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Skills training groups on a psychiatric intensive care unit: A guide for group leaders
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Skills Training Groups on a Psychiatric Intensive Care Unit: A Guide for Group Leaders K e n n e t h R. W e i n g a r d t , Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine R o b e r t A. Zeiss, Veterans Affairs Palo Alto Health Care System
This paper outlines a structured group intervention for use in a locked acute psychiatric intensive care environment. This intervention, described in manualized form, draws upon the empirically vatidated psychosocial skills training approach for the rehabilitation of individuals with chronic mental illness (cf. Liberman et al., 1993). The first section discusses general principles for conducting skills training groups in the acute psychiatric population, including practical strategies for encouraging patients to attend group, group structure, rules, and process. The second part of the paper outlines seven specific skills training modules that provide concrete, step-by-step instructions for conducting groups on such topics as anger management, communication skills, coping with mental illness, and relapseprevention. The reader is invited to critically evaluate, modify, and expand upon the materials presented in order to better serve this challenging poputation.
RAMATIC CHANCES in health care over the past 10 years have effected equally dramatic changes in the delivery of psychiatric services. A person with schizophrenia can no longer routinely receive inpatient treatment for 3 to 6 months from the same team of providers and participate in long-term group and individual therapy. This is particularly true in the psychiatric intensive care environment. With an average length of stay on our unit being approximately 10 days, the focus is necessarily on getting patients stabilized on medications and moved to an o p e n ward or directly back into the community as quickly as possible. What role, then, can a psychologist or other mental health professional play in such an environment? Conducting psychosocial skills training groups such as those described in this paper can be one particularly rewarding role. This p r o g r a m bears resemblance to more intensive, empirically validated social skills training interventions (see Benton & Schroeder, 1990; Liberman, Vaccaro, & Corrigan, 1995; Liberman et al., 1998). It utilizes many of the same core behavioral techniques that define social skills training (cf. Benton & Schroeder) including problem or skills specification, didactic instruction, modeling, role playing, coaching, and verbal reinforcement. However, due to a short length o f stay and high levels of acuity in the psychiatric intensive care environment, the structure and content of the present program depart significandy from m o r e traditional skills training programs. Because social skills training does not typically result in the reduction of psychotic symptoms, even when deliv-
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CognRive and Behavioral Practice 7, 385-394, 2000 107%7229/00/385-39451.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
ered in a long-term, intensive modality (e.g., Liberman et al., 1998), it would be naive to expect the present program to accomplish that goal. Similarly, it would be unrealistic to expect a skills training intervention delivered in the acute psychiatric setting to result in generalized, long-term improvement in social functioning. What goals then might we realistically expect such a program to accomplish? In our experience, implementing this program can result in a significant improvement in the therapeutic milieu. Many patients enjoy participating in these groups and express enthusiasm about attending them. Thus, these groups can be an important source of validation and respect for patients, providing them with a rare opportunity for social interaction while on the ward. Nursing staffs support these groups because topics such as anger m a n a g e m e n t and communication skills directly address some of the m o r e c o m m o n behavioral problems on the ward. Social workers are typically supportive of these groups because they encourage patients to take active steps to plan for discharge and to prevent readmission. Finally, as members of a psychology staff, we have f o u n d these groups rewarding because they allow us to apply our knowledge of cognitive-behavioral interventions in a real-world setting with a population that is sorely in n e e d of help. We firmly believe that any intervention that provides incremental gains in understanding of an illness and its m a n a g e m e n t will ultimately benefit the patient. A W o r d A b o u t This P o p u l a t i o n This population is a difficult one to work with. The majority of patients are chronically mentally ill with very serious disorders such as chronic paranoid schizophrenia, schizoaffective disorder, and bipolar affective disor-
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der. F u r t h e r m o r e , m a n y o f the patients have c o m o r b i d Axis II diagnoses as well as significant histories o f alcohol a n d d r u g abuse a n d d e p e n d e n c e . Finally, psychiatric intensive care patients are typically o n involuntary civil c o m m i t m e n t for dangerousness or grave disability. Many patients are at high risk for suicide or assault, a n d many are quite disorganized a n d have difficulty providing for their own basic needs. T h e r e is an upside, however. Many chronically mentally ill individuals have b e e n in a n d o u t o f m e n t a l institutions for most o f their a d u l t lives, a n d a u n i q u e p a r t o f their culture is that they have a t t e n d e d m a n y g r o u p therapy sessions. O n c e stabilized on medications, patients typiGroups can be an cally know what groups are important source a n d how they are e x p e c t e d to behave in group. Some actuof validation and ally enjoy g r o u p interactions, respect for a n d c o m e to look forward to daily meetings as a place to patients, providing learn new skills a n d discuss t h e m with a rare their problems. Even patients opportunity for who are still d e c o m p e n s a t e d can often behave a p p r o p r i social interaction ately in g r o u p a n d participate while on the ward. to some extent. T h a t b e i n g said, it is important to r e m e m b e r that in o u r milieu, these skills training groups are c o m p l e t e l y voluntary. While patients are often e n c o u r a g e d to sample groups, they are never forced to att e n d a n d are free to leave once the g r o u p begins. Some patients may even be e n c o u r a g e d to leave g r o u p if they are n o t able to follow the rules, respect o t h e r patients a n d staff, a n d participate without c o m p r o m i s i n g the safety o f the g r o u p e n v i r o n m e n t .
General Principles Getting Patients to Come to Group This is o n e o f the most i m p o r t a n t , u n d e r a p p r e c i a t e d roles o f a g r o u p l e a d e r in this e n v i r o n m e n t . In o u r experience, it is most effective to "advertise" the g r o u p at every opportunity, to b o t h s t a f f a n d patients. H e r e are some o f the strategies that have p r o v e n useful: 1. Invite individual patients to attend groups. D u r i n g rounds, tell patients the g r o u p ' s topic for that day a n d how they would benefit from it. F o r patients who r e s p o n d that they already know all a b o u t the topic, e n c o u r a g e t h e m to c o m e a n d h e l p teach the o t h e r patients what they know. F o r patients who are n o t seen in r o u n d s that day, i n t r o d u c e yourself, tell t h e m that you r u n groups o n the unit, a n d that y o u ' d like t h e m to c o m e to the n e x t one, letting t h e m know when a n d where the g r o u p meets.
2. Post the group schedule for the month on the bulletin board in a public space. I n t r o d u c e yourself to new patients a n d p o i n t o u t which g r o u p topics m i g h t be o f interest to t h e m on the board. 3. Inform nursing and psychiatry staff about the group. Engage their h e l p in e n c o u r a g i n g patients to attend. 4. Take advantage of meetings that occur before group. If a c o m m u n i t y m e e t i n g ends early, d o n ' t let the patients w a n d e r off. Instead, e n c o u r a g e t h e m to walk with you immediately to the g r o u p r o o m a n d b e g i n g r o u p right away. 5. Don't be afraid to wake patients up! Stand by their b e d a n d invite t h e m by name. Tell t h e m that y o u ' r e having a g r o u p on topic X a n d that you would really like t h e m to j o i n the group. A l t h o u g h some m i g h t be r u d e a n d uncooperative, o t h e r patients really seem to a p p r e c i a t e the personal invitation. 6. Try, try again! If s o m e o n e d o e s n ' t c o m e to g r o u p o n e day, that d o e s n ' t m e a n that they will never be interested in attending. As patients b e c o m e m o r e stabilized, they may be thinking m o r e clearly a n d d e c i d e to take you u p o n your offer.
7. Call the group topic something that sounds interesting and relevant. F o r example, we d o n ' t ask patients to c o m e to a g r o u p on "Relapse Prevention," we invite t h e m to a g r o u p on "How to Stay O u t o f the Hospital." We've given some suggestions for m a r k e t a b l e names for each topic in the skill m o d u l e s section o f this manual.
Importance o f Continuity and Patient Expectations Most patients on the psychiatric intensive care unit lack structure in their lives. Part o f creating a t h e r a p e u t i c e n v i r o n m e n t on the ward is h e l p i n g t h e m to i m p o s e some structure on their chaotic experiences. While crises a n d "putting o u t fires" are typically the rule in this envir o n m e n t , we strongly e n c o u r a g e you to m a k e every effort to h o l d g r o u p at the same time each day. O n o u r unit, we h o l d g r o u p at 11:00 every day, i m m e d i a t e l y after rounds. Different m e m b e r s of the staff serve as g r o u p leader, dep e n d i n g o n their availability. Regardless o f who leads the group, however, it is always h e l d at the same time a n d place. Thus, we can tell new patients that "we have g r o u p every day at 11:00." Before long, certain patients will begin asking you each m o r n i n g what the g r o u p topic will be for that day.
Group Structure A l o n g similar lines, for reasons o f continuity, it is imp o r t a n t that groups always have the same structure. Review the g r o u p structure at the start o f each m e e t i n g so that new patients know what to e x p e c t a n d a g r o u p cub
Skills Training Groups in Acute Psychiatry ture is established. We typically start groups with the following: "Welcome to our group. We do three things in each group. First we introduce ourselves so that we all know each others' names. Next we go t h r o u g h the five group rules so that we all know how we are expected to behave. The third t h i n g we do is talk a b o u t the topic for today. Today's topic is ."
Introductions "I'11 get started with the introductions. My n a m e is Ken Weingardt, a n d I ' m a psychology i n t e r n here. Let's go a r o u n d the r o o m a n d everyone should say the n a m e that they would like us to call them." Some patients will prefer that you call them by their last name, others by their first, still others by their nickname. Make an effort to r e m e m b e r each of their names a n d to address them by their preferred n a m e t h r o u g h o u t the group.
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get m u c h less irritated when you have to i n t e r r u p t them (which can be quite frequent!). If s o m e o n e violates o n e of the rules d u r i n g group, always go back to the list of rules, p o i n t o u t which o n e was violated, a n d explain why it's i m p o r t a n t that everyone adhere to the rules. After introductions a n d reviewing the group rules, it's time to move Review the group o n to the topic of the day. structure at t h e We've written a brief descripstart of each tion of each of the seven group topics that have worked m e e t i n g s o that well with this population, as new patients know well as a list of the specific arwhat to expect and eas to cover in each of these groups a n d some helpfifl hints. a g r o u p culture is Each skill area is described established. later in this paper. Before turning to the skills t r a i n i n g modules, however, we t u r n our attention to the issue of g r o u p process i n these types of groups.
