nursingforsocialjustice

I mostly work in clinical informatics. At this point you might be asking yourself, “what is informatics?” And to this I will (very briefly) explain that clinical informatics is where technology, healthcare and data science meet to improve healthcare systems. I will leave it at that because the focus of this piece is mental health nursing. I currently (also) work in an inpatient mental health setting. I work there casually now but did work there fulltime from 2017 to 2019. The population served is (mostly) adolescents who live with both mental health and substance use issues. There is a group component to the program that I work in. When you read that you might be thinking group therapy, but it’s more than patients participating in formal therapeutic groups. The content of the groups offered and run ranges from psychoeducational, to recreational to psychotherapeutic. The diversity of groups is so because of the diversity of patients needs. It also ranges because of the mandate of said inpatient mental health and substance use program that provides service to a range of youth, some of whom are in more severe mental health crisis, some of whom are in a different place of their relationship with substances. Additionally, youth services have a range of cognitive ability. In this setting it is challenging to provide psychotherapy groups because patients have different goals and needs when they arrive to the service and are often discharged within 3-4 weeks.  In terms of therapy, this is a short amount of time. The type of psychoeducational groups varies; there are medication management groups, groups about nutrition, social skills groups and mindfulness groups.  There are also recreational groups like artistic and creative groups and exercise groups.   

Without a doubt, one of the major benefits of using a group format in the inpatient mental health setting it that is promotes interpersonal learning. Groups are an effective strategy for teaching youth with mental health issues who have been having issues in multiple domains of their life how to interact with others in a different way that can be more supportive and beneficial for them¹. The importance of the group format creating an environment of human contact, allowing participants to learn from others and interact in a social way that may also allow them to overcome their social fears.  This can greatly benefit those youth who may have been socially isolative prior to their admission to hospital. 

Another major benefit of a group-based inpatient program is the instillation of hope. You can hear the stories of others and might feel less alone, the benefit lies in the sharing one another’s experience in the group, using others as resources of information and giving hope not only that others experience struggles but that progress is possible¹.  For many youth the inpatient mental health setting can be a scary place. There is  mix of those who may be experience mental health issues for the first time but others who have been experiencing years of ongoing struggles, as well as a range of age and life experience.  Bringing a diverse group of people at different stages of their recovery progression is beneficial in instilling hope to members of the group that may feel stuck, alone, and hopeless about possibility of a different future.   

Let’s take a little exploration of some research evidence. A pilot study that compared the effectiveness of a manualized group therapy, Integrated Group Therapy (IGT), for patients living with a diagnosis of both bipolar disorder and substance dependence disorder².  Those who participated in the group therapy had better outcomes on an Addiction Severity Index (ASI), a higher percentage of months abstinent in the 6 month trial period and a higher likelihood of achieving 2 or 3 consecutive abstinent months. This was a pilot study, thus the study population was small and because it was not a randomized control trial it was possible that some of the positive outcomes of the treatment group may have been the result of being closely followed in the study rather than the content of the group itself. However this study did act as a basis for future research on the benefit of group therapy for people living with both bipolar disorder and a substance use disorder.   

In a later study outcomes were compared the outcomes of people who participated in an Integrated Group Therapy (IGT) group versus Group Drug Counselling group³.  The results supported the beneficial outcomes of the IGT approach.  One of the main outcomes was that the IGT group had fewer days of substance use. This supports the benefit of a group therapy approach that addresses both the mental health disorder and the substance use disorder concurrently in a group format rather than focusing on the substance use issues singly.   

A major benefit to a group-based service format, in particular, for those living with mental health and substance use issues is that it helps address the patient/client needs holistically and comprehensively, rather that separating out problems to be treated separately. What does this mean? It means that this is an effective way for treatment of the whole person that is aligned with recovery and strengths-based care that can result in transformative change.  Groups can be a means to provide information to patients/clients and to mediate educational processes¹.  Further, the group format brought clients at different stages in their healthcare journey together which can provide the opportunity to learn from each other.  Of course, there are challenges in carving out the nurses role in this, and some of those challenges lie in structural issues in the healthcare system as well as traditional ways in which care delivery models have been structured and delivered. One of the biggest challenge in nurses having a clear role in delivering group-based programs is the lack of training provided on how to facilitate groups, and with this also comes the lack of clinical supervision for nurses to build their skills. Environmental challenges that lead to less than ideal conditions for how a group format is implemented can also add to problems in successful integration of nurses. For example, lack of limits to the number of clients in the group (the result of trying to get the most patients to participate) can be too large. Again this points to the need for adequate structure, training and support for processes like individualized assessment of the client for group readiness for screen for issues like those clients who might be unable to sit still for 60 minutes, those who were not cognitively able to participate and other types of disruptive clients in the group

So, where does the position of the mental health nurse lie in all of this? In my experience as a mental health nurse who has worked with adults and youth living with mental health and substance use issues I have witnessed the benefit of utilizing a group therapy approach that focused on mental health and substance use issues concurrently. What does this mean? It’s not just formally trained therapists (ie psychologists, clinical social workers, and registered clinical counsellors) who should be facilitating and co-facilitating groups in the inpatient mental health setting. This is skill that mental health nurses should develop as part of their clinical practice. Sometimes we get wrapped up in interventions like crisis management, mental health medications, and one to one assessments and interventions. These are important, especially in settings and services that are for the purpose of acute care and crisis intervention. But, focusing on only these skills leaves a gap in how mental health nurses fit in longer term treatment programs. And, this is a problem in terms of skill utilization and full integration and utilization of mental health nurses in a way that leads to job fulfilment. .           

Peace,

Michelle D.

References

1. Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer Publishing Company. 
2. Weiss, R. D., Griffin, M. L., Greenfield, S. F., Najavits, L. M., Wyner, D., Soto, J. A., & Hennen, J. A. (2000). Group therapy for patients with bipolar disorder and substance dependence: results of a pilot study. Journal of Clinical Psychiatry, 61(5), 361-367. 
3. Weiss, R. D., Griffin, M. L., Kolodziej, M. E., Greenfield, S. F., Najavits, L. M., Daley, D. C., Doreau, B.A., & Hennen, J. A. (2007). A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence.