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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Education & training |
Royal Edinburgh Hospital, Edinburgh EH10 5HF, e-mail: janesutherland{at}doctors.org.uk
Western General Hospital, Edinburgh
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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Special interest sessions are a means of developing additional clinical interests in higher specialist training. We investigated the educational value of developing a group treatment programme for people with multiple sclerosis as well as its benefits for participants.
RESULTS
Feedback from those attending the groups indicated the programme was rated highly or very highly. There was a trend towards improvement in quality of life measures.
CLINICAL IMPLICATIONS
The group programme provided an excellent opportunity for shared interdisciplinary learning. The use of special interest sessions in psychiatry was important in building relationships with a department without direct psychiatric input and allowed the psychiatric trainee to acquire specific disease knowledge.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Fatigue is recognised as a problem in multiple sclerosis: up to 50-60% of people with this disorder identify fatigue as the worst symptom they experience and the one most significantly affecting their quality of life (Branas et al, 2000). It is also the least understood of all symptoms (Hubsky & Sears, 1992). Fatigue management programmes have been used in people with multiple sclerosis for a number of years, with some evidence of effectiveness in clinical practice (Schwartz et al, 1996; Krupp, 2003; Ward & Winters, 2003). In chronic illness generally, group therapy is commonly used to decrease alienation, facilitate expression of emotions related to the disease and allow participants to learn from each other (Mohr et al, 2001). One of the authors (P.C.) has extensive experience in the management of fatigue in individual patients and has previously run fatigue management groups for people with multiple sclerosis with the help of a client-centred counsellor. The other, J.S., has had experience and training in group analytic psychotherapy and cognitive-behavioural therapy.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Group members were recruited from P.C.’s case-load and were suffering from fatigue of a severity that interfered with everyday activity. Referrals to P.C. are from neurologists, whose requests are for treatment of a variety of problems of physical functioning in multiple sclerosis, including fatigue. No specific screening for suitability for group treatment was undertaken; however, P.C. excluded those who had significant cognitive impairment, those she felt would not be suitable for group treatment and those who were not independently mobile with or without aids. Twenty-five people were asked if they wished to participate, and ten were willing and able to attend the group sessions during working hours. All had a progressive form of multiple sclerosis, either primary or secondary, and the time from diagnosis varied between 1 and 36 years.
| Box1. Programme of the fatigue management group
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During the course, group members were issued with hand-outs relating to the topics covered, including fatigue management and energy conservation, physical equipment and environment, exercise, stress management and relaxation, goal setting, sleep, thoughts and feelings, and communication. A one-page summary of each group session was also issued to group members the subsequent week. This was a recognition of the importance of the members’ contributions during the sessions.
Structure of the programme
Week1
The first session commenced with introductions and an overview of the
course, emphasising the importance of what group members would contribute in
order to encourage a self-management philosophy. Following this, a discussion
was facilitated between the group members regarding the experience of having
multiple sclerosis and associated problems and losses. Schwartz & Rogers
(1994) commented that it is
important to address the negative feelings that arise secondary to illness in
order to lay a foundation for the further work of the group. This is done by
raising awareness of these feelings in everyone and by emphasising the
commonality of concerns of group members. Issues such as frustration, anger,
guilt, fear of the future and concerns about attitudes of others were raised
by the group members. Generally there was a sharing of experiences. The
session ended with a brief introduction to the concepts of fatigue, and
instruction on completing activity, fatigue and trigger diaries for the
following week.
Week 2
There was a consolidation of introductions, including each person
describing an interest of theirs. The purpose of this was to encourage members
to introduce an identity independent of their illness. Weekly diaries were
reviewed, looking at activities, fatigue and triggers. Awareness was raised of
associations between physical and mental activity, including stress, and
fatigue. Group members seemed most surprised at the links they found between
mental stresses and subsequent physical fatigue. Often it was mental stress
that led to the most severe fatigue. General discussion continued regarding
the losses and difficulties associated with multiple sclerosis.
Week 3
Weekly diaries were reviewed again, and group members were encouraged to
take a problem-solving approach to what they were learning about their
fatigue. We provided practical suggestions regarding energy conservation,
coping strategies and stress management. Blocks to changing behaviour also
became evident in discussion. In the first three group sessions it seemed
important for the group members to share experiences with each other, and this
commonality may have been important in building up trust in the group. In
subsequent group meetings, however, members were able to bring up more
personal feelings and there was more questioning of each other in these
sessions, for example with regard to raising awareness of blocks to changing
behaviour.
Week 4
Weekly diaries were again reviewed, with group members now being able to
predict fatigue levels, and discussing the impact of behavioural changes they
had tried to make. General discussions centred around the need to accept
changes caused by the illness, rather than fighting it, which people found
from experience increases stress and worsens symptoms. Group members were keen
to learn from others and responded well to suggestions. Goal setting in order
to improve quality of life was introduced. The idea of effective goal setting
is that it breaks down tasks into smaller challenges, which when achieved lead
to an enhanced sense of control.
At times during this and other sessions it was easy for the group to move to a general discussion of external problems such as disabled access, which appeared to be an outlet for emotion related to the illness. This expression of anger could then be highlighted and linked with anger towards the disorder which then allowed the group to move on to discussing their underlying feelings, which also included sadness and grief as well as anger. Although in a short-term, supportive type of group one would not undertake any specific exploration of emotions or defences, we found that some group interpretations were necessary in order to facilitate the recognition of these emotions. Without this it seemed that the group would have kept returning to themes of anger and been unable to move forward with work on making changes.
