Given the complexity of the symptoms, the associated distress and degree of isolation experienced by many youth experiencing an episode of psychosis, the use of group as a therapeutic tool is a valuable option for the clinician. Whether individual youth can be integrated into other youth oriented groups will depend on an assessment of their communication skills, boundaries and maturity.
The group process takes place within the context of youth developmental needs and behaviours and can allow individuals to explore their theory of their illness and assert their autonomy.
Steps in forming a group
Step One: Setting the Goals
The goals of the group need to be clearly articulated prior to involving youth and their families. These goals should be measurable so that they can be incorporated into the evaluation in of the group. A group may have a psychoeducational focus, recreational focus or utilize a specific therapeutic technique (e.g., cognitive behaviour therapy). A group facilitator may also sometimes opt to have a group of a particular framework (i.e., general goals) but then have members of the group play an active role in the selection of more specific goals.
Step Two: Group Attendees
Ensuring that groups have achieved common emotional and social developmental stages is challenging given the devastating impact of psychosis on young people’s lives. To the extent possible, try to ensure that group members fall within the same age range.
Pregroup interviews are recommended with each youth in order to cover the following:
It will be necessary to explain to family members the purpose of the group as well as rules regarding confidentiality and reporting. It is important to establish boundaries clearly before a youth is enrolled in a group.
The Fraser EPI Programs have successfully run a number of youth groups with youth with varied psychotic disorders and a range of severity. The commonalities of youth and of mental illness are more important than their differences. The youth found the ability to socialize with empathic and knowledgeable facilitators essential to the group however, they showed little desire to judge their peers or challenge others’ perceptions of their symptoms or recovery.
Step Three: Location and Timing
The site needs to be youth friendly and offer both privacy and the practical necessity of running a group. Hospitals may represent locations which youth associate with involuntary admissions, authority figures and the acute symptoms. Choosing a site where youth can take breaks, is easy to access and offers safe routes home is essential. The activities of the group can also dictate choice of site if meals or recreational activities are planned. Youth friendly sites can be difficult to find.
Groups attendance is often helped by holiding groups in the afternoon or evening. Medications, lack of energy and need for rest often make mornings particularly difficult for clients.
Depending on the time of the group, the length of each session as well as the number of sessions should be determined by the goals and purpose of the group. The amount of commitment a group attendee must exert in each session is often determined by the number of sessions. Bear in mind that for some youth the group session may be their only activity of the day and that to concentrate and be social may represent a major undertaking. Even the most positive group experiences require energy and commitment from participants.
Step Four: Safety Issues
A thorough review of any assessments needs to look at youth’s social skills, history of behavioural challenges and current substance use. A pre-group interview should address group norms about behaviours, drug use and interactions with other youth from the group. Youth experiencing an episode of mania may have difficulties adhering to appropriate in-group and after group norms about boundaries. It is important to clarify at each session the need to respect each other’s recovery. It is the role of the group leaders to monitor psychological and physical safety issues closely. Ideally there should be two group therapists present for each group.
Step Five: Activities
The range of activities should be broad while recognizing the implications of psychotic symptoms. Many patients experiencing positive symptoms have difficulties regulating their environment – so overstimulation is a risk. Similarly, dilemmas caused by lack of stamina, non-accessible social skills, cognitive impairments and stigma will inhibit the options available. However many activities such as relaxation exercises, role plays, small group activities, discussions and short written assignments are easily conducted. For additional ideas from the experiences of the Fraser South EPI program see the attached document.
Step Six: Evaluation criteria
The evaluation criteria will be defined by the goals and purpose of the group. It is recommended that both a pre and post assessment tool be used to explore the specific domains which were the targets of the group intervention. Client satisfaction evaluations and process notes are the minimum requirements for conducting a group. Checking with the group members throughout the course of the sessions is helpful in determining whether the progress remains helpful. Depending on the abilities of the group members’ – in-session assessments can be done.
Exploring the reasons for drop out may have implications for group. However, not all drop outs from the group mean that the experience was not therapeutic or positive; in some cases, drop out may reflect recovery.
Think about what clinical skills are required of a group facilitator to run a group for youth recovering from psychosis. If you have run a group in the past, think of any problems you have encountered and brainstorm on how you could deal with these problems if encountered again in a future group.