Abstract
Our objective was to evaluate clinicians’ views of the impact of conducting inpatient psychotherapy groups for older adults with enduring mental health issues and/or cognitive impairment.
We conducted a literature review. A focus group was held with four group facilitators using a semi-structured format and open questioning. The transcript was analysed by the interviewer using Interpretative Phenomenological Analysis. Using guidelines provided by Smith and Osborn, themes were identified, clustered and a final set of themes developed. On completion, the researcher reported the findings back to one participant to increase the validity and trustworthiness of the analysis.
Facilitators described impacts that were intra-personal, inter-personal and extra-personal. The capacity and desire to communicate and belong demonstrated by group members challenged their own views (and ageism) and that of staff members.
The facilitators’ experience was of the beneficial and normalising effects of these groups in enabling and enhancing communication, emphasising common humanity, facilitating the expression of emotion and combating isolation by promoting a sense of belonging. Research is needed into the views of the group members. Thought is given to the challenges inherent in this.
Introduction
There are considerable difficulties in obtaining informed consent to conduct research with people with dementia or issues around capacity (British Psychological Society (Professional Practice Board), 2008). This article came out of a consultation in the Research Group at the Retreat Hospital, York, discussing the difficulty of getting meaningful consent to do research involving residents of the Specialist Older Adult Services (SOAS). At that time, there were weekly psychotherapy groups running in each of the older adults’ units—two women’s groups and a men’s group. Because this was an unusual therapeutic intervention for people with the level of cognitive damage typical of our residents, there was interest in researching the effectiveness of the groups. The clinical psychologist in the older people’s service suggested that, given these difficulties, we begin by working with the groups’ conductors. It was agreed to undertake a piece of qualitative research, using the medium of a focus group, looking at the conductors’ experience of the groups and seeking their views about their impact and effectiveness. We hoped this would be the start of a longer process, which would also involve the group members seeking an answer to the question of whether such groups have a role in working with older adults with complex needs. This article reports on the findings of that focus group.
History of The Retreat older adult groups
The first older adult psychotherapy group was set up in 2005. An analytic group was already running for inpatients with psychosis on another unit, conducted by consultant psychologist, GB. This was already unusual. Hearing about this, a staff nurse requested a psychotherapy group for older adults. GB notes that he was disconcerted by the idea, highlighting the ageism (that we all carry). He commented that the reason he said yes was that he could not think of a reason to say no. His disconcerted response is typical. Even today, when we describe our groups, a common response is incredulity.
We are aware that conducting psychotherapy groups with this group of people is unusual and possibly controversial. The SOAS at the Retreat care for those with longstanding, ongoing complex mental health problems and/or dementia. All are sufficiently challenging that they would be difficult to place elsewhere. Many have physical problems, some linked to long-term use of anti-psychotic medication, others simply the result of illnesses of older age. It would be easy to conclude that our residents are too cognitively and emotionally damaged to benefit. However, outcomes of that first group in 2005, while not formally analysed, indicated improvement in various domains: If you could see . . . the enthusiasm and commitment of our group members this would speak . . . for itself . . . We see improved communication and psychological functioning within the groups, but also sustained outside the groups. There are improved relationships in the wider ward environment and an increasing psychotherapeutic stance and interest on the units. (Brownbridge, 2009)
The first older adults’ group closed after about a year. In 2008, two new groups were set up, a men’s group and a women’s group. Shortly after this, the women’s group became two groups, for more and less cognitively able women. Numbers attending the groups varied between three and nine. Membership was open ended. Given that there were usually three staff in the group, on occasion the number of attendees equalled the number of staff. This did not seem to impact the dynamic greatly—as it might in a more conventional group analytic situation. This was possibly because other variables were so great—in particular the physical and mental health of group members which varied greatly and unpredictably week by week.
No groups are running currently due to staffing and accommodation issues.
Structure of the groups
In many ways, our groups ran on the same lines as more traditional analytic psychotherapy groups. They took place weekly at the same time, in the same place. Breaks were scheduled in advance. One therapist was identified as the lead conductor. There was no agenda; people could speak about whatever was on their minds. However, there were several adaptations and differences necessary because of the needs of the patients and the constraints of the unit.
