Introduction
Cognitive behavioural therapy (CBT) is an empirically validated form of psychotherapy, which has been successfully embedded into clinical services worldwide. Although traditionally CBT was designed and practised in an individual format, evidence has suggested that delivering group therapy can offer as much as 50% greater efficacy when compared with individual therapy (Bieling and Kuyken, Reference Bieling and Kuyken2003). This in turn offers both financial and clinical time implications for services, where more than ever there remains an unmet psychological need with services often oversubscribed and with limited access to psychological therapies (Mental Health Taskforce for NHS England, 2016).
Admissions to in-patient units in the UK are costly to the National Health Service (NHS) and it is reported that the severity of need and the number of people being detained under the mental health act continues to increase (Mental Health Taskforce for NHS England, 2016). This has created changes for in-patient units and how services are delivered with more of an emphasis on reducing bed occupancy days. Subsequently the quality of care has been heavily criticised by service users and staff, with many wards described as being over occupied, unsafe, un-therapeutic and not conducive to recovery (Mental Health Taskforce for NHS England, 2016). In addition, there remains a significant absence of in-patient staff trained in psychological therapies (British Psychological Society, 2012).
Historically, in-patient units have utilised psychoeducation-based programmes. However, unpredictable lengths of stays and varying presentations central to the acute environment does not lend itself well to conventional CBT with set numbers of sessions and diagnostic specificity. Whilst there is a growing evidence for the effectiveness of ‘stand-alone’ CBT sessions, these are also often manualised and reliant on diagnostic specificity, which can also be a challenge. An approach to this is open group therapy, which provides a flexible and trans-diagnostic framework whereby members are free to join and leave as they wish and attendees define the therapeutic target at the start of each session; this means there is no pre-set goal, psychoeducational structure or manualised intervention. The trans-diagnostic approach, whilst not considered unique, focuses on the common dysfunctional processes that are shared across disorders. Whilst open group CBT remains empirically untested, previous research has suggested that this format was feasible (Raune and Daddi, Reference Raune and Daddi2011) and helped to promote patients’ problem-solving skills and fostered personal responsibility. When compared with Raune and Daddi (Reference Raune and Daddi2011), the current research highlights a difference in treatment targets, particularly highlighting experiences of care and emotional dysregulation as key factors in psychological distress.
Method
Participants
A total of 75 patients attended groups over a 6-month period (68% male, 32% female), which equated to 40.5% of all acute admissions during this period. All patients were adults aged between 21 and 71years (mean = 43.5) and 92% of participants (n = 69) were of White British origin; of those that attended the group, 30% attended on more than one occasion (n = 23, mean = 1.3, SD = 0.6). In addition, of those that attended the group, 46% (n = 35) also attended individual sessions with a clinical psychologist or psychotherapist, meaning that 54% (n = 40) of participants would not have otherwise received any access to talking therapies during their acute admission if they had not attended the group.
Therapist
The group was facilitated by a qualified and accredited cognitive behavioural therapist and supported by another member of the multidisciplinary team, which included occupational therapists, associate practitioners and health care staff.
Procedure
CBT open group sessions were delivered as part of routine care on two acute treatment units, an adult 18-bed all-male treatment unit and a 15-bed adult mixed sex assessment and treatment unit. The groups were open to all patients regardless of diagnosis and occurred once a week per unit for between 40 and 60 minutes.
The group format followed a standard CBT structure (Vivyan, Reference Vivyan2013) beginning with introductions, confidentiality and ground rules. Patients were briefly socialised to the model of CBT and an agenda was set as a group. The group focused on the ‘here and now’ and the therapist utilised Socratic questioning techniques to inform a basic group formulation of a recent situation. The therapist then introduced some didactic psychoeducation and cognitive change techniques, which were then practised as a group. Patients were encouraged to discuss their own problems and any challenges or disagreements were discussed and actioned within the group. The group utilised a trans-diagnostic approach to CBT that focused on the shared processes that exist between disorders. The final part of the session involved feedback and exercises to effectively close the session, e.g. mindfulness and relaxation.
Measures
A group evaluation questionnaire was developed to assess patients’ experiences of the open CBT format using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Participants were given the option to provide further comments and data were collected on themes chosen to discuss within the group and the attendance and re-attendance rates. The questionnaire was given out to participants immediately after the group; completion remained optional and confidential.
Results
Participants rated the group on a 5-point Likert scale, with most scores indicating that participants either agreed or strongly agreed that ‘I felt understood, respected and/or accepted in the group’ (mean = 4.7, SD = .59), ‘I found the group helpful for sharing experiences’ (mean = 4.5, SD = .73), ‘I felt that I have learnt something useful that will help me in the future’ (mean = 4.3, SD = .95) and ‘I am willing to engage in psychology sessions in the future’ (mean = 4.6, SD = .6) (see Fig. 1).