Week 5
Goal setting was discussed further, using the group to
‘brainstorm’ challenges brought up, such as planning a holiday, by
breaking them down into many small goals. The group members were able to use
their fatigue management knowledge and personal experience to help each other
with only limited input from ourselves. Again the issue of loss was brought
up, and there was a discussion that this is an expected emotion, which seemed
to show some shift in the group in their acceptance of feelings associated
with the illness. The concept of relaxation linking in with stress management
was introduced, and a short relaxation session was conducted with the
participants in a seated position.
Week 6
There was a continuation of reviewing goal setting, in which members fed
back how their goal setting had gone and what they had learnt. There was an
eagerness to find out how others had progressed with their goals, and
subsequent learning from these findings. Education was given on physical
equipment and practical ways of improving the environment. Relaxation and
stress management was then discussed in detail and a 45-min relaxation session
was conducted.
Week 7
Relationships with others and communication were discussed, with role-plays
to facilitate this. Group members took part in a role-play of poor listening
as an exercise with each other. We then role-played a scenario of poor
communication with a partner, in the context of carrying out domestic chores,
to the group. We used this to highlight patterns of communication that people
can fall into and to facilitate discussion of ways of improving communication
in this and other scenarios. This led to some animated discussions in which
group members recognised particular difficulties, which they were keen to work
on changing. It was interesting that all the group members interpreted
different things from the role-play, which in itself highlighted the
importance of communication.
Week 8
There was a review of the topics covered over the 8 weeks, with discussion
from the group on what they had learned and ways of continuing this in the
future. The mood in the group was very positive and group members made
arrangements with each other to keep meeting on a regular basis following the
end of the programme.
Measures and statistical analysis
We monitored quality of life and coping ability with questionnaires before
and after the group programme. The 36-item Short Form Health Survey (SF-36;
Ware et al, 1993),
the Leeds Multiple Sclerosis Quality of Life Questionnaire
(Ford et al, 2001) and
the Coping with Multiple Sclerosis Scale
(Pakenham, 2001) were used.
Those completing the programme were also asked to complete a feedback
form.
Data were analysed with 
2 tests using the Statistical
Package for the Social Sciences, version 10.0 for Windows.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Measures
The trend was towards improvement in all measures
(Table 1). Little meaning can
be taken from these results, however, as we do not have data for the two
people who withdrew, and the numbers are very small. Replies on the feedback
form indicated that those who had completed the group programme rated it
highly or very highly and would recommend it to others. Asked to pick items
that they would like more of and those they would omit, no items to omit were
highlighted. Group members all requested more of certain topics, and all
topics were chosen by at least one person. All answered ‘yes’ to a
question about whether they would like a session for partners.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Recommendations for the future are that increased screening of people regarding their suitability for a group as well as increased planning of the composition of groups may be beneficial. The provision of a more structured fatigue management group as an alternative might also be a worthwhile addition to the service for some. A session that partners could attend was also supported and could be easily added to the programme. Feedback from this group did not clearly indicate any other ways to improve the structure, other than by increasing the length of the course. Feedback from future groups may provide more clarity.
From an educational perspective, one of the main benefits we both experienced from running this group was the opportunity to work closely with a professional from another discipline. This provided an excellent opportunity for shared learning, particularly since our professional backgrounds and areas of expertise were quite different. We were surprised that our approaches towards running the group were so similar; however, this may be due to having similar previous experience in group psychotherapy. This use of special interest sessions was important in allowing the time to build relationships within a department previously without direct psychiatric input, to acquire specific disease knowledge, and subsequently to develop a collaborative treatment.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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FORD, H. L., GERRY, E., TENNANT, A., et al
(2001) Developing a disease-specific quality of life measure for
people with multiple sclerosis. Clinical
Rehabilitation, 15, 247
-258.
HUBSKY, E. P. & SEARS, J. H. (1992) Fatigue in multiple sclerosis: guidelines for nursing care. Rehabilitation Nursing, 17, 176 -180.
KRUPP, L. B. (2003) Fatigue in multiple sclerosis: definition, pathophysiology and treatment. CNS Drugs, 17, 225 -234.[CrossRef][Medline]
MOHR, D. C., BOUDEWYN, A. C., GOODKIN, D. E., et al (2001) Comparative outcomes for individual cognitive-behaviour therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. Journal of Consulting and Clinical Psychology, 69, 942 -949.[CrossRef][Medline]
PAKENHAM, K. I. (2001) Coping with multiple sclerosis: development of a measure. Psychology, Health and Medicine, 6, 41 -428.[CrossRef]
PICTON, T. (2002) Special interest sessions: some
thoughts. Psychiatric Bulletin,
26, 198.
SCHWARTZ, C. E. & ROGERS, M. (1994) Designing a psychosocial intervention to teach coping flexibility. Rehabilitation Psychology, 39, 57-72.[CrossRef]
SCHWARTZ, C. E., COULTHARD-MORRIS, L. & ZENG, Q. (1996) Psychosocial correlates of fatigue in multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 77, 165 -170.[CrossRef][Medline]
STEPHENSON, M. & PUFFETT, A. (2000) Special
interest sessions in psychiatry: Survey of one higher training scheme.
Psychiatric Bulletin,
24, 187
-188.
WARD, N. & WINTERS, S. (2003) Results of a fatigue management programme in multiple sclerosis. British Journal of Nursing, 12, 1075 -1080.[Medline]
WARE, J. E., SNOW, K. K., KOSINSKI, M., et al (1993) SF-36 Health Survey: Manual and Interpretation Guide. Boston: Health Institute.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