The Five Group Rules
Group Process
"In this group, we always follow five group rules. Can s o m e o n e get us started by r e m e m b e r i n g o n e of the rules?" If n o one j u m p s in with one, we usually call o n o n e of the patients who have b e e n in group a n u m b e r of times a n d ask h i m if he can r e m e m b e r one. As patients say the rules, we write them o n the b o a r d so that we can refer to t h e m if s o m e o n e starts violating them. It's important to try to get patients to generate all of the rules themselves. If they get really stuck, help them out. You s h o u l d n ' t s p e n d m o r e t h a n 5 to 10 m i n u t e s o n the introductions a n d rules. You've got a lot of g r o u n d to cover, a n d our group is typically only 30 m i n u t e s long. After s o m e o n e contributes a rule, we ask them why that is an i m p o r t a n t rule to follow. Here's a list of the rules a n d reasons why they are important.
Skills Training Groups Are Not Process Groups T h e reader may be familiar with the principles of the traditional process-oriented group psychotherapy. Suffice it to say that working in psychiatric intensive care, this type of process group simply does n o t work well. O u r patients are typically too disorganized, impulsive, or psychotic to benefit from traditional group therapy. Furthermore, o u r groups are open, a n d o u r turnover is very high due to o u r extremely short length of stay, so it is unlikely that patients will form deep, insightful relationships with one another. Instead, o u r skills t r a i n i n g groups are m u c h m o r e like classes. I n fact, m a n y patients prefer to call group a class, a n d we see n o reason to correct them. Calling it a class may be less stigmatizing to them, a n d to be honest, the concrete, specific, didactic n a t u r e of these groups makes t h e m seem a lot closer to a traditional classroom t h a n a traditional group therapy e n v i r o n m e n t .
1. No cross talk. One person speaks at a time. Reasons: so we can hear what s o m e o n e is saying. Respect. 2. No profanity, threats, or violence. Reasons: safety, respect. 3. Try to stay until the group is o v ~ Reasons: prevent disruption, disrespect. 4. Confidentiality. Reasons: safety. 5. Stay on the topic. Reason: so that we can get some work done. Here, we usually say that we may have to i n t e r r u p t s o m e o n e d u r i n g the group. We make it clear that i n t e r r u p t i n g t h e m d o e s n ' t m e a n that we disrespect them or are n o t interested in what they are saying. We're i n t e r r u p t i n g so that we can all stay o n the topic. With this kind of explanation, patients
You Are the Group Leader, Not the "Facilitator" I n traditional group therapy, the group facilitator often sits back a n d observes interactions a m o n g clients, sharing observations o n the process from time to time. From experience, we can say that taking this sort of passive stance with this patient p o p u l a t i o n is a recipe for disaster! A m u c h more effective role is to think of yourself as the group leader, or teacher, if you prefer. R e m a i n standing t h r o u g h o u t the session. Make liberal use of the whiteboard a n d markers to guide the discussion. Feel free to i n t e r r u p t a p a t i e n t a n d b r i n g the session back o n
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Weingardt & Zeiss topic when necessary. It's okay to be the authority figure, to m a i n t a i n c o n t r o l o f the conversation, to invite particip a t i o n from some g r o u p m e m b e r s , a n d to ask o t h e r m e m b e r s to h o l d a t h o u g h t o r c o m m e n t for a little while. This is n o t to say that you should be autocratic. It's also i m p o r t a n t to r e m e m b e r to use y o u r therapy skills. Temp e r y o u r directiveness with empathy. Allow patients to speak their piece, but only so long as they are addressing the topic at hand. T h e best way to describe this role is p a r t therapist, p a r t teacher, a n d p a r t traffic cop. F o r reasons o f safety a n d support, we often have m o r e than o n e staff m e m b e r p r e s e n t d u r i n g the group. However, each g r o u p has only o n e leader. T h e l e a d e r remains standing, while the o t h e r staff m e m b e r sits in the circle with the group, makes contributions, a n d helps to redirect a n d m a n a g e the m o r e difficult patients. This makes the g r o u p structure very c o n c r e t e a n d u n a m b i g u o u s , which is helpful for the m o r e disorganized patients. If a p a t i e n t must be asked to leave the r o o m because o f difficulty following the g r o u p rules, the s e c o n d staff m e m b e r is available to escort the p a t i e n t o u t o f the group, briefly discuss the request to leave, a n d notify nursing staff.
Engaging Patients in the Process Just as b e i n g too passive with this p o p u l a t i o n can lead to trouble, b e i n g too didactic can cause p r o b l e m s as well. If you stand at the f r o n t o f the r o o m a n d lecture at the patients, y o u ' r e in for trouble. O u r patients' attention spans are too short, a n d they are simply too impulsive to j u s t sit there a n d listen to you. You've got to find s o m e way to engage t h e m - - a n d k e e p t h e m e n g a g e d - - f o r the whole session. H e r e are some suggestions: Questions, questions, questions. While it may seem o d d to think a b o u t using the Socratic m e t h o d with psychiatric patients, a variant o f the Socratic m e t h o d can actually be r e m a r k a b l y effective. A g o o d g e n e r a l strategy that you will see t h r o u g h o u t the skills training m o d u l e s is to ask patients to g e n e r a t e lists a n d t h e n p u t those lists u p o n the board. Ask questions like, "What does it feel like to be angry?" "How d o you know when you n e e d to go see the doctor?" "What makes a relationship a g o o d one?" "How do you avoid using drugs a n d alcohol?" " w h a t does 'coping' mean?" Solicit i n p u t from the patients a n d write it down. Patients really like to see their contributions u p on the board. It reinforces participation a n d validates their contributions. Call on patients by name. Similar to getting patients to c o m e to group, getting patients to participate is often m u c h easier if you give t h e m a p e r s o n a l invitation. Some patients may be too shy o r too disorganized to initiate a c o n t r i b u t i o n on their own, b u t will be h a p p y to contribute if asked. Be p r e p a r e d to r e p e a t the question (often several times) until the patient responds. We've often found it useful to call on those patients whose attention is start-
ing to drift, falling asleep, o r staring at s o m e t h i n g e l s e - calling t h e m by n a m e a n d asking t h e m a question directly can get t h e m to engage with the g r o u p topic once again. (Elementary school teachers seem to have discovered this t e c h n i q u e a l o n g time ago.) Be concrete and specific. Do y o u r best to avoid j a r g o n a n d "50-cent words." Keep your vocabulary a i m e d at an a u d i e n c e that typically has less than a high school education. W h e n talking a b o u t abstract concepts, always tie t h e m back into c o n c r e t e examples (preferably ones that the patients g e n e r a t e themselves). Many e x a m p l e s o f how to be concrete a n d specific can be f o u n d t h r o u g h o u t the descriptions o f the skills training modules. Enlist higher-functioning patients as allies. A l t h o u g h the majority o f patients on a psychiatric intensive care unit have serious t h o u g h t disorders, t h e r e are usually a few patients who are less d i s t u r b e d a n d are motivated to c o m e to group. It can be e n o r m o u s l y helpful to identify these patients a n d let t h e m know that you value their attendance a n d assistance. H i g h e r f u n c t i o n i n g patients are often g o o d at e n c o u r a g i n g o t h e r patients to c o m e to group, r e d i r e c t i n g disruptive patients while in group, a n d providing g o o d m o d e l i n g o f g r o u p behavior for o t h e r patients. In turn, these patients typically feel very validated by sharing their knowledge with others a n d knowing that you genuinely a p p r e c i a t e their help. Get patients talking to each other.. Patients struggle with similar stressors, challenges, a n d problems. They also often share similar goals: to live independently, to stay o u t o f the hospital, to stay clean a n d sober. As patients in g r o u p typically have varying degrees o f success in d e a l i n g with life p r o b l e m s a n d achieving goals, those who have h a d some d e g r e e o f success can be e n c o u r a g e d to give advice to those who have not. H i g h e r f u n c t i o n i n g patients are also typically m u c h m o r e receptive to f e e d b a c k from o t h e r h i g h e r f u n c t i o n i n g patients. Don't take yourself too seriously. H u m o r can be very engaging. T h i n k back o n y o u r own experiences in seminars, workshops, o r groups. You were p r o b a b l y m o r e eng a g e d by speakers who were dynamic a n d flexible, r a t h e r than r i g i d - - t h o s e who could work with whatever material the g r o u p b r o u g h t u p - - t h o s e who were able to laugh at themselves when they misspelled s o m e t h i n g o r momentarily forgot what they were talking about. K e e p i n g the energy level high a n d the m o o d o f the g r o u p lighth e a r t e d ensures that your groups will be less t h r e a t e n i n g than traditional groups. This, in turn, ensures that patients wilt be o p e n to participating actively in your groups a n d that they will look forward to c o m i n g back to g r o u p each day.
