Diary: Bridges in a Group 2

Different strokes

Lemon Polenta cake, Scottish shortbreads and Malteser chocolate bunnies: I could get used to hanging out with stroke survivors, says Billy Mann

I’m only half joking. This outbreak of gluttony came at the start of the final session in a PhD study by Ella Clark at UCLH into testing Bridges Self Management for stroke survivors in a group setting. We were all stuffing our faces and grinning madly.

Bridges is a project pioneered by Prof Fiona Jones at St George’s hospital in Tooting, London. The mission is to help stroke survivors build their own step programmes to meet long-term goals set by themselves. These goals vary in the widest sense, but the Bridges approach seeks to find a series of baby steps by which big gains can become part of everyday life. It’s a method that will work for some but not always for others.

Motivation is a key player in progressive recovery and these four-week trials were part of a study to see if fellow group members (6-8) could play a role in the process by offering mutual support. In the three trials I helped facilitate, the goals of the group members varied depending on the individual, any support they might or might not have, and in the ways their stroke had impacted on their lives. In the second group I joined, one member wanted to try to regain some of the problem-solving skills he had lost. He mentioned crossword puzzles and arithmetic in particular. Another member defined as a goal writing and signing a Thankyou card for her daughter and her husband.

It is always fascinating to watch small-group dynamics unfold. You instinctively reach for the reality-TV stereotypes and make snap judgements about personalities, only to be confounded in the next session by behaviour in total opposition to your initial prejudice. Baddies become goodies and that bossy boots turns into a pussycat. The relationships between individual characters are thrown into relief and you sometimes end up siding with the person you thought at first you would dislike the most.

Group members respond in different ways to different types of stimuli. One identified her goal as getting back to cooking and entertaining. The stroke had left her unable to plan, organise and implement a dinner party for friends. Fatigue wiped her out and the mere thought of it built in her mind to become an impossible task.

By just talking about food, the group learned of some of her favourite dishes and the special ways she prepared them. All of this took place in the context of a natural conversation, so when it was proposed that she might cook a cake for the group, a competitive twinkle appeared in her eye. She wanted to show us she could do it. And she did. The lemon polenta cake mentioned in the opening paragraph is the proof. The zing of the lemon was a sensory delight.

But her determination didn’t stop there. She had also completed and fed friends with specialty dishes of lamb and salt beef. She was obviously on a roll. If we were giving out marks, she passed with distinction.

A recurring issue among members in all the groups I was involved with was whether the post-stroke difficulties they now face and experience were related directly to the stroke, or whether they were part of natural ageing. Forgetfulness was the chief example. This was especially the case among some of the older group members.

Balancing time with health needs emerged as a another challenge. Take on too much and it might end up costing you in terms of stress and fatigue. Take on too little and it seems like you are treading water, stuck in a rut, but all the time feeling you should be more dynamic, making more progress, just doing things.

One member talked about withdrawing from what was once his very active participation on neighbourhood committees and working groups. He had taken several steps back and, by rationing his time more selectively, was able to focus on and tackle a specialist academic mentoring role, which had proved far more personally rewarding and much better suited to the skills he had built over many years.

But in stepping back he also stepped forward to wrest control of low-key domestic aspects of his life from his children, who had intervened to ensure his comfort. He was calling the shots now and, bit by bit, nurturing a newfound self-reliance.

Towards the end of the final session, one of the group asked Ella if she had a title for the published study that would emerge from these eight group trials. Not yet was her answer, so cheekily I asked the group what might be the key words that would help Ella come up with a successful title.

Earlier in the session that day I had tried to summarise the essence of the past four weeks. In my notebook, I had written “the power/potential of peer support”. Looking at this now I am horrified by its inadequacy. In collecting the thoughts of the other group members, the word that won the day was “sharing”.

Throughout the final session, many of the group had identified in their own ways the importance of sharing. One member spoke of how rare it was for her to share her stroke experience with people who could readily empathise. She said she no longer “felt so alone”. Another talked about how positivity breeds positivity and that the group sessions had somehow almost magically instigated an outbreak of optimism.

Sharing is one of the enduring themes of the early 21st century, much of it enabled by the world wide web. Touch that SHARE button on your digital device and look at the ever-growing number of platforms across which you can connect with others: Facebook, Twitter, Instagram, LinkedIn…


Yet, yet, yet… sharing a traumatic experience with relative strangers is not easily done. The group found that doing it in person, face-to-face, with all the risk any kind of human encounter throws up, was overwhelmingly positive. One group member used the word “transformative” and, when pressed, explained how, as bad as having a stroke is, in some respects it offers an opportunity for renewal, a chance to become a new person. Another talked about life after stroke as an exercise in planting seeds. These, for me, were both fitting remarks to herald the onset of Spring and to end what had for me been a fascinating experience.

