A project in re-inforcing the effectiveness of the primary care team in the area of mental health

It seems that increasingly patients are being referred to primary care teams and GPs in health centres rather than to psychiatrists in a hospital setting. With the growth in the number of patients being main tained in the community, it is becoming more import ant to pay attention to this sphere and to aid primary care teams to be clinically effective. It was from this perspective that I became involved as facilitator to a primary care team on a one year project. The following is a description of this project, of the difficulties encountered, and the outcome. I hope my description may be of use to other facilitators, for whom I am arguing there is a growing role. The request was for me to facilitate a weekly staff group meeting set aside for case discussions, as the meetings had become apathetic and stale. It was hoped I would facilitate a process of change where there would be developments in the work instead of stagnation. The primary care team at the health centre con sisted of GPs, social workers, health visitors, nurses (including CPNs) and a part-time psychotherapist doing some long-term psychotherapy. Most of the care team used a brief therapy model, whether individual or family. The staff varied in their level of expertise and training in psychotherapy from the relatively inexperienced to the experienced.

It seems that increasingly patients are being referred to primary care teams and GPs in health centres rather than to psychiatrists in a hospital setting. With the growth in the number of patients being main tained in the community, it is becoming more import ant to pay attention to this sphere and to aid primary care teams to be clinically effective. It was from this perspective that I became involved as facilitator to a primary care team on a one year project.
The following is a description of this project, of the difficulties encountered, and the outcome. I hope my description may be of use to other facilitators, for whom I am arguing there is a growing role.
The request was for me to facilitate a weekly staff group meeting set aside for case discussions, as the meetings had become apathetic and stale. It was hoped I would facilitate a process of change where there would be developments in the work instead of stagnation.
The primary care team at the health centre con sisted of GPs, social workers, health visitors, nurses (including CPNs) and a part-time psychotherapist doing some long-term psychotherapy. Most of the care team used a brief therapy model, whether individual or family. The staff varied in their level of expertise and training in psychotherapy from the relatively inexperienced to the experienced.

Description of the staff meeting
The meeting was held for one-and-a-half hours weekly, chaired by the rotating chairman and was to be facilitated by myself. It was a large group of, at times, 30 people including the primary care team and occasional visitors. During the first few weeks of these meetings, the apathy about which members had complained was noteworthy. At the same time it appeared there was a strong expectation and hope that I would rapidly effect some transformation of the situation. This did not happen. However, I did begin to gradually identify certain inhibiting factors and feed this back to the group members.

Large group phenomena and its influence
In this group, large group phenomena were present. There was a high degree of passivity and members found it difficult to speak out. There was a lot of dependency and idealisation with hopes of the facili tator solving all the problems. There was, however, very little feeling of a working group as had been reported initially.

Idealisation denigration axes
The mood of the group often expressed hopes of solution from the outside. There was unawareness of solutions being found by members of the group. Denigration of the group was obvious in terms of people leaving early to go to other group meetings. The idea that staff were easily replaceable was some times present, in that people did not seem to know when a staff member was leaving, e.g. at retirement. These kinds of attitudes also made the concept of on-going work difficult.

Trainer/trainee phenomena
Quite often a 'trainee' would experience difficulty in case presentation. There was a high awareness of hierarchy in the group and some trainees experienced this as very inhibiting. One solution was to go off to their own separate discussion or supervision group at another institution. In this way some splitting was occurring: the large staff group was seen as "not good", while the separate supervision group was "good". A lot of testing occurred around this issue and in later months, more work was brought to this meeting. The staff group became seen to be good enough to bring work for supervision.

Lack of continuity of casework, of on-going work
There was little sense of continuity about casework. Feelings of failure and of hopelessness were openly expressed about some of the 'difficult problems of individuals and families'. Feelings of frustration were gradually expressed by members about not knowing what happened to cases which had been considered in previous weeks. After discussion about this problem the structure of the group was changed by democratic decision to include a structured follow-up time within the group. This led to greater involvement of members and much on-going work. It was now more of a work-group in Bion's terms (1961).

