Keywords

Introduction

There is a general understanding that children and adolescents develop their self-awareness by making contact with others, equally the sharing of social and cultural knowledge is valuable for personal development (Bo et al., 2017; Rippa, 2016). As in the community, it is common within adolescent mental health units for young people to spend much of their time in one group interaction or another, in school as well as in formal and informal group activities (Griffith, 2010). At the Walker Unit, we acknowledge the importance of group learning, especially with difficult to engage youth who have been isolated from their peers and the community for extended periods. Given many of the young people admitted to the unit have experienced adversity it has been crucial to apply principles of trauma informed care in their treatment (Gudiño et al., 2014).

Group Therapy in the Walker Programme

Young people admitted to the Walker Unit commonly display emotional and behavioral dysregulation which undermines their capacity to function socially. Other interpersonal difficulties include avoidance, ambivalence, and ambiguity within relationships. Most will have a prior history of unstable relationships in their peer groups and families. Our group therapy programme has been designed to target these difficulties and build the young person’s capacity to engage. While the overall structure of group therapy is maintained, there is day to day flexibility to respond to the specific needs of the current patient cohort.

Young people with complex trauma and mental health presentations commonly have difficulties “verbalising” their distress or emotions safely (Chapman, 2014; Cozolino, 2002; Van der Kolk, 2015). The Walker Unit uses a mix of “verbal” and “non-verbal” interventions in the group therapy program. For example, young people are encouraged to take “action” (e.g. body movements, sensory interactions, art and music making) to engage, participate and communicate during the therapy groups. We aim to deliver one verbal and one non-verbal group a day so the young people can engage in therapy through a variety of ways.

A Multidisciplinary and Interdisciplinary Approach

The aims of the therapy groups are to promote social engagement, health literacy, and skills building such as, distress tolerance, emotional regulation, communication, and self-care. Part of the role of the group facilitators is to manage the group dynamics, support the emotions of the young person and expand their window of tolerance. More importantly, the group provides a space for the young people to belong and support their basic needs for interpersonal contact with their peers (Garrick & Ewashen, 2001). In order to promote a greater sense of security and privacy and maintain consistency, some of the groups are closed to observers such as other staff or students (e.g. art psychotherapy group, what’s the feeling group, and teenage life group).

Some of the most established groups as outlined in Fig. 9.1:

  1. 1.

    The ‘What’s the Feeling’ group is conducted by the senior social worker and clinical nurse specialist. It supports patients to reflect on their internal world (feelings and emotions), and facilitates the process of using words to describe their experience and to sit with the corresponding discomfort. Scenarios are used as a tool to initiate discussion and to provide opportunities for the consideration of alternate ways of viewing and responding to situations/feeling states.

  2. 2.

    The ‘Sports group’ is facilitated by experienced nursing staff, and an exercise physiologist when available. This promotes physical and metabolic health, and encourages the young people to nurture a positive body image.

  3. 3.

    The ‘Art Psychotherapy Group’ facilitates non-verbal self-expression for young people using art materials with the goal to integrate a discussion on thoughts and feelings after the art making. This is supported by a registered senior art therapist (See Chap. 11).

  4. 4.

    The ‘Out of Your Comfort Zone’ or ‘Play Therapy’ groups are inter-changeable, depending on the cohort. If the cohort is generally high functioning, the ‘Out of Your Comfort Zone’ introduces Dialectical Behavior Therapy principles to help develop distress tolerance and awareness. If the cohort is generally low functioning, the ‘Play Therapy’ group enhances positive relationships between the young people through verbal and non-verbal communication.

  5. 5.

    The ‘Music Therapy Group’ assists young people to play musical instruments as a non-verbal way of self-expression and this is facilitated by a registered music therapist (see Chap. 12).

  6. 6.

    The ‘Teenage Life Group’ is a space to explore common teenage experiences such as changes to friendship groups, puberty, experimentation, sexuality, peer pressure, schooling, drugs and alcohol, and family/carer dynamics. We find the young people who come to the Walker Unit have typically missed opportunities to learn about or discuss these matters owing to disengagement from school, youth groups, and peers. The aim of ‘Teenage Life’ is to create a safe space whereby young people can hear about experiences which may be the same or different to their own, creating a sense of camaraderie and a greater awareness and empathy for others. It is also a space to provide education on the above topics which young people may otherwise have difficulty accessing reliable information on. Examples include sexuality and recreational drug use. The group is currently facilitated by a speech pathologist and a clinical psychologist.

