A Guide to Creative Group Programming in the Psychiatric Day Hospital

Lois E Passi, Gary Rosenberg, Andrew Weissman

• Publisher: Routledge
• Year: 2012
• Print ISBN: 9780789004062
• eBook ISBN: 9781136378799
• Topic: Medicine
• Subtopic: Health Care Delivery

Unlike any other text that discusses day hospital programming, A Guide to Creative Group Programming in the Psychiatric Day Hospital contains protocols for the invention of new groups, saving you the time and effort needed to create one yourself. Intended for social workers, psychologists, and occupational therapists, this book introduces new and unique methods on how to invent or manage groups for a day hospital program, inpatient unit, or intensive outpatient program. The text also includes exercises that address the topics of motivation, self-esteem, shifting cognitive distortions, and risk-taking in relationships. Because the protocols were created with different types of patient groups in mind, this book contains ideas not offered in typical treatment settings. A Guide to Creative Group Programming in the Psychiatric Day Hospital is designed to help clinicians capture the interest of patients and to promote the discourse of important treatment issues by providing:

• 50 protocols for operating existing day hospital, inpatient or outpatient groups
• advice, professional opinions, and notes from the author to the clinician on all protocols
• exercises to help patients strengthen their abilities to handle the activities of daily living and socialization
• several hypothetical exercises, complete with a list of preparations, a description of the activity, and progress notes from observations with patient assessments
• numerous examples that use parts of popular movies to create new groups and stimulate discussion
• comprehensive, easy-to-follow instructions for both clinicians and patients The protocols in A Guide to Creative Group Programming in the Psychiatric Day Hospital contain detailed example activities complete with worksheets, skits, sample discussions, and hypothetical patient reactions to certain topics. Many exercises request that the patient set goals for himself or herself before starting a new topic. In addition, there is suggested homework for the patient to complete after a topic has been discussed, allowing you to monitor what your patients have learned and how they have improved after the exercise. After reading A Guide to Creative Group Programming in the Psychiatric Day Hospital, you'll be ready to treat your patients using easy, effective methods that will lead to successful group discussions and lessen the chance of patient relapse.

Chapter 1

How to Use This Book

This book was written for clinicians, especially those clinicians charged with designing a clinical program for a day hospital. It is therefore not a book about basic skills in group psychotherapy or other clinical skills. There are plenty of books written on these topics. It is assumed by this writer that the reader possesses basic clinical skills, especially in the area of group psychotherapy. The recent graduate receiving ongoing supervision will be able to utilize this book as well as the experienced clinician.

This book offers ideas for themes and outlines for creative groups that address these themes. Very little is said about process. The group outlines are the skeleton, while the process is the flesh of the group. I provide the skeleton. You provide the flesh.

This chapter begins with a discussion of the modalities utilized in this book. These include the use of movie clips, written exercises, oral exercises, therapeutic games, role-play, homework assignments, and what I call the “use of metaphor.” Each chapter of the book discusses the therapeutic themes addressed in the groups, which include relapse prevention, goal setting and support, cognitive restructuring, activities of daily living, social skills, socialization, self-esteem, affective issues, motivation, and exercise. I also discuss ideas for starting and ending the day. Later in the book I discuss versatility; that is, taking a group outline and adapting it in various ways to fit the needs of the group with which you are working at a specific time.

You should feel free to use these groups as they are presented in the book or to alter them in a way that suits you. My only request is that you clearly state, when presenting the group to others, whether you are using my group or your own version. You may also find that you want to invent your own groups. This is ideal since every program is different. If you learn enough from this book to create your own program without using any of the groups outlined in the book, that is fine. The goal is for you to design a top-quality clinical day hospital program. I place particular emphasis on this because the groups I invented were for use with a psychiatric population participating in a short-term day hospital program. The population I had in mind included people with psychotic disorders, affective disorders, and personality disorders. There are many populations I did not have in mind when I was writing, including recovering addicts, Alzheimer's patients, and young children. So the motto for you is “adapt and invent.”

A NOTE ABOUT CREATIVITY

Some of you may be saying, “I'm not the creative type. I can't do this.” Plenty of people have said this to me. I, therefore, want to offer some encouragement regarding creativity.

First, view everything in your life as potential teaching material for the day hospital. When you go to a movie, be aware of themes and clips that might illuminate issues germane to patients. When you read stories, consider what might be useful. For example, I read the Mahabharata, a Hindu epic which includes the famed “Bhagavad Gita.” While I was reading the Mahabharata for my own personal pleasure, I kept the day hospital in the back of my mind in order to easily recognize useful material for the program. For example, there is a story in it about a king who is addicted to gambling and gambles away his entire kingdom in one day. I thought that the story powerfully illustrated the first of the twelve steps of AA: “We admitted that we were powerless over alcohol (or any addictive substance) and that our lives had become unmanageable.” I read the story (after editing out parts of it) to a group for dually diagnosed patients.

