An evaluation of a Group Psychosocial Intervention for Clients with Schizophrenia

Hennessy, E.M., Carolan, M., Mulcahy, B., Murphy, M. and Corcoran, A.



This study aimed to explore service users’ initial experiences of Cognitive Behavioural Social Skills Training (CBSST), aimed at improving psychosocial functioning in clients with schizophrenia. To date, CBSST has been delivered in the USA and Canada as well as parts of Europe, but not yet in an Irish setting. The main focus of this study was to assess how service users received the programme, if it was acceptable to them, as well as to explore their overall experiences of being in the group to this point.


Introduction and Rationale

Historically, the majority of people with severe and enduring mental health difficulties, such as schizophrenia, resided in psychiatric hospitals and had poor long term outcomes which meant that they were often given little optimism for their future1. As a result, a movement toward a more holistic view of recovery, and recovery-orientated mental health services for this population group, has taken place internationally over the last thirty years2-4. This concept has been growing in Ireland over the last 10 years since the publication of the Government mental health policy document ‘A Vision for Change – The Report of the Expert Group on Mental Health Policy’5 which advocated for recovery as a ‘facilitative process that enables disadvantaged individuals to access as independent a life as possible in social, cultural and economic terms’(p104). Consequently, the formation of rehabilitation and recovery community mental health teams has taken place in order to provide specialised care for people with severe mental health difficulties, which could not be adequately met by the general adult Community Mental Health Teams.

It was further advocated in ‘A Vision for Change’ that service users and their families should be at the centre of all service provision and development, and service users should be viewed as ‘active participants in their own recovery rather than passive recipients of ‘expert’ care’5(p13). It was emphasised that services needed to be evaluated in terms of the benefit and value they were having for service users directly with the hope that their responses would lead to improved service provision for future client groups. So, what do people with severe and enduring mental health difficulties want from mental health services?

Recent national research from the UK surveyed 20,000 mental health service users on their views of the same and found that “too often, care was ‘done to’ them rather than shaped with them and that health professionals did not systematically listen to them or take their concerns seriously”6(p10). In the same vein, Rethink Mental Illness in the UK conveyed in their report entitled ‘The Abandoned Illness: A report by the Schizophrenia Commission’7 that service users wanted to have their experiences validated, to be viewed as an individual outside of their diagnosis and symptoms and to be given hope for the future. Furthermore, research by Byrne and Morrison8, which investigated service users with psychosis’ preferences for services, found that a desire for more information, choice and collaboration in treatment decision-making were the most highly valued. The researchers also noted that services which appreciated people’s individual differences as well as their own identified goals were seen as more acceptable to service users and therefore more effective.

These findings are in harmony with those from Pitt and colleagues1 who looked at service-user defined recovery. Their research illustrated that reconstructing lives; hope for the future and reclaiming a sense of self were highly valued by people with psychosis. Leamy et al.9 created a framework for operationalising recovery after conducting a systematic review of 97 research papers that explored theories of personal recovery from mental health difficulties. Their findings highlighted five main themes, namely: connectedness, hope, identity, meaning and empowerment/choice (CHIME). What is more, Romme10 noted several aspects of standard psychiatric service delivery to be detrimental in their study of 50 people who had recovered from voice hearing experiences. These included the negative impact of hospitalisation, medication and diagnosis; negation of staff to participate with the voice hearing experience; being treated as a “passive victim of pathology”(p27); and a symptom focus over a focus on psychosocial difficulties.

One model of intervention, Cognitive Behavioural Social Skills Training (CBSST), developed by Granholm, Holden, McClure, Link, Perivolitotis and colleagues11 incorporates the training of social, problem-solving, and cognitive skills with clients ‘desire to achieve personally relevant goals in one programme. This is achieved by targeting the negative symptoms of schizophrenia, which in opposition to popular acceptance, are the greatest barriers to recovery12 and are often an unmet need of service users13.

The programme comprises of three modules: Cognitive Skills (used to challenge beliefs that interfere with communication skills, performance and goal-directed actions in the real world); Social Skills (to improve communication skills capacity); and Problem Solving Skills (to address neurocognitive impairment related to solving problems and developing goal-directed action plans). It is a simplified practical learning programme to facilitate recovery goal achievement12.