For example, the second group facilitator was one of several unit staff members and changed depending on shifts. Where people had hearing impairments, the second facilitator enabled them to participate by transcribing the conversation. A support worker or nurse was also present to attend to people’s physical needs. Many residents were in wheelchairs and needed assistance to remain comfortable. Consent to attend the group operated differently. People might give and withdraw consent several times over the hour—absenting themselves by physically coming and going or, more symbolically, by sleeping and waking. Communication might be through speech but not exclusively. Conductors needed to be alert to other ways of communicating, especially with group members who struggled with speech. There was more touch. Communication was not linear, but leapt from one subject to the next, sometimes in dizzying ways. More than one conversation went on at once. Sometimes, people were in their night clothes. Food and drink needed to be available during a group.
Literature review
There are no shortage of books and articles about working psychotherapeutically with older people and people with dementia. Given the ageing population, this is an area of research interest. Penelope Kegerreis’ (2012) bibliography gives an overview of the literature for individuals, couples and groups, for example, Evans and Garner (2004), Terry (2008) and Davenhill (2007).
More has been written about individual therapy than about groups. Reviews and effectiveness studies have been positive about the effectiveness of group psychotherapy with older adults (Hepple, 2004; Krishna et al., 2011; Payne and Marcus, 2008; Steuer et al., 1984).
Other articles describe conducting groups for older people with depression, for example, Husaini et al. (2004) describe a group for depressed elderly women, Scocco et al. (2002) discuss groups for men and women, and Schwartz (2004) explores concurrent group and individual therapy in a day hospital for depressed older people. There are several research articles that highlight the positive outcomes of these interventions. Agronin (2009) movingly describes the increase in self-understanding and self-esteem of Frieda in her psychotherapy group. Canete et al. (2000) describe conducting an analytic group with older people in outpatients, finding benefits in belonging and interdependency and in mutual exploration of issues such as loneliness, loss and death. Evans et al. (2001) explored similar themes in a group for elderly chronically mentally ill patients within a day hospital. The conductors also highlighted ageism, in themselves and the group members. The exploration of this allowed for more playfulness to develop in this eight month group.
Other writers explore groups in which dementia is a factor (Anderson, 2011; Cheston, 2009; Cheston and Jones, 2009; Manthorpe and Moniz-Cook, 2009a; Manthorpe and Moniz-Cook, 2009b; Watkins et al., 2006). Anderson comes closest to describing the experiences we outline, particularly in describing the difficulties of managing projections of loss, anger, shame, disgust, diminished potency, fear of dependency and death. He also discusses the importance of training and looking after teams who care for older people. He too notes the importance of play in these groups: ‘Perhaps groups can offer a space and freedom to play and simply be demented in a world that very often does not want to know’ (Anderson, 2011: 392).
Apart from Brownbridge (2009) who describes an earlier phase of the men’s group, discussed in this article, we found no literature about group therapy with older people with the complex mental health problems typical of our groups.
Method
Ethical procedure
Ethical approval was gained through the hospital’s internal research process. At all stages, the participants’ anonymity and informed consent were adhered to, alongside confidential management of the data. It was ensured that no specific groups or individuals were identifiable in the extracts.
Participants
Nine facilitators and co-facilitators of therapeutic groups in SOAS were invited via internal email to be part of a focus group. Four of them agreed. Those who declined either did not want to be involved or said they could not take time off the ward to attend. Of the four who attended, three were psychotherapists and one a staff nurse with psychotherapeutic training. Three of those who declined were support workers, one was a staff nurse and one a psychology assistant. It is of note that those who accepted were more senior staff. This may have meant they were more free to organize their time to enable participation. Information about the research process was provided and informed consent was gained.
Procedure
All four participants took part in one focus group lasting 90 minutes. A semi-structured format was used. Open questioning allowed participants to lead the discussion and explore relevant issues. The focus group was transcribed and analysed by the interviewer. To protect participants’ anonymity names were changed to numbers.
Analysis
The transcript was analysed using Interpretative Phenomenological Analysis (IPA). IPA was chosen as an appropriate methodology for research focussing on participants’ lived experience. The analysis was performed using guidelines by Smith and Osborn (2008). The researcher engages in a process of interpretation, developing the analysis around extracts from the data to ensure themes are grounded in the text. After an iterative process—identifying emerging themes, clustering and reclustering—a final set of themes were compiled.
Validity
To increase the validity and trustworthiness of the final analysis, the researcher met with one participant to report the findings. This gave the opportunity to validate or contest the researcher’s interpretation (Shaw, 2001). In addition, a presentation of the results to a wider audience, including facilitators and co-facilitators unable to attend the focus group, took place to gain further feedback and response.