Dealing With "Difficult" Patients O u r discussion o f g r o u p process would n o t be complete without acknowledging that some o f o u r patients
Skills Training Groups in A c u t e Psychiatry can b e very h a r d to work with in the g r o u p setting. We'll discuss t h r e e g e n e r a l classes o f patients that can pose p r o b l e m s for you as the g r o u p l e a d e r a n d suggest some ways o f d e a l i n g with them. Floridly psychoticpatients. Some patients on the unit will be floridly psychotic; they will be e x p e r i e n c i n g auditory hallucinations, delusions o f g r a n d e u r o r persecution, ideas of reference, a n d loose t h o u g h t processes. W h e n patients are particularly psychotic a n d disorganized, the best solution usually is to avoid inviting t h e m to group. Sometimes, however, they will see the g r o u p beg i n n i n g a n d want to j o i n in. O u r policy has typically b e e n to let in any p a t i e n t who wants to come. We make special efforts to review the g r o u p rules with the disorganized patient a n d try to make sure that they u n d e r s t a n d that if they fail to a b i d e by them, they may be asked to leave the r o o m . These disorganized patients may t h e n either sit quietly a n d observe the group, m u t t e r to themselves, try to contribute, o r be l o u d a n d disruptive. If they try to contribute, we usually listen closely to h e a r if there is anything relevant to the g r o u p topic in what they are saying. Remarkably, t h e r e often is. If that is the case, we'll p u t their c o n t r i b u t i o n o n the b o a r d a n d move on. Fortunately, m a n y disorganized psychotic patients who are disruptive t e n d to get u p a n d leave the group. T h e best strategy t h e n is to simply n o t let t h e m b a c k in the room. It may be a g o o d i d e a to k e e p floridly psychotic patients o u t o f the g r o u p until you feel somewhat comfortable leading these kinds o f groups. Acutely manic patients. Patients with b i p o l a r affective d i s o r d e r who are in an acute m a n i c phase can be the most difficult patients for the g r o u p leader. They t e n d to d o m i n a t e the discussion a n d can be difficult to i n t e r r u p t o r stop. They invariably are aware that the g r o u p is going o n a n d want to be a p a r t o f it. They are often u n a b l e to sit still for the half-hour group. Like the disorganized patient with schizophrenia, we typically allow t h e m into group, b u t take extra care to make sure that they are aware of the rules a n d the consequences for violating them. If they are disruptive, we address t h e m by name, a n d impress u p o n t h e m that o t h e r patients in the g r o u p n e e d to have a chance to speak, a n d that we're willing to talk with t h e m one-on-one after the g r o u p is over. Manic patients typically want to e n t e r a n d exit the r o o m repeatedly. Again, your best b e t is to let t h e m o u t a n d n o t return. Hostile patients. Floridly psychotic o r acutely m a n i c patients can sometimes be quite hostile. Those patients who r e s p o n d to your invitation to a t t e n d g r o u p in an openly hostile m a n n e r are p r o b a b l y best left alone. Those who previously manifested hostility in g r o u p are best spoken to in a soft, calm voice a n d r e m i n d e d o f the rule p r o h i b i t i n g threats, violence a n d profanity. Verbal escalation can be a p r e c u r s o r to physical assault a n d should be taken very seriously. Patients who are escalating can be r e m i n d e d that
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these groups are entirely voluntary a n d that they are free to leave the g r o u p at any time. If you feel unsafe in the r o o m with the patient, d o n o t hesitate to leave the r o o m a n d inform nursing staff a b o u t what is going on. Finally, m a k e sure that you know where the panic b u t t o n is in the room. You never know when you m i g h t n e e d to use it.
Discussion This p a p e r outlines a novel g r o u p intervention for use in a locked, short-term psychiatric hospital setting. Based o n empirically validated psychosocial skills training approaches, the interventions d e s c r i b e d can e n h a n c e patients' u n d e r s t a n d i n g of their illnesses, as well as their skills in m a n a g i n g them. I m p l e m e n t i n g these groups o n o u r unit has c o n t r i b u t e d to o u r t h e r a p e u t i c milieu by providing patients with m u c h n e e d e d social interaction, validation, a n d respect. This skills training c u r r i c u l u m has proven useful because it directly addresses m a n y of the behavioral p r o b l e m s that are often e x h i b i t e d in the acute psychiatric environment. Because getting patients to a t t e n d g r o u p in this envir o n m e n t can be a challenge, we first d e s c r i b e d a n u m b e r o f different strategies that a g r o u p l e a d e r m i g h t use to ensure g o o d attendance. We n e x t e m p h a s i z e d the importance o f continuity a n d p a t i e n t expectations, as well as the i m p o r t a n c e of a consistent g r o u p structure within each session. We t h e n t u r n e d to a discussion o f g r o u p process, describing the difference between skills training groups a n d traditional process-oriented g r o u p psychotherapy, the role of g r o u p l e a d e r in this type o f intervention, a n d strategies that have proven useful in h e l p i n g patients to e n g a g e in these groups. We identified t h r e e categories o f difficult patients that are e n c o u n t e r e d when r u n n i n g groups, a n d we discussed how to address the challenges that they present. Finally, we o u t l i n e d seven different skills training modules, each o f which is i n t e n d e d to provide the r e a d e r with concrete, specific instructions for c o n d u c t i n g groups on topics such as a n g e r m a n a g e ment, c o m m u n i c a t i o n skills, c o p i n g with m e n t a l illness, a n d relapse prevention. We h o p e that by sharing o u r e x p e r i e n c e s o f l e a d i n g groups in this setting, we have given you some ideas a b o u t how you m i g h t comfortably a n d productively work with this p o p u l a t i o n in the acute setting. If l e n g t h o f stay were longer, these groups would u n d o u b t e d l y be m o r e effective in teaching skills that m i g h t generalize to improving o u r patients' social functioning. Each o f these topics could easily b e e x p a n d e d to fill weeks o f g r o u p time (e.g., L i b e r m a n ' s g r o u p at U C L A holds o u t p a t i e n t skills training groups with schizophrenics 12 hours a week for 6 m o n t h s ) . O u r reality, however, is an average l e n g t h o f stay o f a b o u t 10 days; the material d e s c r i b e d in these pages attempts to e n h a n c e the t h e r a p e u t i c milieu
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SKILLS TRAINING MODULES In each of these modules, tasks, statements, or questions intended for the group leader are printed in plain text. Items in italics represent responses that are likely to be obtained from group members.
Anger Management "What to do when you get angry" 1. Introductions 2. Review g r o u p rules 3. Ask g r o u p m e m b e r s "What does it feel like when y o u ' r e angry?" Put list up on the board. Likely responses include:
My heart beatsfaster I breathe more quickly I get sweaty I feel like lashing out I feel my gut tighten up I feel my muscles tense up 4. I n t r o d u c e exercise by telling group that there are different ways of h a n d l i n g anger; some are g o o d because they lead to positive consequences, and some are bad because they lead to negative consequences. 5. Put two columns up on the board labeled "good" and "bad." 6. "What are some o f the bad ways that you can handle anger?"
Yelling and screaming Hitting Killing Fighting Throwing things Breaking things Drinking alcohol/using drugs "Why are these bad?" Because they lead to negative consequences. "What are some negative consequences that m i g h t happen?"
Jail Get hurt End up back in hospital 7. "What are some good ways of h a n d l i n g anger?" Again, ask the patients to generate the list, and put their responses up on the board.
Exercise Walking Swimming Running Talking about it With someone who understands With someone you trust With the person that you're angry at using "I feel" statements Praying
S o m e g o o d ways to express a n g e r on the ward are:
Tell staff that you're feeling angry Take a PRN Walk away from the situation Spend some time by yourself to cool down 8. What are some g o o d ways of preventing anger?
Have a sense of humor Try to understand where the other person is coming from (empathy, walking a mile in their moccasins, etc.) Try to take responsibility for your own emotions--don 't let other people control them Count to 10 Take deep breaths Walk away
Goals "How to reach your personal goals" This g r o u p is designed to help patients learn how to identify the smaller steps r e q u i r e d for t h e m to achieve their personal goals. W h e n inviting t h e m to this group, tell t h e m that you'll be talking about what goals they would like to accomplish o n c e they get out of the hospital, and that the o t h e r patients will help t h e m figure out how to do it. 1. Introductions 2. Review group rules 3. Ask each g r o u p m e m b e r to identify a goal that he would like to achieve o n c e he gets out of the hospital. Most patients will be able to c o m e up with s o m e t h i n g concrete and specific to work with. G o o d examples include:
Independent living Getting a job Getting a driver's license Visiting with family Going back to school Applying for social security It's i m p o r t a n t that each goal c o m e f r o m the patient himself. You may n e e d to do some p r o b i n g to find o n e that's appropriate to work with. 4. For each patient, write his n a m e o n the board, and on the o t h e r side of the board, write the goal that he has given you. You'll e n d up with s o m e t h i n g like this:
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Here (in Hospital)
Goal
Bob Max Robin Dan Richard
Get an apartment Find a j o b Go back to school Start dating File for Social Security
Then, for each patient, you can work backwards from his goal and identify all of the subgoals or small steps that he needs to accomplish to get from here (on the ward) to there (in an apartment, job, etc.). This can be a great exercise for getting patients talking to each other. For example, you might ask patients "what steps does Bob need to take to get from here to living in his own apartment?" Group members might then volunteer that to get an apartment, one has to find out how much money one can spend per month, make sure that they have first and last month's rent and deposit, figure out what neighborhood they want to live in, get the classified ads, make telephone calls, and so on. Group members usually make good contributions, which you can list sequentially on each person's "timeline" on the board. Try to pace the group so that you don't run out of time before you get a chance to work with each member's goal.
Communication "How to get what you want from other people" This module helps patients to identify the elements of effective communication. A good way to "market" this topic when inviting patients to group is to describe the group as "How to get what you want from other people" or something along those lines. 1. Introductions 2. Review group rules 3. Get things rolling by asking patients what communication means. Generate a list of relevant responses up on the white board. Responses might include: Talking Sending messages Listening Getting your point across Asking questions 4. Point out that communication has three parts: sender, receiver, and message. 5. What are the different ways of sending a message? Discuss verbal vs. nonverbal ("body language," eye contact, etc.). 6. When is communication effective? When we're listening to the other person When we don't get loud or hostile When we try to understand "where the other person is comingfrom"
When our message is clear and direct When we are polite 14#ten we follow the group rules (one at a time, no profanity, threats or violence, stay on the topic)--point out that group rules are good rules to follow outside group 7. Use interaction with staff as an example of effective communication. • How to ask a nurse for something that you want or need • How not to ask a nurse for something 8. Consider role-playing if group interacts well.
