Sinead Hartley, David Leahy, Edgar Lonergan, Mary Kells, Daniel Flynn and Chris McCusker
Over the past 50 years there has been a gradual shift in the view that mental health inpatient units are an environment in which little therapeutic intervention can be offered1. A Vision for Change2, which sets out a comprehensive policy framework for our mental health services, recommended an increase in multidisciplinary group therapy programmes in inpatient settings. Consequently, inpatient units have gradually endeavoured to offer multidisciplinary group therapy programmes with the aims of improving interpersonal skills, decreasing symptoms and facilitating discharge2. In line with AVFC recommendations, acute mental health units across HSE South (Community Healthcare Organisation Area 4; CHO area 4) have introduced ward based therapy programmes. In 2015, the Mental Health Commission published the Judgement Support Framework3 to ensure compliance with regulatory requirements and to improve the quality of services provided to service users in mental health inpatient units. Consequently, the provision of these services has been regularly audited and local Mental Health Services within CHO Area 4 are committed to researching the ward based therapeutic programmes more rigorously in order to shape and improve future delivery. Furthermore, one of the most progressive recommendations in AVFC is that service users should be involved in every aspect of mental health service development and delivery. This report summarises the findings of service user’s perspectives of ward based therapeutic programmes in three adult mental health inpatient units in HSE South.
AVFC recommends user (and carer) involvement at every level of the mental health service delivery and development2. There are a number of reasons why mental health service user involvement is a worthwhile activity with a range of practical and ethical benefits. For example, user involvement may be therapeutic in itself, and may encourage social inclusion4. Consequently, in recent years there has been increasing attention paid to service user feedback in Ireland as it influences the shape and delivery of mental health services. In Ireland and the UK there has been much research conducted on the experiences of mental health service users despite mental health service user involvement being a relatively new phenomenon in the Republic of Ireland5-8. However, there is a limited amount of research targeting service users’ experiences of inpatient groups.
Inpatient Group Therapies
A meta-analysis of 70 studies of inpatient group therapies conducted between 1980 and 2004 reported that inpatient group therapy has a significant positive effect on patient outcomes and recovery9. However, running and evaluating group therapeutic programmes in inpatient settings is notoriously difficult as individuals have acute presentations, are often heavily medicated and are often receiving a standard package of care. Consequently, the ecological validity of applying evidence based treatments in an inpatient setting is questionable due the complexities of outcomes as already stated. At the same time groups can afford an important socialising impact, make a significant contribution to the therapeutic environment of the ward, and can provide structure, purpose and therapeutic features to a hospital stay 7, 10, 11.
O’Donovan et al.12 identified a number of benefits of an inpatient group programme, which were consistent with Yalom et al.’s13 therapeutic factors, such as universality, interpersonal learning and the development of socialization techniques. More recently, findings from research carried out by Dempsey et al.14 in a local regional inpatient unit were consistent with these themes. Indeed the therapeutic elements reported could also be conceptualised as pre-therapy competencies15. Pre-therapy can improve inpatient service users’ capacity for being in contact with others, and communicating about themselves and their world, which can contribute to their ability to participate in, and profit from one to one psychological therapies.
Radcliffe et al.16 also identified benefits of attending inpatient groups. They reported that service users felt more involved in their treatment, perceived the ward as more therapeutic and service users’ relationships with others in the unit improved as a result of attending groups. Furthermore, Shattell et al.17 reported that service users felt that psychoeducational and reference material would support recovery. However, unhelpful aspects of inpatient groups have also been highlighted such as other service users’ disruptive behaviour in groups, and irrelevant content of groups.
The acute mental health units across CHO Area 4 have a long history of providing multidisciplinary care. In line with AVFC recommendations, the ward based therapy programme in its current form was introduced to one of the units included in this study in 2009. The programmes involve a wide range of stand-alone intervention groups, with significant multidisciplinary input from clinical psychology, nurse therapy, occupational therapy, and art therapy. A key objective of the revised programme was to provide a more varied programme of interventions to meet the needs of all service users, with both acute and chronic/enduring mental health difficulties. Parallel programmes have since been introduced in two more mental health inpatient units in the local area.
Specifically, the study aimed to answer the following research question: What are the service users’ experiences of the therapeutic groups in terms of clinical and social aspects, and areas where the programme could be improved. The capacity for such groups to promote key pre-therapy competencies, such as engagement, reflection, working in a relationship with others is important in contextualising the project.
A qualitative methodology was used in this project which was undertaken in three acute adult mental health inpatient units across CHO Area 4. This involved collecting data through the use of focus groups and subsequent thematic analysis.
The three inpatient units involved in the research together provide care and treatment for approximately 110 people. 49 ward based therapeutic groups were included in the evaluation. At the time of the study, all therapeutic groups were open and scheduled Monday to Friday on a daily, bi-weekly and weekly basis. Table 1 outlines the types of therapeutic programmes run at the three units which were facilitated by nurse therapy, clinical psychology, occupational therapy and art therapy at the time the study was undertaken.