Results
Three main themes emerged:
The intra-personal: The facilitators’ experience of the group;
The inter-personal: The interactional experience of the group;
The extra-personal: The external experience of the group.
These further divide into subthemes which are explored under each main theme heading.
The intra-personal: the facilitators’ experience of the group
One way in which the facilitators made sense of conducting these groups was through their individual perspective. The facilitators spoke of the personal impact of the group and how they viewed it in comparison to other groups they conducted. The subthemes are described below:
The group is different
The facilitators had experience of running therapeutic groups within older adult and within adult services. They also ran social groups within SOAS. They all spoke of how different the older adult therapeutic group felt. Examples included the content of the group: There are a whole lot of different issues that come up including issues around loss and death, and how do you make relationships when you are somewhere where you wouldn’t have chosen to be. (P2)
Other reflections were around the amount of life experience in the groups and how this is expressed by individuals with such cognitive impairment: You are also dealing with so much past, because you’re often talking about 60 years or more, 60, 70 years of someone’s history, and they can all of a sudden tell you about a childhood story and the next second they jump onto something that happened last week, so you have got this huge amount of material on all different levels. (P1)
The group members’ physical health also affected the process of the group and impacted on facilitators. Even getting the group members together was very different. Participant one reflecting upon physically getting everyone into the room: . . . before you even start the group you’re going to have to do a certain amount of work on bringing the group together, whereas normally you would wait in the room and the group would come in and join you. (P1)
For the older adult therapy groups, there was also an increased awareness of people physically and of nonverbal communication: There’s a lot of non-verbal stuff that goes on in the groups. It isn’t just the conversation that you’re having with each other, it’s you know, the position that they’re sitting in, whether they’re asleep or awake; whether they respond or they don’t. A whole lot of things. People reaching out to hold somebody else’s hand, all those sorts of things that don’t happen in nearly the same extent in my outpatient groups. (P2)
The group can be difficult to facilitate
The facilitators found aspects of the group difficult to facilitate, particularly in relation to the group members’ physical health, mental health or changes to their treatment or mental capacity: Sometimes they go to sleep because their medication’s been changed or they’re feeling rubbish or they’re tired. (P2) We had to manage a [group member] who became fairly deaf for long periods of time, and [they were] very much part of the group but because [they were not] hearing what was being said would come up with something that was completely off topic, and so I had to stop the group and try and get [them] back into what was being talked about. (P1)
The facilitators also found that they had to provide more direct assistance to group members, as demonstrated in the extract below: We also frequently, the co-facilitators particularly, have to get up to help someone to be more comfortable, change their position or help them move to facilitate their comfort. (P1)
The facilitation of appropriate boundaries within the groups was a common theme: I found the groups to be more challenging in comparing to adults . . . more challenging in a sense that boundaries can be so blurred that I think with people that are cognitively aware, they are aware of certain questions that they cannot ask the facilitator. However with this client group they can ask you as the facilitator any question and somehow you feel obliged to answer. (P3)
One of the facilitators described how emotionally difficult facilitating the group can be: I usually don’t want to go and do the group before it. ‘Aah not again! And then half way through I think, ‘oh, this is extraordinary’. And when I leave I think ‘well why did I have a problem with going to do it?’ And I do think I certainly sway from, the kind of you know, completely—we’ve all talked about it—moving from feeling passionate about it to the complete other side of the coin which is ‘aah, I can’t be—I can’t do this, or there’s no point in doing this, or I can’t be bothered or—And I don’t really understand why I oscillate so much because I don’t do that with my other groups, I don’t you know—I’m much more level about it. (P2)
The group challenges our expectations
The facilitators described the personal impact of facilitating the groups, particularly in challenging their views about older adults: When I first started conducting this group I hadn’t worked with people with dementia before at all and I certainly hadn’t worked with people with that level of physical disability. And I can remember just being overwhelmed by just kind of getting to know them and getting to the, how entirely different in personality each one of them was, despite you know having a kind of, common cognitive impairment. And, you know, that’s my prejudice, of course but just having my eyes opened really. (P2)
Facilitating the group made the facilitators curious about group members’ capabilities: I worry an awful lot that we have very low expectations of our patients sometimes and I think we see in these groups that we should have higher expectations and that actually they are capable of far more than we give them credit for. (P1)
The inter-personal: the interactional experience of the group
A second theme was the interactional aspect of the group. This refers to the communication within the group and the dynamic between the group members and facilitators. The subthemes are described below:
The group can be incongruent