Second, ask others for ideas. Most people will tell you about a therapeutic game they played in a workshop or something they heard a colleague do. Their ideas will be the groundwork for your own ideas.

Third, relax. Don't try to force anything. Ideas will naturally come to you. The more you try to force them, the more blocked you will be. When I try to force something, I am never creative. Then, when I'm lying in bed, something just appears in my mind.

Remember to always keep the therapeutic theme central, not the modality. The modality serves the therapeutic theme. The milieu serves the therapeutic purpose. In other words, you don't want to say, “What kind of group can I make from this movie?” You want to say, “What can I use to discuss the theme of decreasing isolation? Are there any movies that will help me with this?” I can't emphasize this point enough. Many people are pressured to come up with a group. They have some materials (perhaps some art materials or an article) and they ask themselves, “What can I do with this?” This is the avenue for designing a group that serves the clinician's needs, not the patients' needs. It would be better to simply have an open discussion about a topic that is salient for the group than to force a theme from some movie or art material.

STANDARD ACTIVITIES

With some exception, I decided not to discuss standard activities. By standard activities I mean those activities that are often utilized in day hospitals or inpatient units for groups. For example, while I offer a brief discussion about how to view exercise groups from a therapeutic context, I do not discuss specific types of exercise activities. Most programs have equipment for basketball, volleyball, whiffleball, and so forth. I also say nothing about arts and crafts, a frequent activity of inpatient and day hospital programs. Most programs also offer standard vocational groups, which include didactic groups about resume writing, interview skills, vocational goal setting, and so on. Other groups not discussed in this book include the standard, open-forum group psychotherapy, recovery groups for dually diagnosed patients that focus on the twelve-step program, medication education groups, and groups focused on other health concerns, such as safe sex and nutrition. My aim in writing this book is to provide clinicians with creative possibilities beyond the standard groups that are usually offered.

MODALITIES

Earlier I alluded to two different ways of categorizing the groups: by modality and by therapeutic theme. Modality refers to the nature of the milieu itself—to the materials and modes of expression that are used. Using movie clips as a catalyst for discussion is an example of one modality. The movie clips can be used to address a wide variety of therapeutic themes, such as isolation, relapse prevention, and so on.

None of these modalities is unique. Many people have used movie clips to ignite discussions or illuminate themes. Oral and written exercises are certainly not new. Therapeutic games and role-play have been used for years. What I offer in this book is a way of putting these modalities together to create a high-quality day hospital program.

One important aspect of all of these modalities is that they allow you to create a program with very little money. They also allow programming with a minimum of staff and space. It is assumed that many people operate with these restrictions, hence they were kept in mind when designing groups.

Written Exercises

Written exercises help patients to organize and articulate their thoughts about a particular issue. They also provide the patient with something tangible to take home and to refer to in the future. This is especially important because many patients have poor concentration and memory skills. Anything that can be put down on paper has a better chance of being retrieved for future use. Additionally, patients may not be ready to really dig in and do the work on a particular topic when you see them; however, they might be ready to look more closely at that topic six months later. If they can refer to old notes, worksheets, etc., all the better.

Some examples of written exercises offered in this book include Hospitalization Review, The Size of the World, certain parts of the Creating the Support Team series, and Mountain Exercise.

Keep several things in mind about written exercises. First of all, be mindful of people who do not comprehend the written word very well, whether it is because of a language barrier, poor education, or poor intellectual functioning. It may be useful to translate your written exercises into Spanish and any other language you think may be spoken with some frequency by patients in your unit (this is true of all reading material as well). When designing written material, keep the language simple.

You should also be mindful of the person with physical problems who may have difficulty with a writing exercise. For example, cogentin, a frequently prescribed drug that helps to mitigate the side effects of some neuroleptics, causes blurred vision. Lithium as well as other drugs sometimes cause hand tremors, making it difficult for patients to write.

In addition, psychotic thought process may be the cause for a patient's inability to comprehend written material and follow through with the exercise. Also, a debilitating depression may make it difficult for someone to have the motivation to stick with an exercise.

It is important to look around the room and be mindful of who may be struggling with the exercise. Provide individual help where appropriate. Don't just look for people who aren't working. Some people may be writing and, from a distance, may appear to be fine. When you look at what they are writing, you may find that it is psychotic or that they have no comprehension of the exercise. The point is, never assign an exercise and then leave the room or concentrate on something else, such as your own paperwork. Circle the room and take a good look at what patients are doing; make yourself available for questions and individual tutoring.

