group, Vol. 42, No.

1, Spring 2018

The Highs and Lows Through Recovery:

An Integrative Group Combining
Cognitive Behavioral Therapy, Narrative
Therapy, and the Tree of Life
Jeyda Ibrahim1 and Jo Allen2

This study explores an innovative pilot group combining cognitive behavioral therapy
and narrative therapy specifically utilizing the Tree of Life tool. Six participants with
a diagnosis of bipolar disorder took part in this pilot group, which met over eight
weekly sessions. Qualitative data were obtained through a focus group. Four themes
were identified using thematic analysis from the focus group: social support and hope,
the tree of life, understanding and coping for all, and group processes. The identified
themes and their implications are discussed.
KEYWORDS: Bipolar disorder; group psychotherapy; cognitive-behavioral therapy;
narrative therapy; Tree of Life.

Bipolar disorder (BD) has a community lifetime prevalence of 4% and can have
severe and multiple impacts on an individual’s life. Research has consistently
shown that individuals with BD have experienced significant life events contribut-
ing to episodes of BD (Alloy et al., 2006; Alloy, Reilly-Harrington, Fresco, White-
house, & Zechmeister, 1999; S. L. Johnson & Kizer, 2002; S. L. Johnson & Roberts,
1995). Furthermore, considerable research has shown that social support improves
the course of BD, while negative support (e.g., high expressed emotion) from

1 Clinical Psychologist, South London and Maudsley NHS Foundation Trust. Correspondence
should be addressed to Dr. Jeyda Ibrahim, Great Ormond Street Hospital, De Crespigny Park
off Denmark Hill, London, UK SE5 8AZ. E-mail: jeyda.ibrahim@kcl.ac.uk.
2 Clinical Psychologist, South London and Maudsley NHS Foundation Trust.
issn 0362-4021 © 2018 Eastern Group Psychotherapy Society

23
24 ibrahim and allen

significant others has a negative impact on the course of BD (e.g., L. Johnson,

Ludstrom, Aberg-Wistedt, & Mathé, 2003; S. L. Johnson, Meyer, Winett, & Small,
2000; S. L. Johnson, Winett, Meyer, Greenhouse, & Miller, 1999; Miklowitz, Goldstein,
Nuechterlein, Snyder, & Mintz, 1988; Priebe, Wildgrube, & Müller-Oerlinghausen,
1989; Rosenfarb, Becker, Khan, & Mintz, 1998).
Mansell, Morrison, Reid, Lowens, and Tai (2007) described a cognitive inte-
grative model to understanding individuals with BD. He described people with a
diagnosis of BD as having multiple, extreme, and conflicting beliefs about changes
in their internal states, depending on their mood. These states affect and are af-
fected by those beliefs about the individual’s own behavior, physiology, and social
environment (how other people respond to the individual’s behavior). Mansell and
colleagues argued these were factors in maintaining and contributing to the escala-
tion of bipolar symptoms.
The National Guidelines recommend individually tailored psychological in-
terventions that include providing psychoeducation about the disorder, mon-
itoring mood, identifying early warning signs, and enhancing general coping
strategies. In addition, opportunities for social support, such as a befriending
scheme, are recommended (National Institute for Health and Clinical Excellence
[NICE], 2006).
Cognitive behavioral therapy (CBT), the most consistently researched psy-
chological approach and so far, is a hopeful approach for recovering function-
ing in BD (Lam et al., 2000; Scott, 2008; Szentahotai & David, 2010). A recent
meta-analysis has shown a significant overall effect of CBT compared to medical
treatment alone in BD (Szentahotai & David, 2010). The authors argued that a
critical question is for what CBT is most and least effective. Their analysis showed
that CBT has a clear influence on symptoms posttreatment, treatment adher-
ence, quality of life, and life/social adjustment, but it had no significant effects
on relapse and/or recurrence and treatment cost. However, cognitive-based
group therapy has been shown to prevent relapse of BD (Burlingame, Strauss, &
Joyce, 2012).
Narrative therapy (NT) has been combined with CBT (Prasko et al., 2010;
Rhodes & Jakes, 2009) using the practical tools-based elements of CBT while being
thoughtful of the narrative in supporting people with BD to change how they see
themselves. Rhodes and Jakes argued that this therapeutic approach highlights the
importance of collecting resources both old and new in the life of the individual
and simultaneously building new narratives of the self and the individual’s world.
As Mansell, Powell, Pedley, Thomas, and Jones (2010) highlighted, “understand-
ing” was seen as an objectively helpful part of therapy. Individuals who have been
diagnosed with BD frequently suffer from the effects of labeling and the stigma of
having a psychiatric illness. This labeling often interrupts their path to recovery and
stops them from believing that their condition can be managed with the appropri-
ate support. NT can be used therapeutically to enable the individual to re-create
The Highs and Lows Through Recovery 25