Figure 1. Graph showing participant responses.
Psychological themes
The main psychological themes discussed within the group included feeling invalidated disempowered/vulnerable, paranoid and negative thinking, suicide and self-harm including addiction, relationships with staff and experiences of care, emotions as overwhelming and intolerable and coping strategies. The most commonly discussed themes were experiences of care and emotions as overwhelming and intolerable.
Other feedback
As part of the evaluation, qualitative data were also obtained through an optional ‘additional comments box’ on the evaluation form. The feedback overall was positive. Participants stated that, ‘The session was very helpful allowing me to express my thoughts and feelings without worrying about judgement’ and ‘The group really helps me open up’. Others highlighted how the group format was helpful in developing awareness of difficulties, e.g. ‘Sharing other peoples’ experiences has helped me identify negative behaviours that I also have’. It was noted that the CBT group also helped people to re-familiarise themselves with CBT techniques for those that had engaged in therapy previously ‘I found it useful to recap areas of CBT’.
Discussion
The present article aimed to report on the usefulness, feasibility and patient experiences of an open CBT group format on acute in-patient units. Initial feedback indicated that the group was feasible, acceptable and that participants felt respected and understood. The groups had high levels of attendance, with many individuals attending more than one session. Participants indicated that they felt that they had learnt something that would be useful for them in the future. Furthermore, attendees reported that they found the group format useful for sharing their experiences which facilitated self-reflection. Interestingly, in every session participants were able to choose something they wished to focus on and the recurrent themes such as experiences of care, relationships with staff, feeling vulnerable, disempowerment and invalidation were not topics previously covered within stand-alone manualised sessions. This suggests that an open group format is more reflective of clinical need and offers a more dynamic approach that fits firstly with the CBT model and its emphasis on the ‘here and now’ but also with the acuity and unpredictability of the in-patient environment. The findings from the present study support previous research, which tested the feasibility, acceptability of a similar group CBT format (Raune and Daddi, Reference Raune and Daddi2011).
The implementation of psychological groups within an in-patient setting is not without its barriers; whilst the service lends itself to a dynamic approach, the clinical unpredictability and heterogeneous population can result in disruption and difficulties in obtaining co-facilitators from the multidisciplinary team, particularly at times of high activity. In addition, the clinical acuity and unpredictability of the topics discussed would require a cognitive behavioural therapist that had a broad range of experiences within secondary services.
Finally, it is useful to note that of those that attended the group, 54% (n = 40) would otherwise not have had access to psychological intervention during their admission to a treatment unit. This supports the idea that group CBT intervention may increase access to psychological intervention on acute wards, and enhance existing psychological provision.
Limitations and future research
This evaluation shows that open group therapy where participants choose the therapeutic target is feasible and acceptable. A limitation of the current study is the lack of pre- and post-empirically validated measures as participants’ views of the group do not provide evidence that they utilised CBT skills effectively outside of session, or that the group had any impact on validated measures of distress, symptom reduction or bed days. The current research offers limited evidence that this approach would fare better than others. Therefore, future research should focus on measuring clinical effectiveness in comparison with a both a control group and other approaches, e.g. stand-alone sessions or psychoeducation programmes. It is useful to note that those who experienced the group more positively may have been more likely to complete surveys. Future evaluations could consider strategies to engage all group participants. Finally, participants that attended the group reported being more likely to engage in one-to-one psychological intervention post-discharge, therefore future research may consider evaluating this.
Conclusion
The current evaluation highlights how implementing open group CBT therapy on acute adult in-patient units is feasible, acceptable and provides a flexible and trans-diagnostic approach which participants report finding useful for self-reflection and expressing their thoughts and feelings. Further research is needed that offers comparison with alternative methods of group CBT provision and to evaluate clinical effectiveness and sustainability longer term.
Supplementary material
To view supplementary material for this article, please visit: https://doi.org/10.1017/S1352465821000011
Data availability
The data that support the findings of this study are available from the corresponding author (V.B.), upon reasonable request.
Acknowledgements
We thank the staff and patients within the Humber in-patient services for their support and participation throughout.
Financial support
None.
Conflicts of interest
None.
Ethics statement
The evaluation was conducted as part of routine care and authors abided by the ethical principles of psychologists and the code of conduct as set out by the BABCP and BPS. The evaluation was conducted in accordance with local NHS trust policy.
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