill in a lot of questionnaires – and are not very good at it. We are prepared to open the programme to people who are quite floridly psychotic – not so easy to obtain measures from this group. Even with only 4 sessions, consistency of attendance and retention are a problem CSIP grant enabled us to employ an Assistant one day a week for 6 months in order to evaluate the group

33. Measures CORE – routine measure and to gage level of pathology Mental Health Confidence Scale Visual Analogue Goal Setting Scale – administered as part of the first session. Satisfaction Questionnaire at the end gave us some idea of impact on individuals

34. Questionnaire Results Because of high rates of attrition and difficulties obtaining questionnaires in some cases, only 15 complete data sets were achieved Significant self rating of achievement of goal for group attendance Mental Health Confidence Scale: overall results not significant. Only the ‘Coping’ subscale showed significant improvement;’Optimism’ and ‘Advocacy’ subscales did not reach significance - the trend was in the right direction

35. Satisfaction Data Question 1: What was most helpful about the group? – Universality cited: Nice to hear other people open up… Being able to talk and understand each other Q2: What was least helpful about the group? Other people talking too much Should be earlier and more intense

36. Q3: Has it made you think differently about anything? If so, please tell us about this. It made me think about things in my thoughts I feel clearer about what’s real and what’s not, what to share and what is personal Yes without a doubt. I feel better about myself Q4: Please tell us what, if anything, has changed in the way you think about your mental health issues since attending the group. Yes, I am thinking of more positive things about my life I have now realised that I in-fact do have a problem

37. Q5: Please tell us what, if anything, has changed in the way you view yourself since you attended the group. Feel less isolated about the way I see things I have become more confident Q6: What kind of things did you learn in the group? Using mindfulness To be open, to think about what you are thinking, to be self-aware Open Comments: wanting the group to have been longer.

38. Wider Influence AOT became interested as the group drew in previously unengageable clients – co-facilitated A 12 session community version was developed – with the help of a focus group of service user graduates Attended by AOT and CMHT clients This is being more thoroughly evaluated and will be written up Service user report of impact in the chapter on the approach in the Second Edition of Psychosis and Spirituality.

39. Contact details, References and Web addresses Isabel.Clarke@hantspt-sw.nhs.uk AMH Woodhaven, Calmore, Totton SO40 2TA. Clarke, I. (Ed.) Forthcoming Psychosis and Spirituality: consolidating the new paradigm. Chichester: Wiley Clarke, I. ( 2008) Madness, Mystery and the Survival of God. Winchester:'O'Books. Clarke, I. & Wilson, H.Eds. (2008) Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units; working with clients, staff and the milieu. London: Routledge. Durrant, C., Clarke, I., Tolland, A. & Wilson, H. (2007) Designing a CBT Service for an Acute In-patient Setting: A pilot evaluation study. Clinical Psychology and Psychotherapy. 14, 117-125. Phillips,R., Clarke, I. & Wilson, H.(in preparation) Evaluation of an Inpatient Group CBT for Psychosis Program Designed to Increase Effective Coping and Address the Stigma of Diagnosis Psychosis. www.isabelclarke.org www.SpiritualCrisisNetwork.org.uk