The facilitators described how the conversational flow was not always typical. This included group members jumping from topic to topic or responding with incongruent answers to a question or comment: . . . the group can go off at all sorts of tangents and it can be very difficult to keep to a topic . . . we have certainly had situations where someone will be talking about some sort of trauma in their life history, and the next second someone else will come in and talk about, erm, potatoes, or gardening or football. And those can happen in a space of seconds, will swap from a very deep and meaningful topic to something that is maybe humorous. (P1)
This incongruence could at times be difficult to manage. One facilitator commented on the difficulty of keeping a focus: You’ll have a good day where everyone appears to be on the same topic and everyone is contributing but you’ll also have a day where some people are, either quite disassociated or not quite on topic for other reasons. (P1)
The group can be unbearable
The groups can be experienced as emotionally painful and unbearable by facilitators. The interactions, as well as the emotional environment created by the coming together of the group members, was a profound experience for them: . . . it can feel quite relentless and there is a lot of despair around, as well as other things, and that can be quite difficult to bear sometimes. (P2) . . . it can be quite frightening sometimes of things that you hear. (P1) . . . some of the material is much more painful compared to managing younger adult services, and I found it difficult to bear at times, I still find it difficult to bear some of the painful material. (P3)
The group allows something different to happen
The facilitators all spoke about the change in group members when they came together: We’ve seen people coming to the group and behave . . . their presentation is completely different to what it was five minutes ago on the unit, and when they return five minutes later they would have gone back that. But in that hour they were just so different—complete changes in mood, abilities in speech and language and things, it is really surprising. (P4)
The difference in the interactions between group members was also significant, allowing an element of normality to their communication: When allowed to, people will sit and hold hands or reach out and stroke someone else’s face or their arm. And, as an expression of something and I get the impression this doesn’t particularly happen outside the groups. (P2) It also allows you to have a row, because if they have a row on the unit, there will be staff coming in to try and resolve or separate and worry that it might go into something else. Whereas in a group, you can have an argument to a certain extent you, can allow it to go. People need to shout and let anger out at times. (P4)
One facilitator commented on outsider reactions to the group, again indicating how the group allows something very different to happen on an interactional level: When people have been in the group, say staff members are in the group who haven’t usually been in the group for some reason or another, and they would describe a patient’s death, for example, they say, ‘I have never seen the patients talk to each other before’. (P2)
The extra-personal: the external experience of the group
In this third theme, facilitators identified factors external to the group but which nevertheless affected them. They attempted to make sense of particular experiences of the group by questioning how the groups sat within the overall remit of the ward and organisation as a whole.
The groups gets forgotten
The facilitators expressed concern about how the groups got forgotten. Given facilitators’ perception of how differently members interacted in the groups and how important the space was, these organisational and unit level factors were a source of frustration: I think an example of a kind of difficulty about group culture in older people’s services is [unit name] have just moved from one unit to another and there is not a suitable room for having the group in the new ward. Which is really quite difficult. We had it once in the dining room which is echoey and noisy, and there isn’t anywhere else. And I think it is very interesting that it somehow didn’t get included in the design of the unit. It’s not been thought about. How easy it is to forget. (P2) We do our group evaluation with the staff members who are on shift at that point. So we will evaluate it in the office, so whatever is interesting that has come up in the group they know, so they can carry through what we are talking about. And we make those links. And the next day you expect that you would be in their head, you would expect that they would understand the next day, but it has all gone out of their heads. (P3)
The group feels isolated
This experience of being forgotten led to the facilitators feeling isolated from other therapeutic activities on the unit. They tried to make sense of this feeling: I think there is something about, perhaps feeling more isolated with running a, something that comes close to a psychotherapy group on an older adult ward as oppose to running it on an adult ward where it is an accepted part of the culture. And it feels like it isn’t completely an accepted part of the culture and therefore you feel more isolated I think as a facilitator. (P1) I think because they (the staff team) haven’t experienced it, because they weren’t there. All they are hearing is your take on it, and I guess that is harder to take on and take into the job every day. Maybe if they been in that group had seen it themselves it could have had a far more prominent effect on their thinking but because they are hearing it second hand it maybe resonates for a little while and then it is gone. (P4)
It was evident within the discussion how difficult this isolation was for the facilitators: People are always, like you know, I gather your group’s really interesting, can I come and sit in on it. Part of my reaction is ‘this is not a performance, this is psychotherapy. And no you can’t’. And then I have another reaction which is—the more people can see what happens the more likely it is that it will become integrated. (P2)
The group is pointless?