  7. 7.

    The ‘Masterchef Group’ is a cooking group facilitated by the occupational therapist. It is designed to support the young people to develop basic cooking skills in a social environment (see Chap. 13).

  8. 8.

    The ‘Sensory Group’ encourages awareness and experience of tactile, olfactory, auditory, gustatory, and visual sensory input through creating sensory items (see Figure 9.2) and sensory interventions, such as making aroma room spray, creating slime and play dough, practicing mindfulness, and using body movements like ball games and stretches. The sensory group is facilitated by the clinical psychologist and occupational therapist.

  9. 9.

    The ‘Open Studio’ group is designed to facilitate creative expression through the use of clay and art materials for enjoyment purposes, and to support young people to self-sooth in a relaxed and low stimulus environment. At times more embodied images may be expressed which are verbally acknowledged as a form of communication by the facilitator, and then referred back to the art therapist for appropriate follow up. It is facilitated by social work and psychology.

  10. 10.

    The ‘Group Outing’ is designed to support the young people to learn and practice their skills while “exposed” in the community. Skills include maintaining appropriate social behavior, budgeting, purchasing meals or tickets, participating in an age appropriate social activity. The group outing happens every second Friday morning and is facilitated by the occupational therapist and nursing staff.

  11. 11.

    The ‘Walking Group’ occurs after lunch and this is facilitated by the allied health and nursing team. It is usually a 30-minute walk around the hospital grounds and the aim is to encourage fresh air and exercise while practicing being off the ward as a group.

Fig. 9.1
figure 1

Timetable for the Walker Unit Group Therapy Programme. The programme is displayed in the living area of the ward and includes visuals which give an indication of the group content and the names of the staff who will run it

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Fig. 9.2
figure 2

Stages in the development of sensory items created by the young people

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Some of the Challenges in Group Work

Chaos and ambivalence are often apparent in the group dynamics. Loud or playful interactions can turn into disruptive or unsafe behavior very quickly. For this reason, the group facilitators require expertise and clinical skills to manage the group safely, allowing the young person to practice riding this emotional wave with support and understanding. Therefore, the group therapy programme has an intention to allow tensions and distress to occur, so the young people may practice regulating their emotions and behavior.

Usually we have four allied health members working each weekday to ensure that group therapy, family therapy, and individual therapy progress safely. Due to the unpredictability of the young people, there are a variety of ways groups are delivered. For example, alternating non-verbal or verbal groups and the use of therapeutic spaces, such as courtyards or therapy rooms. Spontaneity, flexibility, and playful interactions are encouraged, with a tight frame held around the space for safety. For example, it can be helpful to think about appointments with medical staff, large families, or visiting clinicians during group therapy time to ensure that the group therapy programme does not get hijacked or forgotten.

Evenings and weekends are vulnerable times because the unit is staffed only by nurses. Handover from group facilitators to nursing staff regarding issues arising from group therapy session are essential. Weekend allied health support has also been helpful in the development of the group therapy programme. There is occupational therapy support available on Saturdays for an early breakfast or outing group (see Chap. 13). On Sundays, there is an art open studio group run by the nursing staff with assistance and follow up from the art therapist. This is further supported by ongoing in-servicing to the nursing staff. There has also been a baking group introduced late Sunday afternoons, for times when the young people had difficulty returning to the unit after leave. This would create a nurturing ambience across the ward from the smell of cake in the oven. We have found this intervention most helpful for those young people who might become aggressive when distressed.

Maintaining Therapeutic Gains from the Group Programme

In addition to some of the physical skills the young people gain from these group experiences, corrective emotional responses have been an important outcome and they are more likely to happen in the context of the group. Where some young people may have limitations, input by others can help working through difficult issues. The school room, group therapies, and family therapy meetings all offer opportunities for the young people to practice distress tolerance and emotional regulation. Expanding their window of tolerance and developing their contact with peers both on the ward and in their transition to community is an integrative process at the Walker Unit. Supporting them to re-attach to their peer community, usually at school or through another learning programme is crucial. The group therapy programme is a core foundation to the Walker admission.