See the lemon polenta cake recipe

Diary: Bridges Symposium

Symposium isn’t a word that trips off the tongue. It sounds impossibly proper, serious and really quite grand. When asked by Bridges Self Management to help out at their 7th Annual Symposium at St George's hospital in London I felt out of my depth just reading the email. In an attempt to at least look like I was somehow in the loop, I looked up ‘symposium’ in the dictionary. It is a compound word that dates back to ancient Greece and translates roughly as a ‘drinking party’. A symposium was a bunch of mates getting together for the sole purpose of getting drunk and talking endlessly. That’s more like it. What could possibly go wrong?

What went wrong is that I forgot to mention several key points. Drink had nothing to do with it, and neither was the panic that struck when I arrived in the designated conference room in St George’s at the sight of three, yes THREE screens from which our presentation was to be projected. The main purpose of my involvement was to supply a repeat performance from a 2015 conference in which physiotherapist and Bridges trainer Katie Campion interviews me about how I coped after discharge from hospital following a heamorrhagic stroke. We talk about goal setting and I seize the opportunity to make plentiful reference to football and the team I support, Liverpool.

In outward appearance, our presentation resembles the work of a second-rate comedy duo. We feed each other lines, but they are not always the right ones. I’m always aware of undermining Katie’s proper professional status with my bad jokes, and sometimes the result is confusion. So, in the part where we talk about my understanding of the word 'goal’, I had intended to shoot a line about the importance in football of coaches and captains. I missed the shot. And in the part where I answered questions about devising small steps to big goals, I should have mentioned the importance of visualisation. Again, I fluffed it and the chance went begging.

It wasn't all bad, though. Katie did manage to grab victory from the jaws of defeat while we were on the topic of my early goals when still in hospital. In this section I typically talk about the desire to complete bathroom activities independently. I then move on to describing my attempts at the 'transfer’. This will be familiar to stroke nurses worldwide and involves getting a patient to move themselves safely from wheelchair to bed, and vice versa. At the time I was desperate to master this manoeuvre because being able to snoop around and then return to bed for a snooze was, for me, the very essence of being alive.

Maybe I was a bit too desperate because my early attempts involved hurling myself from a sitting position on the bed in the general direction of the wheelchair seat. The reverse process was not much prettier and, as I outlined this technique to the rapt symposium audience, Katie quite sensibly interjected, “Wasn’t all that hurling a bit risky?” This remark opened a can of worms on the subject of risk, and to what extent patients should be entitled, encouraged even, to explore the everyday fringes of jeopardy. It is a big, important subject, and relevant not only for stroke patients but for anyone living with a long-term condition. Is not the freedom to make mistakes a universal human entitlement? Discuss. Needless to say, we barely scratched the surfaces of it, but I am glad the subject of risk had put in an appearance as Katie and I tumbled our way innocently towards some kind of conclusion to our presentation.

So, as I sat down afterwards, the word PHEW shot to mind. I had barely paid any attention to the symposium’s previous speakers. All I can remember is that two experts from Lewisham CCG, Damian and Angelika, proposed what seemed to me a perfectly valid practical distinction between self-care and self-management, illustrated using a projected Venn-style diagram that looked like a hard-boiled egg. I was pleased to note that the yolk was not centred but irritatingly offset, just like mine are when I make boiled eggs. Another pair, Heide and Tino, ran a video of a lovely chatty couple who were calling for a bit more joined-up thinking from practitioners and clinicians in regard to service users.

Lisa Kidd, a leading goal-scorer for nursing and Scotland, followed our presentation, and made some telling points about how things actually happen on the ward. I am often guilty of gushing praise at the doctors, nurses and therapists who have all contributed to my stroke recovery, to which they most commonly reply, “Thank you, but I was just doing my job”. My response is always the same: “I know, but you choose the way you do your job, so please accept my thanks for that.” I was extremely grateful in this respect to be able to forge good communication with all those involved in my progress after stroke. It is an experience and a lesson I hope I will never forget.

Diary: Bridges in a Group

On four successive Mondays in April I helped on a research project into whether the step process method in stroke rehabilitation as advocated by Bridges Self-Management can be made to work in a group setting. The more interesting details of the study, by UCL's Ella Clark, will I’m sure appear in more scholarly quarters, but what I can report is that about half way through the trial, which brought together seven stroke survivors, Lucinda Brimicombe, Bridges Director of Training and Innovation, raised the question as to what was uniquely "Bridges" about this project? How was it different from other stroke rehab groups? In what ways and to what extent were Bridges methods working successfully? It was at this point that images of bridges started to pop into my head.