Table 1: Summary of Group

Session Session content Approaches used

Introductions, defining BD and
discussing pros and cons of diagnosis, Psycho-education
1
guest service user attended to talk about Service user involvement
her experiences and answer questions
ToL
2 Completing the ToL
Sharing stories
ToL
Storms (life events) and optimal (ideal)
3 Sharing resources
self were discussed
Letters to self
ToL
Discussing what it means to be “high”
4 CBT model for identifying symptoms
(i.e., drought for the tree)
Letter to self
ToL
Discussing what it means to be “low” (i.e.,
5 CBT model for identifying symptoms
flood for the tree)
Letter to self
Identifying early, middle, and late Sharing resources
6 warning signs and coping strategies for CBT for identifying symptoms of relapse
each ToL
Sharing narratives and strengthening
Each participant telling his or her own
own identity
7 story, other participants identifying
Witnessing others’ stories
strengths
Social connection
Discussing how to maintain coping Social connection; exchanging details
8 strategies and reflecting on group; CBT maintenance ideas
certificates were provided Recovery

meaning through his or her narratives that would improve their quality of life
(Ngazimbi, Lambie, & Shillingford, 2008).
The Tree of Life (ToL) is a therapeutic tool based on narrative approaches (Re-
gional Psychosocial Support Initiative [REPSSI], 2007). It uses different parts of the
tree to represent different parts of one’s life. This tool was initially developed to sup-
port children affected by HIV/AIDS in southern Africa (REPSSI, 2007). However,
it has been proven sufficient to be used successfully all over the world in a variety
of contexts (e.g., Hughes, 2013; Jamieson, 2012).

METHOD

Participants

Participants were drawn from the local mental health service for people with psy-
chosis. Care coordinators referred service users with BP who were currently stable
26 ibrahim and allen

in mood. Six adults attended the group regularly. This was defined by attending at
least five sessions, one of which included the final session. Five out of six participants
who attended were female. The mean age of the six participants was 49.5 years, with
a range from 40 to 59 years. Participants were of a variety of different ethnicities,
including White British, Nigerian, African, Columbian, and Scottish.

Procedure

Table 1 summarizes group sessions and approaches used. Sessions were developed
by the two authors and a service user consultant. Sessions were 1.5 hours long, with a
break of 15 minutes. CBT was integrated with a narrative approach, using principles
of CBT acknowledged to be helpful for those with BP, namely, psychoeducation and
coping strategies (NICE, 2006), alongside work on developing alternative meanings
and identity, values, and purpose, similar to that in Rhodes and Jakes (2009). The
ToL was used as a tool to support this work by creating a metaphor that can help
open up conversations and shift the group’s thinking away from problem-saturated
stories to stories of strength and hope for the future.

Focus Group

A focus group was conducted following the final session of the group to gather
qualitative information from individuals on their views, experiences, and opin-
ions about the group. The aim of the focus group was to promote a variety of
responses from participants rather than derive a final conclusion with which ev-
eryone agreed (Hennink, 2007). The moderators for the focus group were the two
group facilitators.

RESULTS

Participants in the focus group were asked three questions: What did you find most
helpful about the group? What did you find least helpful about the group? What
would you like to change about the group?
The focus group was recorded and transcribed verbatim by the first author (JI).
The first author listened to the recordings several times to become familiar with the
reflections before analyzing the data. Both authors then read through the written
transcript several times to establish themes.
The Highs and Lows Through Recovery 27

Social Support and Hope

I’m not on my own.

