‘You can never fully prepare for what might happen on an inpatient unit’

It was my first paid Assistant Psychologist (AP) role, and I was determined to embrace the challenge. The mixed-sex psychiatric intensive care unit (PICU; pronounced 'PQ') was in a city in the North of England, and my role was split between health-care duties and using psychology theories and techniques to support patients. I hoped to increase their understanding of mental health and teach emotion regulation skills. However, supporting patients with acute psychosis amidst waves of Covid-19 emotions and restrictions is no easy feat. 

Now working as an AP in the community, I'd like to share my experience and short success story of delivering psychoeducation groups in such a demanding and emotionally testing environment.

Trial and error, with reward

At 5 foot tall I knew that physical intervention was not my top strength… I needed to use a calm and respectful persona to de-escalate the many tricky situations. I wanted to use my knowledge and 'wisdom' gained from three years of backpacking to bring some tranquillity, introspection and Eastern cultural influences onto the unit. It seemed fitting, then, that my first psychology task was to run group mindfulness sessions.

After a captivating mindfulness workshop I threw myself into this; delivering a range of mindfulness exercises on the unit. For the most part these went pretty well. A little trial and error at times but the reward was unique. Observing a stark change in behaviour – from heightened agitation or manic presentation to calmness and temporary poise – was something to behold. It was great to feel that the sessions were helping and having a positive impact. 

The real challenge was timing sessions so that patients were physically available and willing to engage, alongside finding a free staff member to join the group for safety and encouragement. Once these sessions were up and running, I began preparing psychoeducation groups to run on PICU and other less restrictive inpatient units nearby. 

For preliminary work I engaged patients in conversation; listening to their life narratives, trauma experiences and getting to understand their mindset and behaviour patterns. I thought about what kinds of psychological support they needed and how I could build these factors into practical exercises and topics. I then worked on developing group content, gathering information that patients could engage with and retain. I was careful to keep content educational and 'low-intensity', making sure that discussion topics wouldn't become too personal or distressing.

Asking psychologists and health care professionals who had inpatient or group experience for tips and research papers helped me to theory-base and structure the content. I also started working on a literature review, exploring how other inpatient units have run similar groups, noting how they overcame barriers and challenges. I anticipated that managing disruptive behaviours and sustaining patients' attention could be tricky. The reality of these units can be quite dangerous, so you've got to be confident, alert and decisive. 

From Covid to roll-out

Just as I was getting the groups to a testing phase, we were hit by Covid-19. My unit paused psychology interventions and activities, until we could get our heads around what was happening and maintain safety. During the initial lockdown and shift to home working, I was still up at 5.30am bracing for a 12 hour shift on the ward, wrapped in uncomfortable PPE. Plastic flooded the building but at the same time we felt lucky to have this stock in high supply. There was initially a strong sense of teamwork, pride and a newfound confidence around the team. We received food parcels (and once a free Dominos), but the treats eventually stopped and it was difficult to sustain motivation, feeling exhausted. I frequently craved a 'working from home' role but persevered on the unit, feeling that I had to push through the deflation and stress. 

Just as things were beginning to take their toll on my mental and physical health, I was given the go-ahead to roll out the groups. Motivation came back and it was time to re-focus. Patients had to social distance and rooms needed to be sanitised, but this was manageable. My time spent preparing the groups wasn't going to waste, and I could put my energy into a worthwhile intervention; filling a gap in mental health support that pandemic anxiety had heightened. 

Group topics included anxiety management (my particular favourite and personal struggle), anger management, coping with emotions, self-compassion, goal setting, grounding techniques and improving sleep. I ran the groups on PICU, a male only, female only and another mixed sex unit, with bed capacity ranging from 10-18 patients. Sessions began with introductions, an agenda and classroom-style ground rules. With the general nature of inpatient units being relatively short-stays, the groups were stand-alone topics and for this reason attendance varied each week. I began by knocking on patients doors to invite them to the group, giving at least 30 minutes notice. I made sure this was as welcoming as possible, emphasising that they didn't need to disclose personal information and that the group content would be relatively low-intensity. It's easy to be dismissive if a patient is hesitant about engaging in an activity, but I found that with some light encouragement and perseverance I could challenge some of their fears and motivate them to give it a try. I found that taking a sensitive approach to ease patients' worries increased group attendance. Group size ranged from 3-14 participants (patients and staff members), so some groups felt more intimate than others. 

Groups ran for 30 minutes and each included a few short exercises to sustain engagement. Patients received a colourful handout they could keep with an agenda and easy-to-follow information. My most successfully run groups included other staff members, who actively participated in the group exercises and discussions, contributing brief accounts of their personal struggles. This helped ease the often apparent 'patient-staff power divide'. Benefits of group cohesion cannot be underestimated. Sharing experiences can really help normalise and validate peoples' feelings, reducing a sense of isolation, which has particularly heightened for many since Covid-19 restrictions and lockdowns.

When staff sat with particularly tricky patients and helped manage challenging behaviours, the group was naturally a lot easier to facilitate. I found myself adopting a schoolteacher persona and I was often called 'Miss'. I facilitated group discussions but also used assertive communication to keep everyone on topic. With practice, being assertive became easier and felt more natural, uplifting my self-confidence somewhat. 

I also had to acknowledge that sessions wouldn't always go to plan. You can never fully prepare for what might happen on an inpatient unit. In these cases, you've just got to evaluate what happened, accept it, and use the experience to improve, trying not to take things too personally. I always handed out a short anonymous feedback form too, with four rating-scale questions and an open comments box. I didn't analyse this data, just used it to improve group content and delivery. It also confirmed that people were finding the sessions valuable. It's always nice to hear that your efforts are being well received.

My take home message… 

Inpatient units need stimulating psychological support and activity, and group work should be prioritised by all staff members. I have seen and received feedback from patients and staff that psychoeducation groups are extremely worthwhile. Teaching skills that patients can take away with them is a progressive way to improve mental ill health and (fingers crossed) contribute to the reduction of relapses.

So choose a topic, keep content relatively straightforward, include some interactive exercises and adopt a positive, assertive approach. Following these steps, you can deliver a meaningful psychology group in a challenging environment, making an impact on people who are going through a really difficult chapter of their lives.

Thank you for taking to time to read my story and best of luck to anyone undertaking this task. If you'd like a copy of the group materials or have any questions, feel free to get in touch: [email protected].

- Find more reflections on being an Assistant Psychologist here.