Venue: Anita House, North Hackney CMHT

Duration : 8 sessions (24.10.08 12.12.08)

Group facilitators: Gulsen Huseyin, Clinical Psychologist
Martin Rodriguez-Tellez, Employment Coach
Kerine Robertson, ST4 Psychiatrist
Michael Kabia, CPN
 Who is the Group for?
Those who have distressing psychotic experiences, particularly those
who hear voices.
A closed group comprised of service-users referred from the North and
South Hackney Continuing Care CMHTs.
Service-users who are not likely to feel too uncomfortable in a group
setting, and feel able to actively contribute to group discussion.
Service-users who are currently able to attend and listen to other group
members, and think openly and flexibly about mental health issues.
What does Recovery mean?
The concept of recovery has been introduced primarily by people
who have recovered from mental health experiences, rather than by
mental health professionals. It means different things to different
people and definitions of recovery are multiple.
Mental health recovery is a journey of healing and
transformation enabling a person with a mental health problem
to live a meaningful life in a community of his or her choice
while striving to achieve his or her full potential.
National consensus statement on mental health recovery, December
2004, US Dept of Health and Human Sciences

a personal process or tackling the adverse impacts of

experiencing mental health problems, despite their continuing
or long-term presence. It involves personal development and
change.
Leading mental health charity Rethink (Frak, 2005)
 In line with;

Recommendations from the Alternative Pathways

project, where service users emphasised the
importance of recovery (Sandhu, 2007).
The DoH (2008) asks services and practitioners to
work according to the values and principles of a
recovery approach. Numerous other policy
statements and documents across the disciplines
also call for mental health practitioners to promote
recovery in all aspects of mental health care.
NHS mental health Trust and NICE Guideline targets
to promote recovery, empowerment, social inclusion
and a user-centred service (NIMHE guiding
statement on recovery, 2005)
10 Fundamental Components of Recovery:
Self-direction
Individualised and
Person-Centred
Empowerment
Holistic
Non-linear
Strengths-based
Peer support
Respect
Responsibility
Hope
 Aims of the Group
To promote recovery from psychosis-related mental health problems by:

Creating a safe and supportive space, and a common language

within which mental health experiences can be shared and understood
Sharing knowledge about how perceptual experiences can cause
distress
Sharing skills, or strategies that have helped others to cope with
distressing perceptual experiences
Introduce group members to written materials and other resources
developed by those with similar experiences
Create a sense of belonging and connection with others, in realising
you are not alone
Empower group members to facilitate their own recovery by taking an
expert position in their own lives
Promote mental health awareness and communication between;
those in the group, and between users and workers within mental
health services
 Narrative Therapy
Draws on aspects of Narrative Therapy
(Michael White and David Epston, 1990s)
Aims to be non or anti-pathologising. No position held on the causes
of problems, instead the focus is on unique outcomes and what
works.
Options are made invisible by the dominant narrative, and therefore
need to be made visible by developing and re-constructing a
preferred, more freeing narrative.
Undermines sense of failure and paves the way for co-operation in
struggle against an external problem (the problem, not the person is the
problem).

Promoting recovery using Narrative Therapy

One aspect of facilitating recovery may involve hearing the stories people
have to tell and accepting their own words and terminology, thus creating a
space for dialogue and exploration that can further understanding.
(Dillon and May, 2002)
 Referral Pathways
North and South CMHT meetings
Caseload reviews with Care Co-ordinators
Service-User leaflet and self-referrals
Group Protocol for professionals

Referrals

No. referrals = 10 (8 NHCMHT, 2 SHCMHT)

4 (CP), 3 (Psychiatrist), 2 (CMHN), 1 (Employment coach), 0

(self-referral)
5 attended initial screening appt out of 7 invited to attend, 3
declined, 2 DNA
 Resources needed
Service User authored article
Power to Our Journeys. An Exploration of an
alternative community mental health project.
Dulwich Centre Newsletter, 1997 No. 1
Flipchart board with A1 poster paper and
mixture of chunky and thin felt pens for
group/poster exercises
Copies of Mindfulness of Breath exercise
Structure of the eight week Group:
Topic and paragraph discussed
Session 1 Power to our Journeys
Introduction from authors
Session 2 Giving hope to others through
sharing of the group experience