Runcorn Bridge

I have come to know several bridges, starting with my earliest memories as a child in the back seat of a car crossing the Runcorn Bridge over the River Mersey. It seemed so big with its hard iron frame studded with rivets the size of your fist. It was scary. And more recently I enjoyed the Scandinavian TV crime series The Bridge, which features the Øresund Bridge that connects Sweden and Denmark. It is 16km long, and it is scary. The drama begins with the discovery of a body exactly half way along the bridge. Is this in Sweden or Denmark? Which police force will investigate the crime? The Swedes? The Danes? The story is later complicated when the body is found to have been cut into two equal parts. Scary.

Øresund Bridge

Travelling the Øresund Bridge via Google Earth is an eye-opener. It seems to go on forever, and you can easily get lost in thought along the way. You begin to run your imagination over the symbolism of the bridge as a connector, how a structure can unite two very separate things, what kind of loads will that structure carry, what is the importance of traffic volume, foundations, etc, etc, blah, blah?

Back on dry land and stroke self-management, in Bridges World, small steps to big things is the mantra. I call them 'baby steps'. What I have found from experience is that in setting yourself small goals (for me that means easily achievable) and then exploring ways to hit your tiny targets, you reflect on and modify along the way. For example, what a year ago for me was the stated desire to complete a walk of the famous Seven Sisters along the white cliffs of the Sussex coast from Eastbourne to Cuckmere Haven, has mutated into a daily patrol of my neighbourhood on foot, stopping to chat with the locals, telling children to stop being naughty and checking the ever changing world of an inner-city wildlife garden. The dream of walking the Seven Sisters has not disappeared, but it is much less urgent than it was a year ago (I have even done the walk, on a treadmill with Google Earth on my iPad). In this way, by embracing the small steps as an end in themselves, I learn more about myself and can therefore make better decisions about those big juicy goals.

The approach is even appropriate to activities not remotely related to stroke rehab. Not long ago I used a piecemeal step method to 'build' from visual components a picture of Hammersmith Bridge for my wife's godmother. And she thought I sat around in the cold with a box of paints for several days. Not likely! It's a fake.

Hammersmith Bridge

So how might these 'baby steps' work in a group situation? That is still a work in progress, but I do have one observation from the UCL meetings. I have noticed that motivation is where rehabilitation often stands or falls. I am a very focused and determined person. Most people are not, and I have seen progress in others falter simply because the will to action is simply not there. And in the group work we did at UCL, what surprised me most was the drive shown by some of the group members to help others. They had found a role, a mission, a sense of purpose. They found their motivation, their post-stoke mojo, a reason for doing something. It is as simple as the slogan 'Help others to help yourself'.

It doesn't take a mammoth leap of the imagination to see that this is potentially very powerful. How systems and structures (the bridge?) can be built to support such a self-sustaining programme of mutual enablement is the question. Making it work is the challenge.

Diary: Goal Setting

Back of the net

Can football help in post-stroke recovery? with Kevin Keegan and Kenny Dalglish on your side, anything is possible, reckons Billy Mann

In April I took part in a conference on post-stroke goal setting at the National Hospital for Neurology and Neurosurgery in Queen Square in London in which I was interviewed by Homerton Hospital physiotherapist Katie Campion. She was presenting on behalf of Bridges Self Management, whose stated aim is to "enable people living with long-term neurological conditions to take control of their rehabilitation and daily lives”.

During the interview I alluded to ‘goal’ scoring, as in a football match, and spoke of my childhood memories of watching my heroes Kevin Keegan and Kenny Dalglish in action. The goal was, I said, the thing we remember most about the game, the ball struck by a player hitting the back of the net. Then the crowd goes mental. Nobody remembers the goal nearly scored. But, I said, a great goal is often the product of a series of “baby steps”, a collection of passes, tackles and other tactical movements that culminate in a star player making the final strike and basking in the glory of the goal scored. These steps, I argued, are as, if not more significant than the ultimate goal, and the importance of successful passes, shots on target and tackles completed are now being measured by sports statisticians. Players are now ranked not just for the number of goals they score but also for the "goal assists" they provide.

This gave me a neat way of describing the small hills and big mountains scaled during post-stroke recovery. But that would be taking the mixed metaphor to new extremes.