Drugs and Alcohol "Reasons to use and not to use" Many psychiatric patients struggle with substance abuse. This group is intended to help patients focus on why it is important to remain clean and sober outside of the hospital and to give them some pragmatic suggestions that might help them. 1. Introductions 2. Review group rules 3. As a way of really getting patients engaged on the topic, consider beginning the group by asking patients what they like about using alcohol or drugs: What's good about them? Why do they use them? Typical responses might include: Makes Makes Makes Makes Makes
me feel more relaxed it easier for me to have sex me feel powerful my body feel good me forget my problems
4. Now that you've got everyone's attention, ask them to list some of the bad things that have happened to them when they have been using alcohol or drugs. Typical responses are: I lost all of my money I ended up in jail I got addicted and couldn't stop I had to go back to the hospital I lost my apartment My girl~end left me 5. The "Decisional Balance": typically the list of negative consequences of drinking or using is far longer than the list of positive effects. You can frame the pros and cons of continuing to use as a balance--while using has some attractive aspects, the negative consequences really make it a good idea to stay clean and sober. 6. How to stay clean and sober: Many patients will have had some substance abuse treatment experience, so it should be fairly easy to help the group generate a list of useful strategies. A typical list might be:
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• Avoid certain people: e.g., the so-called friends who only seem to show up at the first of the month, when most of o u r patients get their disability checks. • Avoid certain places. Everyone has their "slippery" places where they're most likely to use----could be a bar, a park, a downtown area, friend's house, etc. • Get help. Emphasize that no one can really stay clean and sober on his or h e r own. Run through a list of resources that are available: self-help groups (AA, CA, NA), and treatment available through your facility and o t h e r facilities in the community. • A relapse isn't the end of the world. Many p e o p l e think that if they slip up and have a drink or smoke that they m i g h t as well j u s t give up and keep o n using. A slip is a mistake that you can learn f r o m - - d o n ' t give up on your sobriety because o f it.
Relationships "How to make new friends" Patients often lack the basic knowledge and skills necessary to initiate and maintain social relationships. They often express interest in dating or making friends, but have little idea how to go about d o i n g that. This m o d u l e is i n t e n d e d to h e l p t h e m begin to o v e r c o m e these deficits. 1. Introductions 2. Review g r o u p rules 3. Ask patients what "relationship" means to them. Most will c o m e up with romantic relationships, but challenge t h e m to think of o t h e r kinds of relationships that p e o p l e can have. A tylaical list m i g h t also include:
Friendship Teacher-student Doctor-patient Neighbor Roommate 4. After making sure that all of the m e m b e r s understand what relationship means, in the b r o a d e r sense, ask t h e m to c o m e up with a list of things that make relationships good. A typical list:
Communication Trust Understanding Listening Respect 5. Make it c o n c r e t e by d o i n g s o m e m o r e specific social skills training. For example, how to initiate a conversation:
Make eye contact Maintain appropriate personal distance Ask another person about themselves
Identify a common interest Listen and respond 6. Consider m o d e l i n g a n d / o r group interacts well.
role-playing if the
Coping With Mental illness T h e majority of patients on the psychiatric intensive care unit are chronically mentally i11. They have suffered a lifetime o f terrifying symptoms, medication side effects, institutionalization and stigmatization. This g r o u p addresses techniques that can be used to help t h e m cope with the difficult aspects of mental illness in a very direct and up-front manner. 1. Introductions 2. Review group rules 3. Ask patients what "mental illness" means to them. Some m i g h t find this definitional exercise heavyh a n d e d or insensitive. Others m i g h t think that it would m e e t with m u c h resistance by patients who d o n ' t consider themselves to be "mentally ill." To the contrary, we have f o u n d patients' responses to this question remarkably insightful and powerful. Notice that this exercise does n o t require patients to label themselves as mentally ill, only to discuss what mental illness means to them. H e r e are s o m e typical responses f r o m our patients:
A different way of thinking A chemical imbalance in the brain Hearing things that other people can't hear Feeling nervous Feeling like everyone is out to get you Can't sleep People treat you differently Needing to take medication 4. Ask patients to define "coping." Again, you'll often be surprised by the degree of insight that patients have into what coping means. Typical responses include:
Dealing with it Adapting Adjusting Doing things differently 5. Finally, ask patients to g e n e r a t e a list of things that they can do to cope with their illness. Typical responses include:
Exercise Taking medication Going to school Lea~wing more about their illness and their medications Educating others about their illness (family, society) Avoiding alcohol and drugs Asking for help when they need it (from doctors, family, friends)
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In our experience, this exercise can take widely different paths. Some groups will focus on more superficial aspects of managing mental illness, while others will delve into heartfelt and poignant discussions of the pain of mental illness, touching upon the loneliness, stigma, and rejection that they have suffered.
Feeling really good Stopping medication Fighting with roommates Not going to appointments
R e l a p s e Prevention
Next, ask patients to make a list of things that they can do the next time they find themselves experiencing these warning signs so that they might be able to prevent rehospitalization. Here's a list of popular relapseprevention strategies:
"How to stay out of the hospital" This group is focused on helping clients to identify the early-warning signs of decompensation and useful strategies that they can employ to help prevent a fullblown relapse and consequent rehospitalization. When you invite patients to a class on things they can do to stay out of the hospital, you're almost guaranteed a good turnout. 1. Introductions 2. Review group rules 3. Ask patients how they know when things are starting to go wrong for them. What are the early-warning signs that they are headed back to the hospital? It's important to emphasize that each person's early-warning signs are different. Therefore, we encourage each patient to make a unique list of things to watch out for. Although it is best to make a list for each patient, if you have a big group, or are r u n n i n g out of time, you can make one big list. Here are some examples: EARLYWARNING SIGNS
Roherto Staying up all night Not eating Spending too much money Using methamphetamine Thinking that other people want to kill me Max
Hearing voices Sleeping too much Feeling hopeless Wife notices something wrong
a n d help patients learn all that they can within that time frame. Some patients (typically the higher f u n c t i o n i n g ones) have indicated that they have gotten a t r e m e n d o u s a m o u n t out of these groups. O t h e r patients (typically the severely disturbed ones) probably retain very little of the information. However, in o u r experience, almost all of the patients who attend these groups get something extremely i m p o r t a n t out of them: a sense of validation a n d respect, something that is often lacking in the psychiatric intensive care e n v i r o n m e n t .
• Call your outpatient doctor. Describe the symptoms you are experiencing, and ask for an appointment so that your medications can be reevaluated. • Talk to someone that you trust. This could be someone different for each patient. It could be a case manager, a board and care operator, a spouse, a counselor, or the patient's parents. Encourage patients to listen to what they say; other people often have a different perspective on our problems that we are not able to see in ourselves. • Don't stop takingyour medication. Many patients start feeling so good that they think that they no longer need to take medication. Ask your group how many people this has happened to (many hands usually go up). Then ask them what h a p p e n e d - usually negative consequences: jail, rehospitalizaLion, etc. • Take care of yourself. Make sure that you eat right and get enough sleep. • Don't use drugs or alcohol. Although drinking or using drugs may seem like a good thing to do when you're not feeling well, they typically lead to more negative consequences; it may work well in the short-term, but makes things worse in the long run. Each group will come up with other, idiosyncratic relapse-prevention strategies that you will have to evaluate for their own merit. Patients who are delusional will often come up with some interesting ones. Ask other patients if they think that the more outlandish strategies will w o r k - - i f not, ask them to give the delusional patient some suggestions about strategies that might work better.
O n e of us (KRW) initially drafted this m a n u a l while o n i n t e r n s h i p at the VA Palo Alto Health Care System. Early drafts proved quite useful in o r i e n t i n g s u b s e q u e n t interns a n d other trainees in how to work with groups in the locked, acute psychiatric e n v i r o n m e n t . As each new intern, trainee, or staff person has gained experience r u n n i n g these groups, he or she has typically seen the p r e s e n t c u r r i c u l u m as a starting p o i n t from which they have a d d e d new group topics a n d modified existing ones. O n a related note, we'd like to leave the reader with a
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Weingardt & Zeiss h u m b l e r e q u e s t . All t o o often, psychologists d e v e l o p an i n t e r v e n t i o n , a therapy, o r a m a n u a l i z e d t r e a t m e n t p r o t o col t h a t b e c o m e s a static entity with a life o f its own. It is l a b e l e d with a catchy a c r o n y m , is e m p i r i c a l l y v a l i d a t e d in clinical trials, a n d is vigorously d e f e n d e d against criticism. In contrast, t h e r e a d e r is invited to treat t h e p r e s e n t p a p e r a n d the p r o g r a m it describes as a w o r k in progress. We invite y o u to alter it a n d a d a p t it to y o u r specific treatm e n t setting. D e v e l o p skills t r a i n i n g m o d u l e s o n differe n t topics. C h a n g e the m o d u l e s to fit y o u r own prefere n c e s a n d needs. T h i n k critically. E x p a n d u p o n t h e m a t e r i a l , m o d i f y it, o r start over, if y o u prefer. So l o n g as y o u r f o c u s is o n i m p r o v i n g the p r o v i s i o n o f p s y c h o l o g i c a l services to a p o p u l a t i o n t h a t is sorely in n e e d o f t h e m , you d o so with o u r blessing a n d e n c o u r a g e m e n t . Finally, we invite you to s h a r e y o u r e x p e r i e n c e s d e v e l o p i n g a n d r u n n i n g t h e s e types o f g r o u p s with us e i t h e r f o r m a l l y o r i n f o r m a l l y so t h a t we c a n c o n t i n u e to i m p r o v e the quality o f services t h a t we p r o v i d e to o u r own patients.
Liberman, R. E, Vaccaro, J. V., & Corrigan, E W. (1995). Psychiatric rehabilitation. In H. I. Kaplan & B.J. Sadock (Eds.), Comprehensive textbook of psychiatry (6th ed., pp. 2696-2717). Baltimore: William & Wilkins. Liberman, R. E, Wallace, C.J., Blackwell, G. A., Eckman, T. A., Vaccaro, J. V., & Kuehnel, T. G. (1993). Innovations in skills training for the seriously mentally ill: The UCLA Social and Independent Living Skills Modules. Innovations and Research 2. 43-59. Liberman, R. P., Wallace, C.J., Blackwell, G., Kopeloicz, A., Vaccaro, J. V., & Mintz,J. (1998). Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. American Journal of Psychiatry, 155, 1087-1091.
Preparation of this manuscript was supported by the VA Health Services Research and Development Service and Office of Academic Affiliations. The authors gratefully acknowledge the valuable contributions of Xavier Apodaca, Ph.D., in developing this program. We would also like to thank Robert R Liberman, M.D., and his colleagues at the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation, whose social and independent living modules greatly influenced the content of the groups described in this manual. Address correspondence to Kenneth R. Weingardt, VAPAHCS (152-MPD), 795 Willow Road, Menlo Park, CA 94025; e-mail: Weingardt@ mailsvr.icon .palo-alto.med.va.gov.
References Benton, M. tC, & Schroeder, H. E. (1990). Social skills training with schizophrenics: A meta-analytic evaluation. Journal of Consulting and ClinicalPsychology, 58, 741-747.