Results of three randomized control trials11,12,14,15 showed that CBSST is an effective psychosocial intervention to improve functioning and reduce negative symptoms in people with schizophrenia (aged 18-65 across all trials). Improving dissemination of evidence-based practice such as CBSST into real-world clinical practice is a public health goal, as research indicates that the psychosocial needs of 90% of clients with schizophrenia are consistently underserved17.

To date, CBSST has been delivered in the USA and Canada, as well as parts of Europe, but not yet in an Irish setting. The current study aims to evaluate service user’s initial experience of a CBSST intervention programme in clients with schizophrenia. This is in line with the need for continued dialogue with service users and their families about their experiences of the mental health services they are receiving18. Although the group is run over a total of 18 sessions, the current evaluation, conducted through a focus group, took place at the end of the first six sessions. The evaluation aimed to assess; how the programme was being received and if it was acceptable to service users, and to explore their overall experiences of being in the group to this point, so as to inform the group going forward.

In order to address the above aims, the following objectives were used to shape the interview schedule and elicit information from participants:

  • Clients’ experiences of being in the group so far.
  • What they find helpful and what they find less helpful.
  • If the group is meeting clients’ needs thus far.
  • Could delivery of the group be improved?
  • Impact of integrating goals and skills into their lives.


These objectives were obtained from best practice guidelines for service user-centric model of care.

Service Context

The service in question works with service users, aged between 18 and 65, with severe and enduring mental health diagnoses, who represent a cross section of society, including both gender and all socio-economic groups. This population of people have been found to suffer significant disablements in their psychosocial adjustment, particularly in the area of refractory symptoms as well as personal care, social skills, vocational and recreational skills. In many cases they may also be unable to maintain independent living skills and so their needs cannot be adequately met at the level of the Sector Service.


1. Design

In order to ensure the experience and views of the group participants were captured, a qualitative methodology was employed for this study. This involved the use of a focus group at the end of the first module (six sessions) to gather the data and subsequent thematic analysis. A doctoral researcher who was not involved in the facilitation of the CBSST group, and did not have any therapeutic contact with the participants carried out the focus group. This was intended to reduce any ensuing research biases from such involvement.

2. Participants

Participants (n=5) were attending a rehabilitation mental health service in Community Health Organisation Four (CHO-4), Ireland, had a diagnosis of Schizophrenia and had identified functional rehabilitation needs. Participants originally included five males and two females of which just the five males completed all six sessions and attended for the focus group.


3. Procedure

Participants were invited to partake in the current study and were informed that should they decline involvement, it would not affect their involvement in the CBSST group. They were given an information leaflet which was explained individually to each participant by the researcher and which outlined the parameters of confidentiality, anonymity and also highlighted the right to withdraw from the study at any time. Following this, if they wished to continue with the study, participants were asked to sign a consent form. The consent forms were then stored in accordance with the Data Protection and Safe Storage Policy.

The focus group was carried out once the first six sessions of the programme were completed and took approximately one hour from start to finish. A semi-structured interview schedule was used, which was informed by the study objectives previously outlined. The full focus group schedule is available on request. Group interaction was stimulated and facilitated by the researcher by encouraging participants to add their perspectives to other member’s responses and also to offer different viewpoints. At the conclusion of the focus group participants were invited to ask any questions that they had about the research study.

Following the focus group, participants were made aware that they had the option to speak privately to the team’s Senior Clinical Psychologist should they wish to discuss any issues that came up for them during the focus group.

The focus group was recorded using the voice recorder function of an encrypted Lenovo ‘ThinkPad’ laptop and transcribed verbatim by the researcher.


Ethical Considerations

The Ethics Committee at the School of Applied Psychology, University College Cork granted ethical approval prior to data collection. Data was only collected following fully informed consent. Specific consideration was taken to ensure that all data was anonymised and names assigned a pseudonym for reference. The data was kept confidential for the duration of the study and was available only to the research team. All data collected was stored securely and safely in accordance with the Data protection and Safe Storage Policy. Data will be retained for a further ten years and then destroyed.



Data were analysed using thematic analysis in accordance with Braun and Clarke’s19 six-stage approach.


Participant’s narratives encapsulated several aspects about their experience of being in the CBSST group. An overall sense of positivity and enthusiasm for the group was evident throughout the focus group and indeed in the analysis. Four main themes, each further explained by sub-themes, were realised from the data set:

  • Positive experience of the group
  • Learning
  • Group factors
  • Social factors


Diagram 1: Thematic Map

psychosis paper diagram


Theme 1: Positive Group Experience

The first main theme provides rich information of how the group was experienced by participants in a clinical context. In order to capture the essence of this experience, it has been divided into three sub-themes: ‘enjoyment’, ‘clinician impact’ and ‘expectations’.