Table 1. Inpatient group programmes
The sample consisted of 17 service users (age range: 20-64 years. See Table 2) who were at the time inpatients. The inclusion criteria outlined that participants should be over 18 years of age, and had the ability to give informed consent. Suitable participants for the focus groups were identified by the clinicians responsible for co-facilitating the respective therapeutic groups. This was based on their perceived wellness and ability to contribute. The selected participants were then invited to participate in the focus groups. No distinction was made between which groups the participants attended as the overall aim was of the programme was the same.
Table 2. Composition of focus groups
|Group 1||5||5||0||20 – 58|
|Group 2||6||2||4||33 – 57|
|Group 3||6||4||2||37 – 64|
|Total (N, gender, age range)||17||11||6||20 – 64|
The study was granted full ethical approval from the local Teaching Hospitals’ Ethical Committee. Those who volunteered to take part in the study were informed that their participation was voluntary and that their withdrawal from the study at any time would not affect their treatment in any way.
Data Collection and Analysis
Data was collected over a period of 4 weeks across three sites in February 2017. One focus group was conducted per inpatient unit. Due to the semi-structured nature of the interviews any new topics raised by participants were explored by the researcher. Moreover, participants were encouraged to be critical as well as positive in their feedback. Focus group facilitators (i.e. the principal researcher plus one clinical psychologist) had no involvement in the delivery of the therapeutic programmes at individual sites. All interviews lasted between 45 and 60 mins.
Qualitative Data Analysis
Thematic analysis was used to identify, interpret and report organising or overarching themes. The steps taken in conducting thematic analysis follow those recommended by Braun et al.18.
The process involved six main stages: verbatim transcription, detailed reading of the data, identiﬁcation of data sets, identiﬁcation of initial themes from the data sets and coding, reﬁnement of themes, and clustering themes into coherent groupings (samples of coding available and full transcripts). The themes and sub-themes identified are summarised in Table 3 below.
Four dominant themes emerged from the data analysis. These themes highlighted the value service users placed on the programmes, the beneficial aspects, as well as emphasizing areas for improvement:
- Self-care & Recovery
- Emotional Connection
- Suggestions for Improvement
Theme 1: Self-Care and Recovery
All participants reported that the therapeutic group programmes were an important aspect of their care and impacted on their recovery. Service users noted that the groups gave them the opportunity to have a better understanding of themselves, helped them to not focus too much on their personal difficulties and improved their psychological well-being.
“They get you to think about your health … they get you out of your own headspace and give your mind a break.” – Participant 13
“I find that they’re good too for recovery, because they’re giving you ways of dealing with your stress and how to deal with your emotions …” – Participant 6
Many participants also described the value of daily structure and routine which the group programme offers, and were generally positive about the encouragement the ward staff provide to attend groups when they cannot self-motivate.
“The groups give a sense of continuation and a sense of achievement at the end of the day.” – Participant 17
Theme 2: Safety
Participants described the sensitivity and respect they were offered by the group programme facilitators which contributed positively to engagement.
“They make you feel a lot more comfortable for you, more relaxed. Safe if you like.” – Participant 9
Many participants also reported that attending the groups allowed them to realise that other people had similar problems which helped them feel less daunted by the experience.
“Everyone is in the same boat that you’re in and you feel that you’re in a sheltered environment, that you’re all in the same boat …We’re all one little close knit community.” – Participant 5
“It helps you to feel normal like. People have different ways of looking at things and it feels nice.” – Participant 1
Theme 3: Emotional Connection
The opportunity to relate to others was highlighted by the majority of the service users as the most important aspect of the therapeutic programmes. They valued the experience of empathising and connecting with others, which for some improved confidence and for others reduced isolation.
“You’re listening to hardships, you’re listening to reality and you can connect with that and you hear someone else that you can also connect with … It’s a huge understanding to feel that connection with others.” – Participant 14
“The groups bring you closer to people, have given me more confidence I suppose … We share the same kind of ongoing things maybe as well.” – Participant 9
“The groups help me to integrate with people a little bit better. It just beings me out of my shell.” – Participant 15
Theme 4: Suggestions for Improvement
Participants noted that some of the groups can be repetitive and unvaried, particularly for those longer stay inpatients, and would like new material introduced.
“At the moment it’s one size fits all. Some people just in the door might love it and people here longer could completely disengage with it.” – Participant 8
Furthermore, some service users expressed a desire for more psychoeducation regarding their specific diagnosis and mental health difficulties to aid recovery. Additionally, they suggested that the groups should focus more on specific illnesses, such as bipolar disorder or depression. Focus groups participants also expressed a strong desire for weekend activities and for additional groups that included music and dance.
“I think somethings that are lighthearted and a little bit fun would be really great.” – Participant 3
Table 3. Themes and subthemes identified in transcripts
The qualitative analysis of service users’ perspectives revealed high levels of user satisfaction. Service users reported many benefits and viewed the therapeutic programmes as an important aspect of their recovery. Structure and routine was viewed as a practical and primary feature of the programmes, which strongly contributed to service users’ emotional health by giving a sense of structure, a sense of achievement, and meaning to their days on the ward. There is an abundance of recovery literature relating to the positive effects of daily structure and routine in coping with many mental health difficulties. For the most part such research reports the crucial components of routine and daily meaning to building healthy life structures19, which for inpatient populations have generally broken down.