Participants talked about their appreciation in relation to being with other people
who were experiencing similar problems. Being able to hear other people’s stories
and share their own made them feel like they were not alone on their own journeys.

I have been, feel very privileged to have heard everybody else’s contributions, and it
has, you know, really reassured me that I’m not on my own.

And doing it in an environment which you are with other people who are experiencing
the same thing, and occasionally somebody sharing just sort of spontaneously a bit
of their experiences, of what they have been experiencing has also been very helpful.

Participants listened very carefully to one another’s experiences throughout the group
and often praised each other for the achievements and strengths they described.
The social aspect of the group was very important to all participants, as all of them
had mentioned that hearing other people’s stories was one of their key aims at the
assessment session.

Light at the end of the tunnel.

Participants talked about feeling more hopeful about the future. Understanding and
thinking about coping strategies helped people to feel more positive about their lives.

When I first started this group I felt negative, negative, negative, because there was
loneliness, boredom, but now I can see a light at the end of the tunnel so that really
makes me happy.

Participants also talked about the importance of writing down what they were go-
ing to do next.

Having to write down is also very helpful to know myself, to help myself cope with
the situation, what am I going to do next? It’s very important.

Here the participant talked about finding this important in coping for the future.
Participants also elaborated the role of the group in taking control of their lives
in future situations.

I strongly feel it’s helpful in that way, I will be in a position to use what I have learnt
here, to take charge of whatever situation I find myself in so, it was very useful.
28 ibrahim and allen

The Tree of Life

Most participants mentioned the ToL as being one of the crucial parts of the group.
They discussed how this tool enriched the stories of their lives.

The Tree of Life was the most, the epic, the top of the icing for me, I really enjoyed it,
and when I was filling it up so many ideas were coming up.

They also described the value of doing this together.

As a group we were collectively able to do it very well.

Completing the ToL in pairs gave the opportunity for people to recognize strengths
in others and support each other in creating a new narrative. Not only were partici-
pants able to gain hope from their own strengths but they also gained hope from
those around them.

I think the Tree of Life as well as working in pairs to go over each other’s Tree of Life
and, in a way, I would have quite liked to have one group Tree of Life, because it made
me realize after that day, gosh, these people who, some them not having a lot of self-
esteem, including myself, yet look, collectively, how much talent there is, in this room,
skills and everything that was kind of presented up at the top, I mean at the front, and
it’s something you can keep going back to and adding to.

The ToL provided a support network and a place for shared hope.

Understanding and Coping for All

Participants talked about how helpful it was to understand what bipolar was and
what it meant. They talked about learning this through the contents of the group
and through listening to other people’s experiences throughout the sessions.

It helped me to understand my problems, and listening to others was very important

because before I did not realize how it was to be high and low.

Coming to a group like this has really helped, to make me understand what exactly
bipolar is.

In particular, participants talked about defining early, middle, and late warning
signs and thinking about coping strategies for each stage as particularly helpful.

Breaking it all up, because of early signs and the later signs and also the thought pat-
tern during those stages, was the most helpful thing, and also identifying that if you
The Highs and Lows Through Recovery 29

can change the way you are thinking, at the early stage, and challenge those thoughts
you are more likely to change the whole situation.

Here the participants talked about realizing the role they can play in changing the
course of their lives. One participant particularly focused on the importance of
writing letters to herself, one of the tasks for each group member to do to keep for
when they are high or low.

For me it was the letters to yourself . . . the most helpful thing was having to focus on
the early, middle, and late warning signs.

Doing things bit by bit, so you work on this bit and then you work on that bit and you
slowly then, without realizing it, to then seeing a more complete picture of staying
well and your illness.

The psychoeducation and staying well plans supported the participants in having a
more complete picture of themselves. Participants spoke about feeling misunder-
stood by other professionals throughout their experiences of mental health services.
Participants invited a pharmacist to the group to discuss their role in their recovery.
Participants valued the opportunity to talk to professionals and suggested that invit-
ing a psychiatrist would enable them to change this relationship.

Psychiatrists are at the top, and yet I feel that they understand the least, that’s how it
feels anyway, but I think it would be good to get one of them in here.