Received: January 25, 2000 Accepted: March 29, 2000
Skills Training Groups on a Psychiatric Intensive Care Unit: A Guide for Group Leaders K e n n e t h R. W e i n g a r d t , Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine R o b e r t A. Zeiss, Veterans Affairs Palo Alto Health Care System
This paper outlines a structured group intervention for use in a locked acute psychiatric intensive care environment. This intervention, described in manualized form, draws upon the empirically vatidated psychosocial skills training approach for the rehabilitation of individuals with chronic mental illness (cf. Liberman et al., 1993). The first section discusses general principles for conducting skills training groups in the acute psychiatric population, including practical strategies for encouraging patients to attend group, group structure, rules, and process. The second part of the paper outlines seven specific skills training modules that provide concrete, step-by-step instructions for conducting groups on such topics as anger management, communication skills, coping with mental illness, and relapseprevention. The reader is invited to critically evaluate, modify, and expand upon the materials presented in order to better serve this challenging poputation.
RAMATIC CHANCES in health care over the past 10 years have effected equally dramatic changes in the delivery of psychiatric services. A person with schizophrenia can no longer routinely receive inpatient treatment for 3 to 6 months from the same team of providers and participate in long-term group and individual therapy. This is particularly true in the psychiatric intensive care environment. With an average length of stay on our unit being approximately 10 days, the focus is necessarily on getting patients stabilized on medications and moved to an o p e n ward or directly back into the community as quickly as possible. What role, then, can a psychologist or other mental health professional play in such an environment? Conducting psychosocial skills training groups such as those described in this paper can be one particularly rewarding role. This p r o g r a m bears resemblance to more intensive, empirically validated social skills training interventions (see Benton & Schroeder, 1990; Liberman, Vaccaro, & Corrigan, 1995; Liberman et al., 1998). It utilizes many of the same core behavioral techniques that define social skills training (cf. Benton & Schroeder) including problem or skills specification, didactic instruction, modeling, role playing, coaching, and verbal reinforcement. However, due to a short length o f stay and high levels of acuity in the psychiatric intensive care environment, the structure and content of the present program depart significandy from m o r e traditional skills training programs. Because social skills training does not typically result in the reduction of psychotic symptoms, even when deliv-
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ered in a long-term, intensive modality (e.g., Liberman et al., 1998), it would be naive to expect the present program to accomplish that goal. Similarly, it would be unrealistic to expect a skills training intervention delivered in the acute psychiatric setting to result in generalized, long-term improvement in social functioning. What goals then might we realistically expect such a program to accomplish? In our experience, implementing this program can result in a significant improvement in the therapeutic milieu. Many patients enjoy participating in these groups and express enthusiasm about attending them. Thus, these groups can be an important source of validation and respect for patients, providing them with a rare opportunity for social interaction while on the ward. Nursing staffs support these groups because topics such as anger m a n a g e m e n t and communication skills directly address some of the m o r e c o m m o n behavioral problems on the ward. Social workers are typically supportive of these groups because they encourage patients to take active steps to plan for discharge and to prevent readmission. Finally, as members of a psychology staff, we have f o u n d these groups rewarding because they allow us to apply our knowledge of cognitive-behavioral interventions in a real-world setting with a population that is sorely in n e e d of help. We firmly believe that any intervention that provides incremental gains in understanding of an illness and its m a n a g e m e n t will ultimately benefit the patient. A W o r d A b o u t This P o p u l a t i o n This population is a difficult one to work with. The majority of patients are chronically mentally ill with very serious disorders such as chronic paranoid schizophrenia, schizoaffective disorder, and bipolar affective disor-
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der. F u r t h e r m o r e , m a n y o f the patients have c o m o r b i d Axis II diagnoses as well as significant histories o f alcohol a n d d r u g abuse a n d d e p e n d e n c e . Finally, psychiatric intensive care patients are typically o n involuntary civil c o m m i t m e n t for dangerousness or grave disability. Many patients are at high risk for suicide or assault, a n d many are quite disorganized a n d have difficulty providing for their own basic needs. T h e r e is an upside, however. Many chronically mentally ill individuals have b e e n in a n d o u t o f m e n t a l institutions for most o f their a d u l t lives, a n d a u n i q u e p a r t o f their culture is that they have a t t e n d e d m a n y g r o u p therapy sessions. O n c e stabilized on medications, patients typiGroups can be an cally know what groups are important source a n d how they are e x p e c t e d to behave in group. Some actuof validation and ally enjoy g r o u p interactions, respect for a n d c o m e to look forward to daily meetings as a place to patients, providing learn new skills a n d discuss t h e m with a rare their problems. Even patients opportunity for who are still d e c o m p e n s a t e d can often behave a p p r o p r i social interaction ately in g r o u p a n d participate while on the ward. to some extent. T h a t b e i n g said, it is important to r e m e m b e r that in o u r milieu, these skills training groups are c o m p l e t e l y voluntary. While patients are often e n c o u r a g e d to sample groups, they are never forced to att e n d a n d are free to leave once the g r o u p begins. Some patients may even be e n c o u r a g e d to leave g r o u p if they are n o t able to follow the rules, respect o t h e r patients a n d staff, a n d participate without c o m p r o m i s i n g the safety o f the g r o u p e n v i r o n m e n t .
General Principles Getting Patients to Come to Group This is o n e o f the most i m p o r t a n t , u n d e r a p p r e c i a t e d roles o f a g r o u p l e a d e r in this e n v i r o n m e n t . In o u r experience, it is most effective to "advertise" the g r o u p at every opportunity, to b o t h s t a f f a n d patients. H e r e are some o f the strategies that have p r o v e n useful: 1. Invite individual patients to attend groups. D u r i n g rounds, tell patients the g r o u p ' s topic for that day a n d how they would benefit from it. F o r patients who r e s p o n d that they already know all a b o u t the topic, e n c o u r a g e t h e m to c o m e a n d h e l p teach the o t h e r patients what they know. F o r patients who are n o t seen in r o u n d s that day, i n t r o d u c e yourself, tell t h e m that you r u n groups o n the unit, a n d that y o u ' d like t h e m to c o m e to the n e x t one, letting t h e m know when a n d where the g r o u p meets.
2. Post the group schedule for the month on the bulletin board in a public space. I n t r o d u c e yourself to new patients a n d p o i n t o u t which g r o u p topics m i g h t be o f interest to t h e m on the board. 3. Inform nursing and psychiatry staff about the group. Engage their h e l p in e n c o u r a g i n g patients to attend. 4. Take advantage of meetings that occur before group. If a c o m m u n i t y m e e t i n g ends early, d o n ' t let the patients w a n d e r off. Instead, e n c o u r a g e t h e m to walk with you immediately to the g r o u p r o o m a n d b e g i n g r o u p right away. 5. Don't be afraid to wake patients up! Stand by their b e d a n d invite t h e m by name. Tell t h e m that y o u ' r e having a g r o u p on topic X a n d that you would really like t h e m to j o i n the group. A l t h o u g h some m i g h t be r u d e a n d uncooperative, o t h e r patients really seem to a p p r e c i a t e the personal invitation. 6. Try, try again! If s o m e o n e d o e s n ' t c o m e to g r o u p o n e day, that d o e s n ' t m e a n that they will never be interested in attending. As patients b e c o m e m o r e stabilized, they may be thinking m o r e clearly a n d d e c i d e to take you u p o n your offer.
7. Call the group topic something that sounds interesting and relevant. F o r example, we d o n ' t ask patients to c o m e to a g r o u p on "Relapse Prevention," we invite t h e m to a g r o u p on "How to Stay O u t o f the Hospital." We've given some suggestions for m a r k e t a b l e names for each topic in the skill m o d u l e s section o f this manual.
Importance o f Continuity and Patient Expectations Most patients on the psychiatric intensive care unit lack structure in their lives. Part o f creating a t h e r a p e u t i c e n v i r o n m e n t on the ward is h e l p i n g t h e m to i m p o s e some structure on their chaotic experiences. While crises a n d "putting o u t fires" are typically the rule in this envir o n m e n t , we strongly e n c o u r a g e you to m a k e every effort to h o l d g r o u p at the same time each day. O n o u r unit, we h o l d g r o u p at 11:00 every day, i m m e d i a t e l y after rounds. Different m e m b e r s of the staff serve as g r o u p leader, dep e n d i n g o n their availability. Regardless o f who leads the group, however, it is always h e l d at the same time a n d place. Thus, we can tell new patients that "we have g r o u p every day at 11:00." Before long, certain patients will begin asking you each m o r n i n g what the g r o u p topic will be for that day.
Group Structure A l o n g similar lines, for reasons o f continuity, it is imp o r t a n t that groups always have the same structure. Review the g r o u p structure at the start o f each m e e t i n g so that new patients know what to e x p e c t a n d a g r o u p cub
Skills Training Groups in Acute Psychiatry ture is established. We typically start groups with the following: "Welcome to our group. We do three things in each group. First we introduce ourselves so that we all know each others' names. Next we go t h r o u g h the five group rules so that we all know how we are expected to behave. The third t h i n g we do is talk a b o u t the topic for today. Today's topic is ."
Introductions "I'11 get started with the introductions. My n a m e is Ken Weingardt, a n d I ' m a psychology i n t e r n here. Let's go a r o u n d the r o o m a n d everyone should say the n a m e that they would like us to call them." Some patients will prefer that you call them by their last name, others by their first, still others by their nickname. Make an effort to r e m e m b e r each of their names a n d to address them by their preferred n a m e t h r o u g h o u t the group.
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get m u c h less irritated when you have to i n t e r r u p t them (which can be quite frequent!). If s o m e o n e violates o n e of the rules d u r i n g group, always go back to the list of rules, p o i n t o u t which o n e was violated, a n d explain why it's i m p o r t a n t that everyone adhere to the rules. After introductions a n d reviewing the group rules, it's time to move Review the group o n to the topic of the day. structure at t h e We've written a brief descripstart of each tion of each of the seven group topics that have worked m e e t i n g s o that well with this population, as new patients know well as a list of the specific arwhat to expect and eas to cover in each of these groups a n d some helpfifl hints. a g r o u p culture is Each skill area is described established. later in this paper. Before turning to the skills t r a i n i n g modules, however, we t u r n our attention to the issue of g r o u p process i n these types of groups.