Session 3 Acknowledgement of our

experience section
Session 4 Changing our relationship with
the voices
Session 5 Sharing experiences and The
negative voices and visions as
wreckers section
Session 6 Lightness of being section

Session 7 Justice and Medication section

Session 8 Logo and Conclusion section

 Structure of each session
Session plan sheets were provided for all participants at the
beginning of each session:

Review ground rules e.g. Confidentiality, respect time to talk

Feedback from last session
Read and discuss article (with trigger questions)
15 minute break
Flipchart exercise
Most Important Event Question
Mindfulness of Breath exercise
 Flipchart Exercises

Advantages and disadvantages of:

Sharing with others

Stepping outside of the expectations of
others
 Attendance
The table below shows the number of clients who attended the group
each week:
Group Sessions Total no. of
Member attended sessions attended

LC 1, 3, 4, 5, 7, 8 6

SD 5 1

JE 1, 2, 4, 5, 6 5

AK 1, 3, 4, 6, 7 5

JW 2 1
Recovery Group Outcomes
Mental Health Recovery Measure (MHRM):
(Young & Bullock, 2003)
Group Member MHRM pre-group MHRM post-group
score score
LC 87 94

SD - -

JE 74 71

AK 90 99

JW - -

Total score = 120, Average score = 80 (SD = 20)

 MHRM Conceptual Scores
GM MHRM pre-group conceptual scores MHRM post-group conceptual scores
OS SE L BF OWB NP S A & E OS L BF OWB NP S A
& S E & &
SR SR E

LC 10 10 11 13 11 10 7 9 12 13 13 12 13 13 8 10
* * * * * * *

SD - - - - - - - - - - - - - - - -

JE 10 10 14 9 8 10 6 7 9 9 11 9 10 9 6 8
* *

AK 13 10 12 12 12 12 8 11 15 12 13 12 13 16 7 11
* * * *

JW - - - - - - - - - - - - - - - -

Eight conceptual model-based subscales of the MHRM are as follows:

Overcoming Stuckness (OS)
Self-Empowerment (SE)
Learning and Self-Redefinition (L&SR)
Basic Functioning (BF)
Overall Well-Being (OWB)
New Potentials (NP)
Advocacy/Enrichment (A&E)
Also the role of Spirituality in the recovery process (S)
(* denotes an increase in scores)
Qualitative Outcome Data
Thematic Analysis
of Post-group
facilitator notes
 Disconnection and Loss
Group Example of notes and comments
Session

2,5,6 Paranoid beliefs as a cause of disconnection

Knowledge and skills that may have been

buried

Loss of friends and jobs/prospects

Loss of a sense of belonging

 Solidarity, connection and sense of belonging
Sub-ordinate themes Group Example of notes and comments
Session
Facilitators of group 1,4,5,6,8 Drinking tea and smoking
cohesion together
Feedback phrase
Same religious background
Teamwork through flip chart
exercises
Solidarity and 2,3,6,7,8 Shared sense of injustice within
connection with mental health services
others Developing a shared language
for experiences
Reference to absent group
members

Future plans for 6 Lets have an end of group

members of the party!
group Go to same the care home?
Same gym?
Causal and maintenance factors of mental health problems
Sub-ordinate themes Group Example of notes and comments
Session
Drugs 1,3,6 Cannabis, crack cocaine use

personal and family 1,6,8 Family pressure and tensions

circumstances
Interplay between biological 3 Weakness in the brain
and social factors Stress and stigma

Cultural and spiritual 4 Source of fantasies

influences
Perceived expectations of 6,7,8 Family expectations e.g. marriage
others that lead to feelings of
low self-worth
Stigmatisation 1,2,3,4,5 Experiences and fears of
stigmatisation
Keeping silent about the voices
Feeing guilty, ashamed and
misunderstood
 Ways of coping with mental health problems and
voices
Sub-ordinate themes Group Example of notes and comments
Session

Positive ways 4,6,7,8 Social support

Medication enables to interact with
others
Praying, reading the Quran and having
faith in your religion as well as yourself
Support from Care co-ordinator
Mindfulness exercises to cope with
stress
Putting the voices in pigeon holes
Telling the voices to naff off
Talking to others and gaining another
perspective
Negative ways 5,7 Alcohol and drugs lead to a loss of
control and an altered mind
Medication
Gaining knowledge and 4,5 Learning
multiple perspectives Gaining knowledge from others
 Sharing