1.1 Enjoyment

All participants reported enjoying the group, describing it as ‘interesting’.

‘It’s good yeah, very interesting, it’s very good’

‘…I was happy once I knew there was something that could help’

Participants also reported that they were enjoying all aspects of the group so far, with one participant naming ‘learning’ as part of what he enjoys and another naming ‘goal setting’.

‘I’d be into all of it’

‘It is interesting to learn something like’

‘It’s the goals I like’


1.2 Clinician Impact

Input from the clinicians involved in running the group was noted to contribute to participants overall positive experience. Support from the clinicians was particularly noted as helpful to participants.

‘They are there to help everybody…if you’re having hassle writing down your notes or thinking of goals, they will give you a hand’

‘Ah they try hard to make it good like’

‘I can honestly say…[Clinician], [Clinician] and [Clinician] are great’

  1.3 Expectations

Participants discussed their expectations of what they had thought the group would be like before commencing. The majority agreed that they were unsure of what to expect.

‘I wasn’t exactly sure but when I started the first day, I got to know what it was about’

‘I thought it would be more like the walking group we did last year, but then we came in on the first day and they showed goal setting and I was like yeah, yeah, but I got into it then’


One participant stated that he feared the group would rely heavily on literacy skills.

‘Be writing and spelling and things like that…hard words and small words…’

He stated that this was not the case on beginning the group, when asked in the focus group.


Theme 2: Learning

The second theme encapsulates participants perceived learning from the programme so far. Participants spoke about using the ‘Three C’s’ as a method of learning how to challenge their thoughts as one of the skills taught. They also spoke about learning how to break tasks and goals down into small steps in order to help them achieve these. The skills taught were viewed as positive overall for participants. This theme is discussed under the sub-themes ‘use of skills’ and ‘benefits of skills’.


2.1 Use of skills

Participants discussed their use of the skills they have acquired thus far in the group.

‘I get anxious travelling, so I am using them with that’

‘I’ve tried to give up smoking and it was like: why? What are you waiting for? Why haven’t you started yet? So I said what I had to do…’

‘The three c’s was great and I’m trying to enact them in my life constantly now’

(learning) if you don’t want to do something, then you don’t have to do it’


They described learning to break tasks down into small steps in helping them to achieve their goals as beneficial.

‘I’ll try and do it in the same way again…kind of figure out what I must do and break it down’

‘They are in small steps so if you do one, two, three and then fail on four, you just start again from where you left off’

‘The whole thing is breaking it down into small steps…instead of looking at one big goal and thinking I’ll never f***ing achieve that!’


Participants conveyed that the skills learned have been valuable to them in helping their thinking styles. Although one participant noted that changing their thinking style was one of the most difficult parts he has learned.

‘It gives you a proper way of thinking about things’

‘Changing your thoughts is the worst part…the most difficult’


2.2 Benefit of skills

The group discussed some benefits of learning new skills in the group and how they are beginning to effect change in their lives.

‘You get smarter with it like…and you get interested in things’

‘It’s helping me with my anxiety and how to control it’

Participants portrayed a sense of empowerment gained from the group.

‘…to learn how to build yourself up, to feel like it and actually want to do it’

Learning new skills in the group was noted to be an alternative to taking medication and described as a more favourable option.

‘If you are on tablets and you want to do something, the tablets would tire you down’


Theme 3: Group Factors

The third theme discusses factors relating to the functioning of the group and is divided into two sub-themes: ‘current functioning’ and ‘future functioning’. On the whole it was acknowledged that the group is very much still in its early stages and the remainder of the group is positively anticipated by participants.

3.1 Current Functioning

When speaking about the current functioning of the group participants described the teaching element and how this impacts on them. They noted that the way the group is run, in that it is required that a person completes tasks at home before the following group is a motivating factor.

‘Knowing you have to come in and state what you did and didn’t do…it gives you a push’

‘You can’t come in every week and say you didn’t do anything’

They also expressed that having three clinicians facilitating the group has been helpful for them in accessing the teaching materials.

‘…everybody nearly has somebody sitting beside them to give a hand with the paper stuff’

‘The teacher explains it to us and goes through it with us on the sheets’

Participants reported satisfaction with the composition of the group in that there was an appropriate amount of members without being overcrowded and that it meant that they were not one-to-one with a professional.

