Content uploaded by Chris Code
Author content
All content in this area was uploaded by Chris Code on Feb 23, 2016
Content may be subject to copyright.
Creating psychological connections
between intervention recipients:
development and focus group
evaluation of a group singing session
for people with aphasia
Mark Tarrant,
1,2
Krystal Warmoth,
1
Chris Code,
3
Sarah Dean,
1,2
Victoria A Goodwin,
1,2
Ken Stein,
1,2
Thavapriya Sugavanam
2,4
To cite: Tarrant M,
Warmoth K, Code C, et al.
Creating psychological
connections between
intervention recipients:
development and focus group
evaluation of a group singing
session for people with
aphasia. BMJ Open 2016;6:
e009652. doi:10.1136/
bmjopen-2015-009652
▸Prepublication history for
this paper is available online.
To view these files please
visit the journal online
(http://dx.doi.org/10.1136/
bmjopen-2015-009652).
Received 7 August 2015
Revised 4 December 2015
Accepted 7 December 2015
For numbered affiliations see
end of article.
Correspondence to
Dr Mark Tarrant;
m.tarrant@exeter.ac.uk
ABSTRACT
Objectives: The study sought to identify key design
features that could be used to create a new framework
for group-based health interventions. We designed and
tested the first session of a group intervention for
stroke survivors with aphasia which was aimed at
nurturing new psychological connections between
group members.
Setting: The intervention session, a participant focus
group and interviews with intervention facilitators were
held in a local community music centre in the South
West of England.
Participants: A convenience sample of 10
community-dwelling people with poststroke aphasia
participated in the session. Severity of aphasia was not
considered for inclusion.
Intervention: Participants took part in a 90-min group
singing session which involved singing songs from a
specially prepared song book. Musical accompaniment
was provided by the facilitators.
Primary and secondary outcome measures:
Participants and group facilitators reported their
experiences of participating in the session, with a
focus on activities within the session related to the
intervention aims. Researcher observations of the
session were also made.
Results: Two themes emerged from the analysis,
concerning experiences of the session (‘developing a
sense of group belonging’) and perceptions of its
design and delivery (‘creating the conditions for
engagement’). Participants described an emerging
sense of shared social identity as a member of the
intervention group and identified fixed (eg, group size,
session breaks) and flexible (eg, facilitator
responsiveness) features of the session which
contributed to this emergence. Facilitator interviews
and researcher observations corroborated and
expanded participant reports.
Conclusions: Engagement with health intervention
content may be enhanced in group settings when
intervention participants begin to establish positive and
meaningful psychological connections with other group
members. Understanding and actively nurturing these
connections should be a core feature of a general
framework for the design and delivery of group
interventions.
Groups are employed to deliver health-
related interventions in a variety of domains,
including rehabilitation,
1
health promotion
2
and the management of long-term condi-
tions such as multiple sclerosis
3
and
stroke.
45
Groups are often assumed to be
cost-effective, relative to individual interven-
tions,
6
although there is a recognised lack of
data in this regard.
2
Moreover, the observed
heterogeneity in their design and delivery
Strengths and limitations of this study
▪The study addressed a recognised gap in knowl-
edge about how new group-based health inter-
ventions can be designed and delivered.
▪The study adopts an evidence-based approach to
assembling new groups for the delivery of health
interventions and identifies and defines a set of
core (group) intervention features.
▪The study provides triangulation of findings,
drawing on data from three sources (a focus
group, interview with group facilitators and
research observations of the intervention
session).
▪While the findings resonate with previously
reported general processes of group formation,
the conclusions are drawn from data from a
single session of group singing for people with
one health condition.
▪Participants were clear about the potential health
and well-being benefits of participating in group
interventions like the one studied here, but it is
not possible to conclude definitively that this
participation actually affected health. Additional
research, employing other research designs, is
needed to address this question.
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 1
Open Access Research
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
highlights a need for greater detail in the reporting of
group interventions, particularly given the increasing
frequency with which they are being employed.