Unexpressed rivalry in different sub-groups
A strong covert rivalry between different sub-groups gradually emerged. This was being expressed in a very negative way and deadening the group. Some GPs absented from the meetings, or left early. Once a month nurses went to their separate 'nurses' meeting'. One sub-group of staff who worked with older patients, absented themselves emotionally by never bringing any cases but sitting silently through out the group. It was only gradually that this pattern of absenting in one way or another became obvious.
Thus, there was a feeling of'groupiness' within the group, with rival interests and underlying fears that different groups were only interested in themselves. A certain intensity and level of trust had to be reached before these feelings could be expressed. I was used as a safe witness with whom to ventilate such communi cations and feelings. Also, coming from 'outside', I was seen as having no particular bias or affiliation with any particular sub-group inside. The group used me as a safe container for these intense group rivalries. Once expressed, there was a fuller partici pation and exchange between members, making room for more friendly working feelings and a true work group.

The paranoid element
At several stages there was an increase in paranoid feelings in the group and people became less willing to use it. This was particularly in evidence following a meeting in which there were a number of visitors, some of whom appeared unannounced and had to be identified. There was an atmosphere of chaos and flooding at that meeting and hardly any real dis cussion took place. Many people voiced worries about confidentiality and also said they felt over whelmed sometimes by the number of visitors. It became obvious that there was no clear protocol for vetting visitors' reliability about confidentiality and limiting the number of visitors in any one group. With further discussion it became clear that there was a need to introduce a more formalised structure to ensure the boundaries were kept. An organising chairman was then appointed who could be approached during the week concerning visitors. The effect of this development was to increase real work relationships between members of the group, its boundaries were more clearly defined, and it was able to become more of a work group.

Some examples of work in case discussions
Sometimes cases were presented, obviously for help with referral to other agencies. At other times cases Rosen were presented for 'information exchange'. Cases were increasingly presented where case-workers wanted to handle the case more effectively them selves, that is, to provide more effective primary pre vention. This involved some kind of brief therapy at regular or irregular intervals. A whole range of problems came under this category, and as the group became more of a work group and there came to exist a setting and structure where such work could occur, staff were enabled to become more aware of defensive operations in patients, such as avoidance, denial, splitting, avoidance of depen dency needs, and the key-workers could then take up these relevant issues constructively with their patients.

Range of problems in case discussions
These included: separation problems, psychosomatic problems, problems of the dying and bereaved, alco holics, drug addicts, puerperal problems, and abuse problems.
My task asfacilitator I found my task as facilitator encompassed the following: reliable identifier of difficulties and inhibitory factors within the group as non-partisan facilitator, I was safe to ventilate anxieties and rivalries, allowing group members to reach a more objective view builder and maintainer of boundaries of the group which had previously been much too fluid for constructive work.

Comment
The difficulties of the staff group were such that the level of functioning was rather low and seen to be so by the members. In Bion's (1961) terms there was very little presence of a work group in evidence. He stated that the work group was "constantly per turbed by influences which come from other group phenomena". My function was to find, observe and identify such disturbing influences and feed these observations back to the staff group. Group mem bers were then gradually able to deal with these other group phenomena so clearing the way for more effec tive work. There was an increase in the number of patients being treated, for example, a group was started for patients able to use group therapy and there was a new project launched to give certain addictive patients therapy. Staff members of all disciplines became increasingly confident and competent in their brief individual therapy and family therapy and effectively using the group for supervision. It would also appear that this was a cost-effective use of a psychiatrist/psychotherapist's time, in that for one-and-a-half hours per week 30 health care staff were able to have supervision and the numbers of patients with psychological problems treated by the primary care team over the year increased. I have attempted to describe the process of increasing the effectiveness of the staff group in this paper and hope this may be useful for facilitators in other primary care teams. 471