The Five Group Rules
Group Process
"In this group, we always follow five group rules. Can s o m e o n e get us started by r e m e m b e r i n g o n e of the rules?" If n o one j u m p s in with one, we usually call o n o n e of the patients who have b e e n in group a n u m b e r of times a n d ask h i m if he can r e m e m b e r one. As patients say the rules, we write them o n the b o a r d so that we can refer to t h e m if s o m e o n e starts violating them. It's important to try to get patients to generate all of the rules themselves. If they get really stuck, help them out. You s h o u l d n ' t s p e n d m o r e t h a n 5 to 10 m i n u t e s o n the introductions a n d rules. You've got a lot of g r o u n d to cover, a n d our group is typically only 30 m i n u t e s long. After s o m e o n e contributes a rule, we ask them why that is an i m p o r t a n t rule to follow. Here's a list of the rules a n d reasons why they are important.
Skills Training Groups Are Not Process Groups T h e reader may be familiar with the principles of the traditional process-oriented group psychotherapy. Suffice it to say that working in psychiatric intensive care, this type of process group simply does n o t work well. O u r patients are typically too disorganized, impulsive, or psychotic to benefit from traditional group therapy. Furthermore, o u r groups are open, a n d o u r turnover is very high due to o u r extremely short length of stay, so it is unlikely that patients will form deep, insightful relationships with one another. Instead, o u r skills t r a i n i n g groups are m u c h m o r e like classes. I n fact, m a n y patients prefer to call group a class, a n d we see n o reason to correct them. Calling it a class may be less stigmatizing to them, a n d to be honest, the concrete, specific, didactic n a t u r e of these groups makes t h e m seem a lot closer to a traditional classroom t h a n a traditional group therapy e n v i r o n m e n t .
1. No cross talk. One person speaks at a time. Reasons: so we can hear what s o m e o n e is saying. Respect. 2. No profanity, threats, or violence. Reasons: safety, respect. 3. Try to stay until the group is o v ~ Reasons: prevent disruption, disrespect. 4. Confidentiality. Reasons: safety. 5. Stay on the topic. Reason: so that we can get some work done. Here, we usually say that we may have to i n t e r r u p t s o m e o n e d u r i n g the group. We make it clear that i n t e r r u p t i n g t h e m d o e s n ' t m e a n that we disrespect them or are n o t interested in what they are saying. We're i n t e r r u p t i n g so that we can all stay o n the topic. With this kind of explanation, patients
You Are the Group Leader, Not the "Facilitator" I n traditional group therapy, the group facilitator often sits back a n d observes interactions a m o n g clients, sharing observations o n the process from time to time. From experience, we can say that taking this sort of passive stance with this patient p o p u l a t i o n is a recipe for disaster! A m u c h more effective role is to think of yourself as the group leader, or teacher, if you prefer. R e m a i n standing t h r o u g h o u t the session. Make liberal use of the whiteboard a n d markers to guide the discussion. Feel free to i n t e r r u p t a p a t i e n t a n d b r i n g the session back o n
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Weingardt & Zeiss topic when necessary. It's okay to be the authority figure, to m a i n t a i n c o n t r o l o f the conversation, to invite particip a t i o n from some g r o u p m e m b e r s , a n d to ask o t h e r m e m b e r s to h o l d a t h o u g h t o r c o m m e n t for a little while. This is n o t to say that you should be autocratic. It's also i m p o r t a n t to r e m e m b e r to use y o u r therapy skills. Temp e r y o u r directiveness with empathy. Allow patients to speak their piece, but only so long as they are addressing the topic at hand. T h e best way to describe this role is p a r t therapist, p a r t teacher, a n d p a r t traffic cop. F o r reasons o f safety a n d support, we often have m o r e than o n e staff m e m b e r p r e s e n t d u r i n g the group. However, each g r o u p has only o n e leader. T h e l e a d e r remains standing, while the o t h e r staff m e m b e r sits in the circle with the group, makes contributions, a n d helps to redirect a n d m a n a g e the m o r e difficult patients. This makes the g r o u p structure very c o n c r e t e a n d u n a m b i g u o u s , which is helpful for the m o r e disorganized patients. If a p a t i e n t must be asked to leave the r o o m because o f difficulty following the g r o u p rules, the s e c o n d staff m e m b e r is available to escort the p a t i e n t o u t o f the group, briefly discuss the request to leave, a n d notify nursing staff.
Engaging Patients in the Process Just as b e i n g too passive with this p o p u l a t i o n can lead to trouble, b e i n g too didactic can cause p r o b l e m s as well. If you stand at the f r o n t o f the r o o m a n d lecture at the patients, y o u ' r e in for trouble. O u r patients' attention spans are too short, a n d they are simply too impulsive to j u s t sit there a n d listen to you. You've got to find s o m e way to engage t h e m - - a n d k e e p t h e m e n g a g e d - - f o r the whole session. H e r e are some suggestions: Questions, questions, questions. While it may seem o d d to think a b o u t using the Socratic m e t h o d with psychiatric patients, a variant o f the Socratic m e t h o d can actually be r e m a r k a b l y effective. A g o o d g e n e r a l strategy that you will see t h r o u g h o u t the skills training m o d u l e s is to ask patients to g e n e r a t e lists a n d t h e n p u t those lists u p o n the board. Ask questions like, "What does it feel like to be angry?" "How d o you know when you n e e d to go see the doctor?" "What makes a relationship a g o o d one?" "How do you avoid using drugs a n d alcohol?" " w h a t does 'coping' mean?" Solicit i n p u t from the patients a n d write it down. Patients really like to see their contributions u p on the board. It reinforces participation a n d validates their contributions. Call on patients by name. Similar to getting patients to c o m e to group, getting patients to participate is often m u c h easier if you give t h e m a p e r s o n a l invitation. Some patients may be too shy o r too disorganized to initiate a c o n t r i b u t i o n on their own, b u t will be h a p p y to contribute if asked. Be p r e p a r e d to r e p e a t the question (often several times) until the patient responds. We've often found it useful to call on those patients whose attention is start-
ing to drift, falling asleep, o r staring at s o m e t h i n g e l s e - calling t h e m by n a m e a n d asking t h e m a question directly can get t h e m to engage with the g r o u p topic once again. (Elementary school teachers seem to have discovered this t e c h n i q u e a l o n g time ago.) Be concrete and specific. Do y o u r best to avoid j a r g o n a n d "50-cent words." Keep your vocabulary a i m e d at an a u d i e n c e that typically has less than a high school education. W h e n talking a b o u t abstract concepts, always tie t h e m back into c o n c r e t e examples (preferably ones that the patients g e n e r a t e themselves). Many e x a m p l e s o f how to be concrete a n d specific can be f o u n d t h r o u g h o u t the descriptions o f the skills training modules. Enlist higher-functioning patients as allies. A l t h o u g h the majority o f patients on a psychiatric intensive care unit have serious t h o u g h t disorders, t h e r e are usually a few patients who are less d i s t u r b e d a n d are motivated to c o m e to group. It can be e n o r m o u s l y helpful to identify these patients a n d let t h e m know that you value their attendance a n d assistance. H i g h e r f u n c t i o n i n g patients are often g o o d at e n c o u r a g i n g o t h e r patients to c o m e to group, r e d i r e c t i n g disruptive patients while in group, a n d providing g o o d m o d e l i n g o f g r o u p behavior for o t h e r patients. In turn, these patients typically feel very validated by sharing their knowledge with others a n d knowing that you genuinely a p p r e c i a t e their help. Get patients talking to each other.. Patients struggle with similar stressors, challenges, a n d problems. They also often share similar goals: to live independently, to stay o u t o f the hospital, to stay clean a n d sober. As patients in g r o u p typically have varying degrees o f success in d e a l i n g with life p r o b l e m s a n d achieving goals, those who have h a d some d e g r e e o f success can be e n c o u r a g e d to give advice to those who have not. H i g h e r f u n c t i o n i n g patients are also typically m u c h m o r e receptive to f e e d b a c k from o t h e r h i g h e r f u n c t i o n i n g patients. Don't take yourself too seriously. H u m o r can be very engaging. T h i n k back o n y o u r own experiences in seminars, workshops, o r groups. You were p r o b a b l y m o r e eng a g e d by speakers who were dynamic a n d flexible, r a t h e r than r i g i d - - t h o s e who could work with whatever material the g r o u p b r o u g h t u p - - t h o s e who were able to laugh at themselves when they misspelled s o m e t h i n g o r momentarily forgot what they were talking about. K e e p i n g the energy level high a n d the m o o d o f the g r o u p lighth e a r t e d ensures that your groups will be less t h r e a t e n i n g than traditional groups. This, in turn, ensures that patients wilt be o p e n to participating actively in your groups a n d that they will look forward to c o m i n g back to g r o u p each day.