In addition, one of the key benefits reported by participants was being provided with the opportunity to relate to and connect with others, which fostered a sense of belonging, improved social interaction, increased communication, and thus, reduced isolation. They also described a process of normalisation through shared experiences, which provided a sense of safety and comfort. These findings are similar to research conducted on group therapeutic programmes in adult mental health inpatient units 12, 14. Moreover, these reported benefits reflect Yalom et al.’s 13 therapeutic factors of participating in a group format, specifically, universality, interpersonal learning, cohesiveness and the development of socialisation techniques20. These generic benefits appear to be prevalent irrespective of the service users’ preferred type of group or service users’ individual difficulties. The results support the notion that ward groups improve morale21. This provides positive affirmation and support for the current offerings of therapeutic programmes in the participating units. Moreover, no specific group format was described overall as the most or least beneficial, highlighting the range of individual preferences and the value of a variety of groups. A holistic approach incorporating activity based groups, discussion based groups, and groups focussing on coping strategies, has been reported in the literature as necessary to promote recovery and wellbeing22. These reported therapeutic benefits are important because (1) they are core aspects of psychological wellbeing and positive experience; (2) they promote pre-therapy competencies of sociality, and a return to reality; and (3) in light of the difficulties of researching and running evidence based therapies within an inpatient setting, the process of taking part in groups may well be one of the primary therapeutic benefits at this level of care.
Very few aspects of the programmes were seen as unhelpful by the participants. Some participants highlighted that the content of some groups was repetitive and undeveloped and considered it a potential contributing factor to disengagement and reduced attendance. They described this as a drawback for (1) those who had more insight into their difficulties, and (2) for those who were on longer hospital stays. Additionally, they suggested developing programmes depending on ability levels and length of stay. The inpatient units included in the study cover a large catchment area, with rural, sub-urban and urban regions. Therefore running group programmes that take into account a variety of backgrounds, educational levels, and length of stay can be particularly difficult. However, it may be possible to address this by recommending particular groups to participants depending on levels of educational ability and current functioning12. Alternatively, a modular structure could be implemented enabling service users’ to tailor their own therapeutic programme.
Other participants highlighted the need for specific groups that focus on particular conditions and more psychoeducation provided regarding different mental health difficulties. This reflects findings by Shattell and colleagues17, who reported that service users felt that education, information and reference material would support recovery. The provision of group activities at weekends was also regarded as an area for improvement as some participants felt that a reduced structure and engagement with others at weekends interrupted personal progress achieved during the week. Furthermore, helpful suggestions regarding the inclusion of music based activities, animal therapy, and more ‘light hearted’ offerings were also expressed and considered important for overall mental health and wellbeing. It was acknowledged that the services already attempt to deliver a varied range of activities targeted at different interests and ability levels. Related to this point, participants also noted that generally their ability to engage in different groups on daily basis depended on their mental states.
There are limitations to the study which need to be considered when interpreting the results. This was a small scale study with a small sample size therefore themes should be regarded as indicative rather than representative, particularly as participants of alternative group therapy programmes might privilege different issues. It was undertaken in only three acute inpatient units in HSE South and therefore findings are contextually bound. As already mentioned, user satisfaction was high and most responses were positive in nature. This could be related to the fact that focus groups were conducted while they were inpatients and it is possible that participants were reluctant to make negative comment because of possible repercussions. Furthermore, it is also recognised that participants may have experienced difficulty expressing their opinions in a focus group setting if they had previously struggled with group membership.
From this, a number of recommendations arise:
- Suggestions and critical reviews by the service users’ should be reflected on and considered for future programme development in order for service user involvement to be meaningful and more than simply a political mandate. For example, implementing a modular structure enabling service users’ to tailor their own therapeutic programme.
- At a time when resources are limited, recommended further research should explore whether it is largely the process of taking part in groups that benefits inpatients, and which core principles make a therapeutic programme valuable.
- Informed by the main themes identified in this evaluation, services and the reported benefits could implement a protocol aimed at improving membership to group programmes grounded in the lived-experience of those who actually use the service
- Periodical audits should continue to be conducted to ensure comprehensive evaluations given the acuity of presentations in inpatient wards on any given week and the possibility of identifying further therapeutic gains and areas for improvement.
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Sinead Hartley, Psychologist in Clinical Training, UCC, HSE. email@example.com
Dr David Leahy, Senior Clinical Psychologist, South Tipperary.
Dr Edgar Lonergan, Principal Clinical Psychologist, Cork /Kerry.
Dr Mary Kells, Principal Clinical Psychologist (Specialist), Cork.
Dr Daniel Flynn, Principal Psychology Manager, Cork/Kerry, HSE.
Dr Chris McCusker, Senior Lecturer in Clinical Psychology, Director Doctor of Clinical Psychology, UCC.
Thanks to Claire O’Sullivan, Senior Clinical Psychologist and John Brennan, Clinical Psychologist for their help with co-facilitating the focus groups; to the nursing staff in participating hospitals for their help with recruitment; and to all those who participated in the focus groups.