Sub-ordinate themes Group Example of notes and comments

Session

Advantages 2,3,7,8 Sharing knowledge and strategies as

way of strengthening the brain
Reducing isolation by interacting
through group discussion

Disadvantages 4,5 Concerns about negative impact for

self and others mental well being
Makes us feel vulnerable
Can lead to feelings of shame
 Recovery
Individual pathways to 1,4 Going at your own pace, finding
recovery your own pathway and making
choices
Reflecting about where you are
and where you want to be
Developing independence 6,7 Developing self confidence and
independence through the group
Ambivalence about becoming
independent
Shifting away from 6 Spending money more wisely
materialistic values
Overcoming 1,2,4,8 Giving up smoking
obstacles Resolving personal and family
issues
Deciding not to withdraw and
attend the group
Learning from experiences
Pooling sources of support and
overcoming fears to access them
Gaining a sense of 6 Through group attendance
achievement (through Through seeing a group session to
group) the end
Relationship with NHS mental health services
Sub-ordinate Group Example of notes and
themes Session comments

Negative 3,5,7,8 The system people doing

(unhelpful wrong against us
unjust Hospitalisation traumatic
Dis- Adverse experiences in
empowering) Hospital with medication
Having decisions made for you
Free will taken away

Compliance 7 Eager to please - a

contradiction of self

Medicalising Treating mental health

mental health 3,7 problems like physical health
problems problems
 Promoting empowerment
Sub-ordinate Group Example of notes and comments
themes Session

Ownership 1,2,3,4,5,8 Volunteering to do writing,

reading and dishes!
Making choices
Equalizing
level playing field
Allies in a partnership

Independence 4 Less dependence on group

facilitators and the need to
dominate the group space
Taking an expert 5,6,8 Teaching others e.g. Coaching
position other ways of coping
 Boundaries
Sub-ordinate Group Example of notes and
themes Session comments

Breaking down 1,2,3,4,7,8 Gaining group consensus

us and them Breaking down barriers
barriers between service-users and
mental health professionals
Alliance and partnership
Experiences are global and
normal
Testing 7 As a means of establishing
boundaries control
Crossing SU- 7,8 Personal disclosure from
professional facilitators tensions and
boundaries demands
Over familiarity
Respect and 1,5 Careful to choose what times
Reciprocity to talk and what to say
Taking time to talk and listen,
making tea!
Feeling listened to
 Safety

Sub-ordinate Group session Example of notes and comments

themes
Feelings of safety 1,2,3,4,5,8 Overcoming fears of attending
Ground rules reassuring
Awareness of the need to look after
selves
Memories of school and the
classroom leading to unease
Ambivalence about group attendance

Trust 1,2,3,4,5,7 Feeling comfortable

Revealing vulnerabilities
Openness and honesty about the past
 Coping in a group
Sub-ordinate Group Example of notes and
themes session comments

Request others 3,7 Request to listen and sit back

do not place Complaints of feeling unwell
demands on or stressed
them Dependence on others

Support group 1,5,6,7 Seeking explanation of words

Supportive, kind and
welcoming of one another

Reward 6 Mindfulness exercise as a

gift
 Most Important Event

Question:
Of the events that occurred this
session, which one do you think was
the most important for you personally?
Why was it so important for you?
 The table below lists the most important events chosen by group members:
Event category M.I.E chosen by group members

Personal relevance of the article Visions and voices are wreckers in work, friendship and family
(Shared experiences and normalisation) Basically we tackle situationsrelevant to the cause
From the Power To Our Journeys I found it interesting because
of people dealing with the same problem far away
Hearing voices and seeing visions discussion was interesting
because Ive had fresh experiences.
Universality*
Self-understanding*
De-stigmatization All non-judgemental
Acceptance*
Continuity Continuity important for me on an equal level
Discussing feedback from last session. This was about being
professionally handled by medical staff.
Continued discussion
Every session is important
Attendance Attendance

Group cohesion Group discussions a continuing improvement

Language of the article
I like talking in the group. (2)
More of a collective contribution
Its going really well
Friendship and learning
I like people who attend
Spirit very important
Acceptance*
Big words