Group Processes

Participants highlighted the role of facilitators in reducing anxiety, particularly in

the pregroup assessment.

Having two people running the group who are very understanding and have made
me feel as calm about coming here as possible.

They reported valuing opportunities to talk openly with the group and not just
focusing on the worksheets.

Because this is the first time you have done it, this one, so really personally, I don’t
think what you did was too much or you know you have allowed people to interrupt . . .
and still manage to cover all of the practical worksheets.

Participants appreciated that there was enough space to interrupt, whether it was to
ask a question or to talk about their own experiences. Participants found that they
needed to attend all the sessions to get the full value of the sessions.
30 ibrahim and allen

I think one of the biggest drawbacks of the group is that people didn’t attend every
session, and I’d missed two sessions myself, and I really felt that, when I came back,
I had missed out quite a lot.

DISCUSSION

This study explored a pilot study combining a NT and a CBT approach within a
group therapy context for individuals with BD. The four main themes identified using
thematic analysis of participants responses in a post-treatment focus group were (a)
social support and hope, (b) the ToL, (c) understanding and coping for all, and (d)
group processes. Peer support through a befriending scheme is a key recommendation
made by the National Guidelines (NICE, 2006, 2011). The group format of psycho-
therapy was thought to provide an opportunity for this. Participants were given the
opportunity to share their stories and bear witness to others’ stories, supporting the
reauthoring of their and others’ lives. Participants specifically mentioned that coming
to the group made them realize that they are not alone. This is an important concept of
narrative approaches, as individuals with mental health problems are often described
as “outsiders” and as not as “rational” as others (Foucault, 1965; Harper, 2004). We
believe that the group deconstructed this narrative and constructed a new narrative,
in which individuals had met other people who had experienced similar difficulties.
Participants talked about feeling more hopeful and positive about their future.
It is believed that the ToL encouraged individuals to move away from a problem-
saturated story toward one that acknowledged strengths. Furthermore, this task
supported individuals in thinking about dreams and goals they may want to work
toward in the future. Thinking about an ideal self in terms of what a tree may need
also encouraged people to think and explore multiple resources that may be present
in their lives. Strengths and resources have been shown to be important in reducing
risk of relapse (MacLeod & Moore, 2000). Given that CBT independently has not
shown significant effects in reducing relapse (Szentahotai & David, 2010), the ToL
is a promising approach to tackle difficulties with reducing relapse rates.
The ToL was the only therapeutic tool that was valued by all participants. This
reflects the usefulness of the ToL for individuals from a diverse range of backgrounds
and educational contexts (Byrne et al., 2011). It appears that the ToL both directly
and indirectly helped improve participants’ self-esteem. Any future study should
consider including a specific measure exploring self-esteem to measure this effect
quantitatively.
The second theme highlighted understanding and thinking about ways to cope.
Participants discussed the helpfulness of gaining an understanding of the nature of
BD. The CBT model also supported participants in gaining self-awareness at different
levels of early, middle, and late warning signs. Participants talked about breaking it
up in terms of cognitions, behaviors, emotions, and physical symptoms as helpful.
This supports previous research that has shown that CBT is a promising approach
The Highs and Lows Through Recovery 31

for improving functioning for individuals with BD (Lam et al., 2000; Scott, 2008).
Furthermore, the narrative, ToL, and CBT taken together contributed to restructuring
some of the biased appraisals suggested by cognitive models (Mansell et al., 2007).
The third theme identified was understanding and coping for all. The partici-
pants perceived the facilitators as validating their difficulties. They commented on
being allowed to interrupt but still complete tasks of the session. We believe that
a successful therapeutic relationship was built by empowering participants in the
structuring of the group, by asking them about their expectations at the beginning
of the group, by facilitators sharing their own ToL, and by allowing enough time
for discussion. Castle and colleagues (2007) reported a similar approach during
their group sessions (Pearson & Burlingame, 2013). Once again, this contributed to
the social support individuals received from facilitators during the group sessions.