Oral Exercises

Oral exercises are those structured exercises that do not require writing. Some examples in this book include Stating Your Case, some parts of the Creating the Support Team series, and conflict resolution skits, What's in a Hospital? and What Is Relapse Prevention?

Again, with oral exercises, be mindful of anyone who may have a limited command of the English language. You will need to employ all your group-work skills to handle overactive and underactive patients, impulsive patients, and grossly psychotic patients.

Role-Play

Role-play is standard fare in didactic groups. Some examples of exercises in this book in which role-play is key include parts of Creating the Support Team, and conflict resolution skits Old Maid with a Twist and Rewriting Your Life.

Props can be useful in role-play. For example, play telephones are useful when rolep-laying the invitational call for Creating the Support Team. I will often begin by doing the role-play myself. I will start with someone who is more proficient at it and later include less proficient people. Sometimes I ask one or two proficient patients to sit next to someone who is lower functioning so that they can feed them lines when they get stuck.

For example, I once ran an assertiveness training group in which one of the patients was having great difficulty refusing entry to her alcoholic friends who often came knocking at her door late at night. She was chronically suicidal and identified this stressor as one of the causes for her suicidality. The group room in which we were working was adjacent to a kitchen with a door. I asked three strong-willed men in the group to play the part of her friends. They got cups of water to simulate alcoholic beverages. The patient was sent into the kitchen with the remaining three patients, who were to coach her in ways to keep these men from entering the kitchen when they knocked to come in. Not only did the patient improve her ability to assert herself, but the other three patients learned from the experience as well (as observed by their comments at the end of the group when I asked what they learned). Additionally, one of the men developed an awareness of the impact of his actions on others (he, at times, imposed his will on others). Last but not least, a good time was had by all—including me.

Therapeutic Games

Therapeutic games, as well as movie clips, help to make a full day of therapy—day in and day out—bearable. No one could stand four hours' worth of intense psychotherapy, even if they were highly motivated, psychologically sophisticated, and possessed the ability for delayed gratification, which is not the case for many people in a day hospital. Therapeutic games provide fun along with difficult therapeutic work. Another advantage to therapeutic games is that dynamics often are played out without the conscious awareness of the patients. They do not have to confess their dynamic shortcomings during the game, they only have to act them out. The discussion comes afterward (therapeutic games should always end with process). Some examples of therapeutic games included in this book are Self-Expression Game, The Balancing Act, Crisis Game, and the various games in Games Made Therapeutic.

I also include a discussion of ways to adapt for your use existing therapeutic games not necessarily constructed for a psychiatric population. Some therapeutic games, however, such as those that involve jumping from trees into other peoples' waiting arms, are simply unsuitable for this population (and do not meet the insurance requirements of the hospitals, in all probability!).

In my experience, several key things are required to make therapeutic games work. First, designing them and setting them up require a lot of work. Second, it is important to screen out people who cannot handle the therapeutic game and run an alternative group for them. Possibilities include people who cannot handle the game for physical reasons (such as someone who experiences dizziness for an eyes-closed exercise) or people who can't handle the demands of the game for psychological reasons (too psychotic or developmentally disabled to comprehend). There is nothing worse than running a game with a handful of people who can play full out and another handful of people who have no idea what's going on!

Third, be mindful of space when designing therapeutic games. Make sure you choose indoor games that can be used in the winter, summer, or in inclement weather. If the game requires people to be out in the hallways, make sure that they will not be too noisy or disruptive if there are other practitioners in adjoining offices conducting therapy sessions. Also, be aware of patients who tend to wander if the game requires them to leave the room. It is much harder to supervise people once everyone leaves the group room.

Use of Metaphor

By “use of metaphor” I am referring to the use of some special prop or set of props to metaphorically illustrate a ...

Table of contents

• Cover
• Half Title
• Routledge Social Work in Health Care
• Full Title
• Copyright
• Dedication
• About the Author
• CONTENTS
• Acknowledgments
• The Groups in Alphabetical Order
• Chapter 1. How to Use This Book
• Chapter 2. Theory and Technique: The Context for Creative Groups
• Chapter 3. Beginning the Day
• Chapter 4. Relapse Prevention
• Chapter 5. Goal Setting and Support
• Chapter 6. Cognitive Restructuring
• Chapter 7. Activities of Daily Living
• Chapter 8. Social Skills
• Chapter 9. Socialization
• Chapter 10. Self-Esteem
• Chapter 11. Motivation
• Chapter 12. Affective Issues
• Chapter 13. About Exercise
• Chapter 14. Versatility
• Chapter 15. Ending the Day
• Bibliography
• Index