*Therapeutic group factor (Bloch et al., 1979)

 Most Important Event (M.I.E.)
Bloch et al (1979)
Taking all the qualitative data analysis into account, the group was most notably observed to
fulfil at least 7/10 group therapeutic factors classified.
Namely;

Self-disclosure
(The act of revealing personal information to the group)
Learning from interpersonal actions
(The attempt to relate constructively and adaptively within the group)
Universality
(Perceiving others as having similar problems and feelings, therefore reducing own sense
of uniqueness)
Acceptance
(Sense of belonging, being supported, cared for and valued by others unconditionally)
Altruism
(Feeling better about oneself/learning something positive through helping other group
members)
Guidance
(Receiving useful information and advice about problems from others)
Self-understanding
(Learning something important about behaviour, thoughts etc through feedback or
interpretation by the group)
The remaining 3, which were not so obviously observed, were:
Instillation of hope
Catharsis
Vicarious learning
 What came after
Therapeutic letters (a therapeutic document)
A document of knowledge and affirmation
Helpful when people are in danger of losing their
preferred identities (consolidating the subjugated
narrative they have developed)
Useful in stressful situations when people are most
likely to forget the knowledge and skills that they have
acquired
Follow-up appointments to develop a
recovery plan
 Summary of Evaluation
Q. What do the outcomes tell us about the extent to which we have met the group
aims?
The main aims were to promote recovery from psychosis-related mental health problems by:

Aim Supporting evidence in theme and MIE

category:
Creating a safe and supportive space, and a common Safety
language within which mental health experiences can Trust
be shared and understood Support group
Coping in a group
Causal and maintenance factors of mental health
problems
Boundaries
Respect and Reciprocity
Personal relevance of the article (MIE)

Sharing knowledge about how perceptual experiences Sharing

can cause distress Stigmatisation
Disconnection and loss
Loss
Openness and honesty
Trust
Sharing skills, or strategies that have helped others to Ways of coping with mental health problems and
cope with distressing perceptual experiences voices
Recovery
Overcoming obstacles
 Aim
Introduce group members to written materials
and other resources developed by those with
similar experiences
Create a sense of belonging and connection
with others, in realising you are not alone
Empower group members to facilitate their
own recovery by taking an expert position in
their own lives
Promote mental health awareness and
communication between; those in the group,
and between users and workers within mental
health services
Supporting evidence in theme and MIE
category:
Personal relevance of the article (MIE)
Language of the article (MIE)
Solidarity, connection and sense of belonging
Breaking down us and them barriers
Group cohesion (MIE)
Personal relevance of the article (MIE)
Promoting empowerment
Boundaries
Medicalising mental health problems
Relationship with NHS mental health services
De-stigmatisation (MIE)
 Recommendations
More referrals for bigger groups

Use non-verbal materials produced by service-users e.g. DVDs.

Art, photos to tap into peoples different strengths.

Ensure goodness of fit between materials and group members

i.e. level of educational attainment, concentration and attention

Move beyond psychosis to include recovery from other severe

and enduring mental health problems e.g. those diagnosed with
BPAD

Promoting wider use of a recovery-based approach by

continually involving non-psychologists as co-facilitators. Ideally
these should be permanent CMHT workers so that the skills and
knowledge stay within the service.
 Future Possibilities
Recruit service-users as paid co-facilitators
Possible funding via the Florid Organisation?
Increase access to the recovery group for
others, including;
Non-English speaking service-users and other ethnic
minority groups (in line with the Delivering Race
Equality initiative in mental health care; DRE, DoH,
2005).
Those in other Hackney mental health services e.g.
AOS, Rehab & Recovery Team? Voluntary Sector
services?
Open up to other boroughs within the trust?
February 2009
 Members Said
By sharing our experiences we gain knowledge of our
conditions
Contact with mental health staff is useful but it must
be professionally handled
To understand and make time to find out about a
persons background and history
Team work, positive sharing, positive outcome
Bridging the gap between mental health professionals
and peoples understanding of mental health
experiences and problems
Being aware of sources of support, overcoming fear,
and finding confidence to access support
 Contact

gulsen.huseyin@eastlondon.nhs.uk
martin.rodriguez-tellez@eastlondon.nhs.uk