LIMITATIONS AND FUTURE DIRECTIONS

The described group and its analysis had several limitations. The group consisted of
only eight sessions, which is not in line with the National Guidelines (NICE, 2006,
2011), which recommend 16 sessions. The group was also a small sample size, and
future research would need to repeat this group with more participants.
Furthermore, participants did not attend all sessions, making it difficult to
know from which parts participants benefited the most, although all participants
completed their own ToL and some additional practical tasks. This also may have
made it difficult for participants to follow the metaphorical structure of the group.
There are several ways to improve the participants’ understanding of the content of
the group, including by providing a manual for each participant with all worksheets
during the first session, providing a structure for each session at the beginning of
the group, giving an opportunity to contact facilitators if there was something they
did not understand, providing an example letter for each template, reinforcing the
importance of attendance and timekeeping, and recapping the previous session at
the beginning of each session.

CONCLUSIONS

We believe the combination of CBT and NT, specifically the ToL, for BD has the
potential to address a number of important factors that contribute to recovery and
reduce relapse, such as an increased self-awareness, self-control, and identification
of resources and strengths. The opportunity for individuals to share experiences
with others, and to learn from others, contributed to participants feeling socially
included and supported. Delivering interventions in a group therapy approach
reduces waiting-list times and is cost-effective.
32 ibrahim and allen

REFERENCES

Alloy, L. B., Abramson, L. Y., Neeren, A. M., Walshaw, P. D., Urosevic, S., & Nusslock, R.
(2006). Psychosocial risk factors for bipolar disorder: Current and early environment
and cognitive styles. In R. Bentall & S. Jones (Eds.), The psychology of bipolar disorder:
New developments and research strategies (pp. 11–46). Oxford: Oxford University Press.
Alloy, L. B., Reilly-Harrington, N., Fresco, D. M., Whitehouse, W. G., & Zechmeister,
J. S. (1999). Cognitive styles and life events in subsyndromal unipolar and bipolar
disorders: Stability and prospective prediction of depressive and hypomanic mood
swings. Journal of Cognitive Psychotherapy, 13(1), 21–40.
Burlingame, G., Strauss, B., & Joyce, A. (2012). Change mechanisms and effectiveness
of small group treatment. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of
psychotherapy and behavior change (6th ed., pp. 640–689). Hoboken, NJ: John Wiley.
Byrne, A., Warren, A., Joof, B., Johnson, D., Casimir, L., Hinds, C., & Griffiths, S. (2001).
“A powerful piece of work”: African and Caribbean men talking about the Tree of
Life. Context 117, 40–45.
Castle, D., Berk, M., Berk, L., Lauder, S., Chamberlain, J., & Gilbert, M. (2007). Pilot of
group intervention for bipolar disorder. International Journal of Psychiatry in Clinical
Practice, 11, 279–284.
Foucault, M. (1965). Madness and civilization: A history of insanity in the age of reason.
New York: Vintage.
Harper, D. J. (2004). Storying policy: Constructions of risk in proposals to reform UK
mental health legislation. In B. Hurwitz, T. Greenhalgh, & V. Skultans (Eds.), Narrative
research in health and illness (pp. 397–413). Hoboken, NJ: John Wiley.
Hennink, M. M. (2007). International focus group research: A handbook for the health and
social sciences. Cambridge: Cambridge University Press.
Hughes, G. (2013). Finding a voice through “The Tree of Life”: A strength-based approach
to mental health for refugee children and families in schools. Clinical Child Psychology
and Psychiatry, 19, 139–153.
Jamieson, C. A. (2012). A case study exploring the use of the Tree of Life as a narrative
intervention tool with a Black adolescent girl who was sexually abused in South Africa
(Unpublished doctoral dissertation). University of Johannesburg, South Africa.
Johnson, L., Lundstrom, O., Aberg- Wistedt, A., & Mathé, A. A. (2003). Social support in
bipolar disorder: Its relevance to remission and relapse. Bipolar Disorder, 5, 129–137.
Johnson, S. L., & Kizer, A. (2002). Bipolar and unipolar depression: A comparison of
clinical phenomenology and psychosocial predictors. In I. H. Gotlib & C. L. Hammen
(Eds.), Handbook of depression (pp. 141–165). New York: Guilford Press.
Johnson, S. L., Meyer, B., Winett, C., & Small, J. (2000). Social support and self-esteem
predict changes in bipolar depression but not mania. Journal of Affective Disorders,
58, 79–86.
Johnson, S. L., & Roberts, J. E. (1995). Life events and bipolar disorder: Implications from
biological theories. Psychological Bulletin, 117, 434–449.
Johnson, S. L., Winett, C. A., Meyer, B., Greenhouse, W. J., & Miller, I. (1999). Social sup-
The Highs and Lows Through Recovery 33