‘I think it’s kind of cosy’

‘Yeah you wouldn’t want too many and you wouldn’t want to just be in here yourself with another person’

It was not reported to be of importance if the group was composed of males and females or just males.

The frequency of sessions and overall duration of the group programme was an important topic during the focus group and was given much attention by the participants. As the group had been running twice per week participants were eager to know if this format would continue going forward. This topic was revisited several times during the focus group.

‘So it’s going to be one class a week from now on is it?’

‘Is it only once a week from now on?’

‘Is it going to be for how many months did you say?’

Participants stated they were happy with the timing of the group, which was 12pm-2pm. Equally the location of the group was acceptable to participants, with transport noted not to be an issue for them.

‘It’s not eight or nine so it’s good’

‘I’m just up the road’

‘I’m from (town) but I have a van so I can drive here’


3.2 Future Functioning

On the whole the group did not have very many recommendations for the future functioning of the group. They stated they were happy with how it was going so far and in some cases felt that it was too early to know what they would like to change.

‘Ehhh…no, not really’ (any recommendations for the future)

‘To improve it? Ah no, I like it the way it is’

‘We will know more when the sessions start back – we will have to let you know’

‘There will be more weeks of it, so I’ll know more in the next week or so’

Following from this, a view of positive anticipation was portrayed by the group when looking to the future functioning. Moreover, participants reported a sense of motivation in being able to achieve their goals in the future of the group.

‘Yeah I’ll be looking to get into it again once it starts’

‘By the end of it I’ll be able to do it’

‘…I’m going to try again when the group starts back’

The group reported that they enjoyed the break they had been getting in the middle of the session to go for a walk. They stated they felt this would be finishing as it was part of another ‘walking group’ they had been involved in, and had since achieved their goals from that group. Being allowed to keep the walking break was referred to as a recommendation for the future running of the group.

‘The walk would refresh you like, it would clear your head’

‘It’s good because when you are up early in the morning you would be tired and the walk helps’

‘Oh yeah we won’t be walking now because we’ve finished’

One participant stated that he would like the group to run for a little longer.

‘I don’t know really, maybe stay on a bit longer? Maybe an extra 20 minutes’

When asked more about this he stated ‘I think it is because we finish a bit earlier or something usually’ and did not elaborate further.

Participants reported that they would recommend the group for future participants and urged them to be open to giving it a try.

‘Just stick with it’

‘Yeah give it a shot’

Theme 4: Social Factors 

The fourth and final main theme looks at the social factors participants outlined as being associated with the group. These are discussed under two sub-themes: ‘space to connect’ and ‘shared experience’.


4.1 Space to Connect

All participants described the group in terms of social benefits. They reported that it is a place where they meet other people and commented that without the group, they may not have had another opportunity that week to connect with others.

‘I could be at home all week and meet nobody except the family’

‘I’m getting out more’

‘Yeah it’s good to meet people’

‘I get to come here and see the lads and we have a bit of a chat like’

One participant noted that the group offered him something more than what he receives in his shared housing.

‘Well I am in (supported accommodation) so there is people around there all the time but really it is in the courses where you meet people’


4.2 Shared Experience

During the focus group the participants spoke about knowing each other for a long time. They also noted that they were open to meeting new people through the groups.

‘Well we have known each other a while now’

‘I know him about seven or eight years’

‘I only met (name) during the sessions’

They referenced this with regard to somewhat of a shared experience of being in the service and having attended groups and outings together in the past. Of note, the group became quite animated when discussing this and appeared to be an important point for them to get across.

‘There was a group before, a young person’s group, and we used to go to the cinema together’

‘It was with the national learning network for three years’…’I was up there too…’

‘…and we went to Tayto Park together last year’



This section will discuss the overall findings from the study with reference to existing empirical literature and potential implications for the service.

The first main theme identified in the findings, ‘Positive Group Experience’ suggests that participants are enjoying the group and are finding the content interesting. This positive atmosphere is important to maintain so that participants continue to attend all sessions and get the most they can from the programme. It was also found that participants value the support they receive from clinicians during the group which should be kept in mind by the facilitators as they continue the programme, particularly as some of the participants highlighted that they struggle with literacy. It is also important to note as it is in contrast with research from service users in the NHS6 which found that too often they felt health professionals were not listening to them and thus contributed to a negative service experience.