This subtheme expressed how the facilitators experienced the older adult groups within a wider therapeutic framework. The facilitators had a strong sense that something unique happens within the groups that is important to continue to facilitate yet found it difficult to pinpoint exactly what it was, even at times questioning why they were doing the group.
The theme is titled as a question to reflect their deep concern about how they could justify framing the groups within a therapeutic model: . . . what is behind psychotherapy is usually promoting some kind of recovery, and people in these groups are not going to recover in terms of them being able to go back out into the community and live independently and all those sorts of things. They are likely to deteriorate cognitively and physically and often they are going to be there until they die, so why are we offering this type of psychotherapy? I think it’s a really important question that keeps coming up for me. What is the benefit we are providing them? (P2) What we could call this an evaluation of. Because is it an evaluation of psychotherapy groups? It’s not really because they certainly would not meet some of the criteria but it is an evaluation of something between a psychotherapy group and err—it’s certainly not a task orientated group. (P1) I’m never quite sure what the task is apart from to be there in the room together and see what happens. And that might be nothing, but it never is nothing. (P2)
Discussion
This is a small study and, as such, our findings are limited in scope. The focus group however seemed an effective means of researching the experience of the facilitators. It enabled them to compare their experience in a group—mirroring the process of the groups they were facilitating—and allowing a richer and more creative interaction than might have occurred in individual research interviews. The findings did demonstrate how working with an older adult group can challenge our expectations. It would have been easy not to have attempted it, given the initial reaction to setting up the groups and the reactions towards the groups while they were running. The facilitators found that even though the groups challenged them in many ways, there remained a strong sense that it was important and that it gave the group members an opportunity to do something different and be different together.
The facilitators learnt early that they needed to be extraordinarily flexible to keep these groups going. The rules and boundaries that characterize psychotherapy groups had to be adapted. Facilitators had to combat their own ageism and that of others. Both the groups themselves and the learning from the groups seemed easily forgotten/overlooked by the wider institution and by unit staff members. A significant challenge was to our view that psychotherapy groups should only exist to promote enduring change. This could not be the case for the members of these groups whose physical and psychological trajectory was not of recovery but of increasing impairment. The groups did nonetheless provide something that is a characteristic of—and vital element in—more traditional psychotherapy groups. They provided a space for the members to feel a sense of togetherness and belonging. As one group member succinctly put it, ‘everybody needs a group’.
The groups seemed also to promote a sense of normality and safety. The facilitators commented on the surprise of staff when members, normally silent on the unit, not only spoke in the group but also spoke to each other. The groups seemed to encourage greater freedom to express emotion. Just as in more traditional therapy groups, this could be expressed in rowing or disagreement but equally in tenderness, a shared acknowledgment of their plight and of their common humanity. In the space of the group, there was more natural warmth in the interactions than in the institution more generally. One participant commented that the task was to be in the room together and see what happened—and even in these groups of impaired and distressed older adults, something always happened.
Conclusion
The SOAS admit people from all over the country; these are often people with challenging behaviour—those who other institutions have struggled to accommodate.
The findings, themes and outcome that emerged from this focus group are consistent with those reported by facilitators over nearly 10 years of conducting these groups. The effects of the groups are undeniably difficult to measure reliably. We need now to develop ways that the research could be extended to group members. The issue of consent to research with this client group is difficult. Over the course of a group, members may give and withdraw their consent to even attend several times in both overt and covert ways. Similarly, consent to participate in research one day may be withdrawn the next. However, we remain interested in this area of research and optimistic that an evaluation method can be developed. Should the outcome of such research be positive, there would be opportunity to trial the model we have developed with other patient groups.
Footnotes
Acknowledgements
Our thanks are due to the men and women who were members of the psychotherapy groups discussed here and to staff involved in the facilitation of the groups, especially the participants of the focus groups. Thanks in particular to Garry Brownbridge, former Consultant Clinical Psychologist at the Retreat, who started the Older Adult Service psychotherapy groups and steadfastly encouraged us to establish ours. Thanks also to Rose Clarke for facilitating the submission stages of this article.