Dealing With "Difficult" Patients O u r discussion o f g r o u p process would n o t be complete without acknowledging that some o f o u r patients
Skills Training Groups in A c u t e Psychiatry can b e very h a r d to work with in the g r o u p setting. We'll discuss t h r e e g e n e r a l classes o f patients that can pose p r o b l e m s for you as the g r o u p l e a d e r a n d suggest some ways o f d e a l i n g with them. Floridly psychoticpatients. Some patients on the unit will be floridly psychotic; they will be e x p e r i e n c i n g auditory hallucinations, delusions o f g r a n d e u r o r persecution, ideas of reference, a n d loose t h o u g h t processes. W h e n patients are particularly psychotic a n d disorganized, the best solution usually is to avoid inviting t h e m to group. Sometimes, however, they will see the g r o u p beg i n n i n g a n d want to j o i n in. O u r policy has typically b e e n to let in any p a t i e n t who wants to come. We make special efforts to review the g r o u p rules with the disorganized patient a n d try to make sure that they u n d e r s t a n d that if they fail to a b i d e by them, they may be asked to leave the r o o m . These disorganized patients may t h e n either sit quietly a n d observe the group, m u t t e r to themselves, try to contribute, o r be l o u d a n d disruptive. If they try to contribute, we usually listen closely to h e a r if there is anything relevant to the g r o u p topic in what they are saying. Remarkably, t h e r e often is. If that is the case, we'll p u t their c o n t r i b u t i o n o n the b o a r d a n d move on. Fortunately, m a n y disorganized psychotic patients who are disruptive t e n d to get u p a n d leave the group. T h e best strategy t h e n is to simply n o t let t h e m b a c k in the room. It may be a g o o d i d e a to k e e p floridly psychotic patients o u t o f the g r o u p until you feel somewhat comfortable leading these kinds o f groups. Acutely manic patients. Patients with b i p o l a r affective d i s o r d e r who are in an acute m a n i c phase can be the most difficult patients for the g r o u p leader. They t e n d to d o m i n a t e the discussion a n d can be difficult to i n t e r r u p t o r stop. They invariably are aware that the g r o u p is going o n a n d want to be a p a r t o f it. They are often u n a b l e to sit still for the half-hour group. Like the disorganized patient with schizophrenia, we typically allow t h e m into group, b u t take extra care to make sure that they are aware of the rules a n d the consequences for violating them. If they are disruptive, we address t h e m by name, a n d impress u p o n t h e m that o t h e r patients in the g r o u p n e e d to have a chance to speak, a n d that we're willing to talk with t h e m one-on-one after the g r o u p is over. Manic patients typically want to e n t e r a n d exit the r o o m repeatedly. Again, your best b e t is to let t h e m o u t a n d n o t return. Hostile patients. Floridly psychotic o r acutely m a n i c patients can sometimes be quite hostile. Those patients who r e s p o n d to your invitation to a t t e n d g r o u p in an openly hostile m a n n e r are p r o b a b l y best left alone. Those who previously manifested hostility in g r o u p are best spoken to in a soft, calm voice a n d r e m i n d e d o f the rule p r o h i b i t i n g threats, violence a n d profanity. Verbal escalation can be a p r e c u r s o r to physical assault a n d should be taken very seriously. Patients who are escalating can be r e m i n d e d that
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these groups are entirely voluntary a n d that they are free to leave the g r o u p at any time. If you feel unsafe in the r o o m with the patient, d o n o t hesitate to leave the r o o m a n d inform nursing staff a b o u t what is going on. Finally, m a k e sure that you know where the panic b u t t o n is in the room. You never know when you m i g h t n e e d to use it.
Discussion This p a p e r outlines a novel g r o u p intervention for use in a locked, short-term psychiatric hospital setting. Based o n empirically validated psychosocial skills training approaches, the interventions d e s c r i b e d can e n h a n c e patients' u n d e r s t a n d i n g of their illnesses, as well as their skills in m a n a g i n g them. I m p l e m e n t i n g these groups o n o u r unit has c o n t r i b u t e d to o u r t h e r a p e u t i c milieu by providing patients with m u c h n e e d e d social interaction, validation, a n d respect. This skills training c u r r i c u l u m has proven useful because it directly addresses m a n y of the behavioral p r o b l e m s that are often e x h i b i t e d in the acute psychiatric environment. Because getting patients to a t t e n d g r o u p in this envir o n m e n t can be a challenge, we first d e s c r i b e d a n u m b e r o f different strategies that a g r o u p l e a d e r m i g h t use to ensure g o o d attendance. We n e x t e m p h a s i z e d the importance o f continuity a n d p a t i e n t expectations, as well as the i m p o r t a n c e of a consistent g r o u p structure within each session. We t h e n t u r n e d to a discussion o f g r o u p process, describing the difference between skills training groups a n d traditional process-oriented g r o u p psychotherapy, the role of g r o u p l e a d e r in this type o f intervention, a n d strategies that have proven useful in h e l p i n g patients to e n g a g e in these groups. We identified t h r e e categories o f difficult patients that are e n c o u n t e r e d when r u n n i n g groups, a n d we discussed how to address the challenges that they present. Finally, we o u t l i n e d seven different skills training modules, each o f which is i n t e n d e d to provide the r e a d e r with concrete, specific instructions for c o n d u c t i n g groups on topics such as a n g e r m a n a g e ment, c o m m u n i c a t i o n skills, c o p i n g with m e n t a l illness, a n d relapse prevention. We h o p e that by sharing o u r e x p e r i e n c e s o f l e a d i n g groups in this setting, we have given you some ideas a b o u t how you m i g h t comfortably a n d productively work with this p o p u l a t i o n in the acute setting. If l e n g t h o f stay were longer, these groups would u n d o u b t e d l y be m o r e effective in teaching skills that m i g h t generalize to improving o u r patients' social functioning. Each o f these topics could easily b e e x p a n d e d to fill weeks o f g r o u p time (e.g., L i b e r m a n ' s g r o u p at U C L A holds o u t p a t i e n t skills training groups with schizophrenics 12 hours a week for 6 m o n t h s ) . O u r reality, however, is an average l e n g t h o f stay o f a b o u t 10 days; the material d e s c r i b e d in these pages attempts to e n h a n c e the t h e r a p e u t i c milieu
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SKILLS TRAINING MODULES In each of these modules, tasks, statements, or questions intended for the group leader are printed in plain text. Items in italics represent responses that are likely to be obtained from group members.
Anger Management "What to do when you get angry" 1. Introductions 2. Review g r o u p rules 3. Ask g r o u p m e m b e r s "What does it feel like when y o u ' r e angry?" Put list up on the board. Likely responses include:
My heart beatsfaster I breathe more quickly I get sweaty I feel like lashing out I feel my gut tighten up I feel my muscles tense up 4. I n t r o d u c e exercise by telling group that there are different ways of h a n d l i n g anger; some are g o o d because they lead to positive consequences, and some are bad because they lead to negative consequences. 5. Put two columns up on the board labeled "good" and "bad." 6. "What are some o f the bad ways that you can handle anger?"
Yelling and screaming Hitting Killing Fighting Throwing things Breaking things Drinking alcohol/using drugs "Why are these bad?" Because they lead to negative consequences. "What are some negative consequences that m i g h t happen?"
Jail Get hurt End up back in hospital 7. "What are some good ways of h a n d l i n g anger?" Again, ask the patients to generate the list, and put their responses up on the board.
Exercise Walking Swimming Running Talking about it With someone who understands With someone you trust With the person that you're angry at using "I feel" statements Praying
S o m e g o o d ways to express a n g e r on the ward are:
Tell staff that you're feeling angry Take a PRN Walk away from the situation Spend some time by yourself to cool down 8. What are some g o o d ways of preventing anger?
Have a sense of humor Try to understand where the other person is coming from (empathy, walking a mile in their moccasins, etc.) Try to take responsibility for your own emotions--don 't let other people control them Count to 10 Take deep breaths Walk away
Goals "How to reach your personal goals" This g r o u p is designed to help patients learn how to identify the smaller steps r e q u i r e d for t h e m to achieve their personal goals. W h e n inviting t h e m to this group, tell t h e m that you'll be talking about what goals they would like to accomplish o n c e they get out of the hospital, and that the o t h e r patients will help t h e m figure out how to do it. 1. Introductions 2. Review group rules 3. Ask each g r o u p m e m b e r to identify a goal that he would like to achieve o n c e he gets out of the hospital. Most patients will be able to c o m e up with s o m e t h i n g concrete and specific to work with. G o o d examples include:
Independent living Getting a job Getting a driver's license Visiting with family Going back to school Applying for social security It's i m p o r t a n t that each goal c o m e f r o m the patient himself. You may n e e d to do some p r o b i n g to find o n e that's appropriate to work with. 4. For each patient, write his n a m e o n the board, and on the o t h e r side of the board, write the goal that he has given you. You'll e n d up with s o m e t h i n g like this:
Skills Training Groups in Acute Psychiatry
Here (in Hospital)
Goal
Bob Max Robin Dan Richard
Get an apartment Find a j o b Go back to school Start dating File for Social Security
Then, for each patient, you can work backwards from his goal and identify all of the subgoals or small steps that he needs to accomplish to get from here (on the ward) to there (in an apartment, job, etc.). This can be a great exercise for getting patients talking to each other. For example, you might ask patients "what steps does Bob need to take to get from here to living in his own apartment?" Group members might then volunteer that to get an apartment, one has to find out how much money one can spend per month, make sure that they have first and last month's rent and deposit, figure out what neighborhood they want to live in, get the classified ads, make telephone calls, and so on. Group members usually make good contributions, which you can list sequentially on each person's "timeline" on the board. Try to pace the group so that you don't run out of time before you get a chance to work with each member's goal.
Communication "How to get what you want from other people" This module helps patients to identify the elements of effective communication. A good way to "market" this topic when inviting patients to group is to describe the group as "How to get what you want from other people" or something along those lines. 1. Introductions 2. Review group rules 3. Get things rolling by asking patients what communication means. Generate a list of relevant responses up on the white board. Responses might include: Talking Sending messages Listening Getting your point across Asking questions 4. Point out that communication has three parts: sender, receiver, and message. 5. What are the different ways of sending a message? Discuss verbal vs. nonverbal ("body language," eye contact, etc.). 6. When is communication effective? When we're listening to the other person When we don't get loud or hostile When we try to understand "where the other person is comingfrom"
When our message is clear and direct When we are polite 14#ten we follow the group rules (one at a time, no profanity, threats or violence, stay on the topic)--point out that group rules are good rules to follow outside group 7. Use interaction with staff as an example of effective communication. • How to ask a nurse for something that you want or need • How not to ask a nurse for something 8. Consider role-playing if group interacts well.
Drugs and Alcohol "Reasons to use and not to use" Many psychiatric patients struggle with substance abuse. This group is intended to help patients focus on why it is important to remain clean and sober outside of the hospital and to give them some pragmatic suggestions that might help them. 1. Introductions 2. Review group rules 3. As a way of really getting patients engaged on the topic, consider beginning the group by asking patients what they like about using alcohol or drugs: What's good about them? Why do they use them? Typical responses might include: Makes Makes Makes Makes Makes
me feel more relaxed it easier for me to have sex me feel powerful my body feel good me forget my problems
4. Now that you've got everyone's attention, ask them to list some of the bad things that have happened to them when they have been using alcohol or drugs. Typical responses are: I lost all of my money I ended up in jail I got addicted and couldn't stop I had to go back to the hospital I lost my apartment My girl~end left me 5. The "Decisional Balance": typically the list of negative consequences of drinking or using is far longer than the list of positive effects. You can frame the pros and cons of continuing to use as a balance--while using has some attractive aspects, the negative consequences really make it a good idea to stay clean and sober. 6. How to stay clean and sober: Many patients will have had some substance abuse treatment experience, so it should be fairly easy to help the group generate a list of useful strategies. A typical list might be:
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• Avoid certain people: e.g., the so-called friends who only seem to show up at the first of the month, when most of o u r patients get their disability checks. • Avoid certain places. Everyone has their "slippery" places where they're most likely to use----could be a bar, a park, a downtown area, friend's house, etc. • Get help. Emphasize that no one can really stay clean and sober on his or h e r own. Run through a list of resources that are available: self-help groups (AA, CA, NA), and treatment available through your facility and o t h e r facilities in the community. • A relapse isn't the end of the world. Many p e o p l e think that if they slip up and have a drink or smoke that they m i g h t as well j u s t give up and keep o n using. A slip is a mistake that you can learn f r o m - - d o n ' t give up on your sobriety because o f it.