The second theme, ‘Learning’, discusses the skills that participants have obtained and used from the group and also the benefit they have been to them. Participants spoke about feeling as though the skills have given them hope that they will be able to achieve their goals as they offered them a way of breaking tasks down into manageable chunks. Moreover, they spoke about failure, and how this makes them feel, but that by using the small steps approach this feeling is lessened as they can start again from where they left off. This is significant as information gathered by Rethink Mental Illness7 and by Pitt et al.1 noted that service users wanted to be given hope for the future when asked what it was they needed from the mental health services. In addition, it was acknowledged by one participant that the group offers a positive alternative to taking medication. This finding links with findings from Romme et al.10 who highlighted medication as one potentially harmful aspect of psychiatric care.

The third theme describes participant’s perceptions of the current functioning of the group and also their thoughts on the future of the group. Overall participants are happy with how the group is being facilitated currently. Clinicians should continue with the same format going forward but ensure to inform participants in advance how many days per week the group will run and for how long, as this topic was discussed on several occasions during the focus group. This links with Byrne and Morrison’s8 research which found that service users with psychosis had a desire for more information and choice in their treatment.

With regard to the future functioning of the group, participants reiterated that they are happy with how the group currently runs and did not have any suggestions for improvement as such. One participant did recommend a longer session however. Participants were clear in their thoughts that they enjoyed the ‘walking group’ element at break times in the group and that it had a positive impact on how they functioned in the group. This should be noted going forward and incorporated if possible. On the whole, participants are looking forward to starting with the group again.

The final theme, ‘Social Factors’, illustrates important information about what participants get from the group outside of direct programme learning. Participants conveyed that the group offered them a space to connect with other people and in some cases was noted to be the only opportunity for social experiences in the week. This social gain could easily be overlooked when planning a therapeutic group but is important to remember when thinking about what attendance at groups such as this offers people, and how it adds to their everyday lives. This corroborates with Leamy and colleagues9 who found that the theme of connectedness was linked to personal recovery from mental health difficulties. Of note, they also highlighted themes of hope, meaning and empowerment in relation to recovery which are also attended to in the current study. Finally, it must be recognised from the findings that participants valued the experiences they have shared with the other group members over the years and how important it appeared to be for them to have a space to share these memories.


As the focus group was carried out after six of the 18 sessions, it highlights participant’s initial experiences of being in the group and cannot as such be generalised to how they will experience the entire programme, although the service has made plans to address this in future research. Furthermore due to the small sample size, the themes identified should be considered suggestive rather than representative, as a different group of participants may favour different issues, especially female service users as they are not represented in this study. It is also possible that some participants may find it difficult to express their views in a focus group setting, particularly if they are new to the group who stated they know each other for some years. In this instance individual interviews may be more appropriate and will be addressed by the end of programme research.

Future Research

Future research has already been planned by the service and will include individual interviews to assess participants overall experience of the full CBSST programme using similar questions to the current study. This research will also look at clinical psychometric measures taken routinely by the service before and after the intervention so as to assess the therapeutic effectiveness. Measures will include:

  • Independent Living Skills Survey (ILSS)20
  • Goal Attainment Scaling (GAS)21
  • Scale for the Assessment of Negative Symptoms (SANS)22
  • Comprehensive Modules Test (CMT)11,12,14,15
  • The Defeatist Performance Attitude Scale (DPAS)23



This study aimed to explore service user’s initial experience of a CBSST intervention programme aimed at improving psycho-social functioning in clients with schizophrenia. Findings from a focus group carried out with participants at the end of the first six sessions of the programme illustrate that it is well received by service users, they are learning helpful skills to support them in their day-to-day living and they are looking forward to continuing with the programme. Additionally participants reported that they find a great social element to the group which is of importance to them. These findings are the first to be realised for this programme in an Irish context and can be looked at positively going forward with the group. At this point it does not seem that changes need to be made to the delivery of the programme as participants report that it is well received. There are a number of limitations to the study as outlined earlier, some of which will be addressed by future research planned by the service. This future research which is to be carried out at the end of the completed CBSST programme will provide a more detailed picture of participants experience of the group in its entirety and may lend itself to amendments if required at this time.


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Emma Hennessy, Clinical Psychologist in Training, HSE/UCC.

Mairead Carolan, Senior Clinical Psychologist.

Breda Murphy, Mental Health Nurse.

Maeve Murphy, Occupational Therapist.

Dr Alan Corcoran, Consultant Psychiatrist.


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