port and the course of bipolar disorder. Journal of Abnormal Psychology, 108, 558–566.
Lam, D. H., Bright, J., Jones, S., Hayward, P., Schuck, N., Chisholm, D., & Sham, P. (2000).
Cognitive therapy for bipolar illness: A pilot study of relapse prevention. Cognitive
Therapy and Research, 24, 503–520.
MacLeod, A. K., & Moore, R. (2000). Positive thinking revisited: Positive cognitions,
well-being, and mental health. Clinical Psychology and Psychotherapy, 7, 1–10.
Mansell, W., Morrison, A. P., Reid, G., Lowens, I., & Tai, S. (2007). The interpretation of,
and responses to, changes in internal states: An integrative cognitive model of mood
swings and bipolar disorders. Behavioural and Cognitive Psychotherapy, 35, 515–539.
Mansell, W., Powell, S., Pedley, R., Thomas, N., & Jones, S. A. (2010). The process of re-
covery from bipolar I disorder: A qualitative analysis of personal accounts in relation
to an integrative cognitive model. British Journal of Clinical Psychology, 49, 193−215.
Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1988).
Family factors and the course of bipolar affective disorder. Archives of General Psy­
chiatry, 45, 225–231.
National Institute for Health and Clinical Excellence. (2006). Bipolar disorder: The manage­
ment of bipolar disorder in adults, children, and adolescents, in primary and secondary
care. Retrieved from https://www.nice.org.uk/guidance/CG38
National Institute for Health and Clinical Excellence. (2011). Service user experience in
adult mental health: Improving the experience of care for people using adult NHS mental
health services. Retrieved from https://www.nice.org.uk/guidance/CG136
Ngazimbi, E. E., Lambie, G. W., & Shillingford, M. A. (2008). The use of narrative therapy
with clients diagnosed with bipolar disorder. Journal of Creativity in Mental Health,
3, 157–174.
Pearson, M. J., & Burlingame, G. M. (2013). Cognitive approaches to group therapy: Pre-
vention of relapse in major depressive and bipolar disorders. International Journal of
Group Psychotherapy, 63, 303−309.
Prasko, J., Diveky, T., Grambal, A., Kamaradova, D., Latalova, L., Mainerova, B., Vrbova,
K., & Treova, A. (2010). Narrative cognitive behavior therapy for psychosis. Activitas
Nervosa Superior Rediviva, 52, 135–146.
Priebe, S., Wildgrube, C., & Müller-Oerlinghausen, B. (1989). Lithium prophylaxis and
expressed emotion. British Journal of Psychiatry, 154, 396–399.
Regional Psychosocial Support Initiative. (2007). The mainstreaming psychosocial care and
support: A manual for facilitators. London: Regional Psychosocial Support Initiative.
Rhodes, J., & Jakes, S. (2009). Narrative CBT for psychosis. London: Routledge/Taylor
and Francis.
Rosenfarb, I. S., Becker, J., Khan, A., & Mintz, J. (1998). Dependency and self-criticism
in bipolar and unipolar depressed women. British Journal of Clinical Psychology, 37,
409–414.
Scott, J. (2008). Cognitive-behavioural therapy for severe mental disorders: Back to the
future? British Journal of Psychiatry, 192, 401–403.
Szentagotai, A., & David, D. (2010). The efficacy of cognitive-behavioral therapy in bipolar
disorder: A quantitative meta-analysis. Journal of Clinical Psychiatry, 71, 66–72.
Copyright of Group: Journal of the Eastern Group Psychotherapy Society is the property of
Eastern Group Psychotherapy Society and its content may not be copied or emailed to
multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.