The groups were set up to meet the needs of service users with chronic psychotic illnesses (including bipolar), and to implement the recommendation for offering arts therapies in the NICE guidance for management of psychosis and schizophrenia (CG178, recommendation 18.104.22.168).
In line with the guidance, the focus of the groups is therefore particularly on the negative symptoms of psychosis such as struggles with motivation and concentration, withdrawal, isolation, and depression. The first group was set up in 2016- 17 in East Hertfordshire and ran for 30 weeks. In Jan 2018 we extended this to two groups, one in East Herts and one in North West Herts, both of 20 week duration, and have repeated this for 2019. The groups are for up to 6 participants and take place at the community mental health buildings. They are co-facilitated by a dramatherapist and a dramatherapy trainee.
A range of dramatherapeutic activities are utilised, tailored to the groups needs, interests and confidence with the overall aims of building motivation, concentration, self-worth, skills and confidence in relating and communicating with others.
Individuals are welcome to attend up to 3 groups depending on spaces.
Outcome measures: CORE, Goal based outcomes, and patient feedback questionnaires, are used to evaluate the groups. Responses from participants have been very positive.
Aims and objectives
The group was created for people living with psychotic symptoms who may be finding it difficult to find motivation, to engage socially, to voice and connect with their feelings. The focus is on strengthening the ego and resilience by building sense of self and identity, confidence in ability, reducing isolation and building communication. This is done through drama exercises. The group members are also invited to come up with their own individual goals and rate them at the start and end of therapy.
The dramatherapy activities applied have different aims:
Mediation and grounding - noticing what is going on in mind and body, letting go of anxieties and tension, bringing focus into the session.
Games and improvisation:
Noticing and relating to others, memory and concentration , fun, spontaneity, physical and mental dexterity, confidence.
Role play and enactment of stories:
Expression of feelings and experiences through the containment of dramatic distance. Other group members act as audience and witness, giving the service users the space to be seen, heard, and acknowledged. Practicing spontaneity and being in relationship with others.
Opening and closing rituals:
Containment, safety, leaving difficult feelings in the room.
Reasons for implementing your project
HPFT provide health and social care for over 400,000 people with mental ill health, physical ill health and learning disabilities across Hertfordshire, Buckinghamshire, Norfolk and North Essex. They also deliver a range of nationally commissioned specialist services including Tier 4 services for children and young people, perinatal services and medium and low secure learning disabilities services.
This project sits under the adult community mental health services. In these services dramatherapy and art psychotherapy are available for service users across Hertfordshire. The project has been started in the East and the North West quadrants.
This client group were not getting the access to the arts therapies in the community that other groups of people were. From the BADth network of dramatherapists working across the NHS this seemed to be a national picture.
Our aim sat well with AHPs into Action Impact 4: Deliver evidence based/informed practice to address unexplained variances in service quality. The arts therapies have been recommended in the NICE guidelines for psychosis since 2009 yet this had only been a small percentage of our referrals in community services. Referrals are more often for people who are actively seeking therapy to understand and help with their difficulties, which is not so common with this group of service users. Our other dramatherapy groups and individual sessions are explorative in nature and may not be what this group of service users need or want.
The CMHT in East Herts had identified a group of service users who quietly remain under the care of the community mental health services but had little meaningful activity. We wanted to tailor a group specifically to the needs of this client group, adapting ideas from the work Louise Combes had been doing in an EIP service in Leeds.
How did you implement the project
We facilitated the groups within our existing service provision, addressing the inequity in availability of dramatherapy to service users with a psychotic illness. We realised that the group would be a great experience for a student on placement to co-facilitate and so the groups are timed around this.
We actively sought referrals, promoting the group and its aims to care co-ordinators. One of our challenges has been in identifying with care co-ordinators who might want to engage and benefit.
When recruiting for a dramatherapy vacancy in NW Herts we actively recruited someone to set up a service for people who experience psychosis.
We bought in training and clinical supervision from Louise Combes.
We offer initial 1.1 meetings, and where identified for people new to dramatherapy, brief 1.1 of up to 6 sessions as preparation for the group.
We have taken a more active role for these groups in enabling participants to get to the sessions, such as support workers in bringing people, giving someone a reminder call 2 hours before the group.
We use our standard PROMS: CORE, goal based outcomes, service user feedback questionnaire, and in addition from 2018, we have added a questionnaire specific to the group.
The results below demonstrate the impact on the health and wellbeing of individuals in this population group.
All 8 group members who completed the course of therapy in in 2018 showed improvement towards achieving at least one of their goals. 7 out of 8 showed improvement in CORE scores.
Other positive changes were observed: someone being able to stay in the room for the whole session, reduction in psychotic experiences and anxiety, and improvement in mood during sessions.
Comments made in sessions:
“I really enjoy acting. Being someone else for a little while distracts me from what is going on in my head.”
“Usually I feel that I am the puppet and my voices are pulling the strings so it felt good to be the puppet master and control the puppet.”
Responses to questionnaire:
What did you like, if anything?
"Doing well in exercises makes you feel good"; "Interacting"; "Using my imagination"; "Helped me to meet new people with same problems".
What did you find helpful, if anything?
"Everything"; "Mindfulness"; "Doing something out of my comfort zone"; "Talking"; "Listening to other people"; "Every exercise in all sessions have improved my confidence".
" I haven't had so much fun in ages".
Key learning points
We have been evaluating and learning from each group. We have compared feedback from, and our experiences of, the two groups that run concurrently, facilitated by different dramatherapists, sharing challenges, successes and ideas.
We have learnt that a few months is needed to gather referrals and offer 1:1 sessions to individuals before starting the new group, and will set aside the time for this.
At the end of this current group we will consider the merit of support workers supporting people to get to the sessions, ensuring good attendance and punctuality, against the achievements members have made this year in getting to the group themselves, which has meant more missed sessions and late arrivals, and a less cohesive group.
We have learnt to be flexible over what living with psychosis means and will consider what is available to those with other mental health conditions who would benefit from the creative expressive approach to dramatherapy used in this group.