Relationships "How to make new friends" Patients often lack the basic knowledge and skills necessary to initiate and maintain social relationships. They often express interest in dating or making friends, but have little idea how to go about d o i n g that. This m o d u l e is i n t e n d e d to h e l p t h e m begin to o v e r c o m e these deficits. 1. Introductions 2. Review g r o u p rules 3. Ask patients what "relationship" means to them. Most will c o m e up with romantic relationships, but challenge t h e m to think of o t h e r kinds of relationships that p e o p l e can have. A tylaical list m i g h t also include:
Friendship Teacher-student Doctor-patient Neighbor Roommate 4. After making sure that all of the m e m b e r s understand what relationship means, in the b r o a d e r sense, ask t h e m to c o m e up with a list of things that make relationships good. A typical list:
Communication Trust Understanding Listening Respect 5. Make it c o n c r e t e by d o i n g s o m e m o r e specific social skills training. For example, how to initiate a conversation:
Make eye contact Maintain appropriate personal distance Ask another person about themselves
Identify a common interest Listen and respond 6. Consider m o d e l i n g a n d / o r group interacts well.
role-playing if the
Coping With Mental illness T h e majority of patients on the psychiatric intensive care unit are chronically mentally i11. They have suffered a lifetime o f terrifying symptoms, medication side effects, institutionalization and stigmatization. This g r o u p addresses techniques that can be used to help t h e m cope with the difficult aspects of mental illness in a very direct and up-front manner. 1. Introductions 2. Review group rules 3. Ask patients what "mental illness" means to them. Some m i g h t find this definitional exercise heavyh a n d e d or insensitive. Others m i g h t think that it would m e e t with m u c h resistance by patients who d o n ' t consider themselves to be "mentally ill." To the contrary, we have f o u n d patients' responses to this question remarkably insightful and powerful. Notice that this exercise does n o t require patients to label themselves as mentally ill, only to discuss what mental illness means to them. H e r e are s o m e typical responses f r o m our patients:
A different way of thinking A chemical imbalance in the brain Hearing things that other people can't hear Feeling nervous Feeling like everyone is out to get you Can't sleep People treat you differently Needing to take medication 4. Ask patients to define "coping." Again, you'll often be surprised by the degree of insight that patients have into what coping means. Typical responses include:
Dealing with it Adapting Adjusting Doing things differently 5. Finally, ask patients to g e n e r a t e a list of things that they can do to cope with their illness. Typical responses include:
Exercise Taking medication Going to school Lea~wing more about their illness and their medications Educating others about their illness (family, society) Avoiding alcohol and drugs Asking for help when they need it (from doctors, family, friends)
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In our experience, this exercise can take widely different paths. Some groups will focus on more superficial aspects of managing mental illness, while others will delve into heartfelt and poignant discussions of the pain of mental illness, touching upon the loneliness, stigma, and rejection that they have suffered.
Feeling really good Stopping medication Fighting with roommates Not going to appointments
R e l a p s e Prevention
Next, ask patients to make a list of things that they can do the next time they find themselves experiencing these warning signs so that they might be able to prevent rehospitalization. Here's a list of popular relapseprevention strategies:
"How to stay out of the hospital" This group is focused on helping clients to identify the early-warning signs of decompensation and useful strategies that they can employ to help prevent a fullblown relapse and consequent rehospitalization. When you invite patients to a class on things they can do to stay out of the hospital, you're almost guaranteed a good turnout. 1. Introductions 2. Review group rules 3. Ask patients how they know when things are starting to go wrong for them. What are the early-warning signs that they are headed back to the hospital? It's important to emphasize that each person's early-warning signs are different. Therefore, we encourage each patient to make a unique list of things to watch out for. Although it is best to make a list for each patient, if you have a big group, or are r u n n i n g out of time, you can make one big list. Here are some examples: EARLYWARNING SIGNS
Roherto Staying up all night Not eating Spending too much money Using methamphetamine Thinking that other people want to kill me Max
Hearing voices Sleeping too much Feeling hopeless Wife notices something wrong
a n d help patients learn all that they can within that time frame. Some patients (typically the higher f u n c t i o n i n g ones) have indicated that they have gotten a t r e m e n d o u s a m o u n t out of these groups. O t h e r patients (typically the severely disturbed ones) probably retain very little of the information. However, in o u r experience, almost all of the patients who attend these groups get something extremely i m p o r t a n t out of them: a sense of validation a n d respect, something that is often lacking in the psychiatric intensive care e n v i r o n m e n t .
• Call your outpatient doctor. Describe the symptoms you are experiencing, and ask for an appointment so that your medications can be reevaluated. • Talk to someone that you trust. This could be someone different for each patient. It could be a case manager, a board and care operator, a spouse, a counselor, or the patient's parents. Encourage patients to listen to what they say; other people often have a different perspective on our problems that we are not able to see in ourselves. • Don't stop takingyour medication. Many patients start feeling so good that they think that they no longer need to take medication. Ask your group how many people this has happened to (many hands usually go up). Then ask them what h a p p e n e d - usually negative consequences: jail, rehospitalizaLion, etc. • Take care of yourself. Make sure that you eat right and get enough sleep. • Don't use drugs or alcohol. Although drinking or using drugs may seem like a good thing to do when you're not feeling well, they typically lead to more negative consequences; it may work well in the short-term, but makes things worse in the long run. Each group will come up with other, idiosyncratic relapse-prevention strategies that you will have to evaluate for their own merit. Patients who are delusional will often come up with some interesting ones. Ask other patients if they think that the more outlandish strategies will w o r k - - i f not, ask them to give the delusional patient some suggestions about strategies that might work better.
O n e of us (KRW) initially drafted this m a n u a l while o n i n t e r n s h i p at the VA Palo Alto Health Care System. Early drafts proved quite useful in o r i e n t i n g s u b s e q u e n t interns a n d other trainees in how to work with groups in the locked, acute psychiatric e n v i r o n m e n t . As each new intern, trainee, or staff person has gained experience r u n n i n g these groups, he or she has typically seen the p r e s e n t c u r r i c u l u m as a starting p o i n t from which they have a d d e d new group topics a n d modified existing ones. O n a related note, we'd like to leave the reader with a
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Weingardt & Zeiss h u m b l e r e q u e s t . All t o o often, psychologists d e v e l o p an i n t e r v e n t i o n , a therapy, o r a m a n u a l i z e d t r e a t m e n t p r o t o col t h a t b e c o m e s a static entity with a life o f its own. It is l a b e l e d with a catchy a c r o n y m , is e m p i r i c a l l y v a l i d a t e d in clinical trials, a n d is vigorously d e f e n d e d against criticism. In contrast, t h e r e a d e r is invited to treat t h e p r e s e n t p a p e r a n d the p r o g r a m it describes as a w o r k in progress. We invite y o u to alter it a n d a d a p t it to y o u r specific treatm e n t setting. D e v e l o p skills t r a i n i n g m o d u l e s o n differe n t topics. C h a n g e the m o d u l e s to fit y o u r own prefere n c e s a n d needs. T h i n k critically. E x p a n d u p o n t h e m a t e r i a l , m o d i f y it, o r start over, if y o u prefer. So l o n g as y o u r f o c u s is o n i m p r o v i n g the p r o v i s i o n o f p s y c h o l o g i c a l services to a p o p u l a t i o n t h a t is sorely in n e e d o f t h e m , you d o so with o u r blessing a n d e n c o u r a g e m e n t . Finally, we invite you to s h a r e y o u r e x p e r i e n c e s d e v e l o p i n g a n d r u n n i n g t h e s e types o f g r o u p s with us e i t h e r f o r m a l l y o r i n f o r m a l l y so t h a t we c a n c o n t i n u e to i m p r o v e the quality o f services t h a t we p r o v i d e to o u r own patients.
Liberman, R. E, Vaccaro, J. V., & Corrigan, E W. (1995). Psychiatric rehabilitation. In H. I. Kaplan & B.J. Sadock (Eds.), Comprehensive textbook of psychiatry (6th ed., pp. 2696-2717). Baltimore: William & Wilkins. Liberman, R. E, Wallace, C.J., Blackwell, G. A., Eckman, T. A., Vaccaro, J. V., & Kuehnel, T. G. (1993). Innovations in skills training for the seriously mentally ill: The UCLA Social and Independent Living Skills Modules. Innovations and Research 2. 43-59. Liberman, R. P., Wallace, C.J., Blackwell, G., Kopeloicz, A., Vaccaro, J. V., & Mintz,J. (1998). Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. American Journal of Psychiatry, 155, 1087-1091.
Preparation of this manuscript was supported by the VA Health Services Research and Development Service and Office of Academic Affiliations. The authors gratefully acknowledge the valuable contributions of Xavier Apodaca, Ph.D., in developing this program. We would also like to thank Robert R Liberman, M.D., and his colleagues at the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation, whose social and independent living modules greatly influenced the content of the groups described in this manual. Address correspondence to Kenneth R. Weingardt, VAPAHCS (152-MPD), 795 Willow Road, Menlo Park, CA 94025; e-mail: Weingardt@ mailsvr.icon .palo-alto.med.va.gov.
References Benton, M. tC, & Schroeder, H. E. (1990). Social skills training with schizophrenics: A meta-analytic evaluation. Journal of Consulting and ClinicalPsychology, 58, 741-747.
Received: January 25, 2000 Accepted: March 29, 2000