78
The current research aimed to inform a guidance
framework for the development and delivery of new
group interventions for long-term health conditions, in
accordance with the Medical Research Council’s model-
ling phase of complex intervention development and
evaluation.
9–11
We designed, delivered and evaluated an
introductory session of a group intervention for stroke
survivors with aphasia. Besides impaired language func-
tion, people with aphasia experience a range of health
problems that negatively affect psychosocial functioning,
including social isolation and distress, which are not typ-
ically addressed in speech and language rehabilitation
programmes.
12 13
Group-based interventions may be a
way of addressing psychosocial functioning needs of
people with long-term conditions such as aphasia, by
providing valuable opportunities for social interaction
and fostering the rebuilding of core skills (eg, social par-
ticipation, confidence).
14
In support of this idea, obser-
vational, experimental and qualitative studies have
suggested that psychosocial problems may be addressed
in some group contexts.
41516
Our study drew on principles of social identity
theory,
17
which holds that the psychological connections
members of a social group establish with each other
structure their attitudes, cognitions and behaviours,
including those related to health.
18
Belonging to a social
group, and valuing that membership, is an important
basis for psychological well-being.
16 18–20
Although the
benefits of group membership have been demonstrated
across a range of health conditions, including long-term
conditions such as multiple sclerosis,
3
much less is
known about how social identity can be actively nurtured
in new group settings. Social identity is unlikely to
emerge spontaneously as a result of merely bringing
people together in a new group
21
and, we suggest, needs
to be carefully nurtured through the actions of the
group facilitator(s).
22
Because of the inevitable variabil-
ity between people in medical (eg, physical function-
ing), psychological (eg, symptom perceptions) and
wider sociological (eg, socio-economic status) factors,
fostering the development of a common frame of refer-
ence and shared social identity in participants seems
necessary to prevent the factions and schism that may
otherwise occur in novel group settings.
23
Our study sought to identify key features that could be
used to design a framework for creating social identity in
new group interventions. Because feeling psychologically
connected to a group is strongly associated with group
commitment, or loyalty,
24
nurturing an early and positive
sense of social identity is likely to motivate participant
attendance at subsequent sessions of an intervention
programme and encourage more ready engagement
with intervention material and participant interaction.
Establishing social identity could be a key variable influ-
encing the progression of group interventions. For this
reason, we focused on the introductory session of an
intervention.
The intervention we focused on was organised around
a programme of group singing for people with aphasia.
Numerous examples exist of community-based singing
groups for people with such long-term conditions, and
there is a growing research interest in the potential ben-
efits of group singing on well-being and quality of life,
both for healthy populations and those with long-term
conditions such as aphasia.
25
Some uncontrolled and
qualitative studies have suggested that singing groups
may help address the psychosocial needs of people with
long-term conditions such as aphasia,
26–28
although
there is a lack of rigorous data concerning both the
health benefits of participation in such group interven-
tions and their design and delivery.
7
Objectives/aims. The aim of this study was to deliver an
introductory session of a new group intervention and
explore participants’experiences of it. Specifically, the
study examined participants’experiences of taking part
in the session in terms of (A) its capacity to nurture psy-
chological connections between participants (shared
social identity) and (B) barriers and facilitators of parti-
cipants’engagement with it.
METHOD
Design
A qualitative approach was selected on the basis of a
constructionist epistemology. We utilised the construc-
tionist assumption that the ‘truth’has multiple mean-
ings and is subject to individual interpretation and the
context of the current situation
29 30
but retained a theor-
etically underpinned approach grounded in principles
of social identity theory because this combination of
approaches was in line with our exploratory aims. Our
approach combined non-participant observation of the
introductory session of the group singing intervention, a
focus group with session participants and individual
interviews with music facilitators.
Sample
A convenience sample of stroke survivors with aphasia
(n=10) was recruited through a local network for people
with aphasia. Severity of aphasia was not considered for
inclusion. Potential participants were initially contacted
with the assistance of a local co-ordinator of an aphasia
network who was also a stroke survivor with aphasia.
Those interested in taking part in the study were pro-
vided with an information sheet explaining that they
would be asked to attend the singing session and con-
tribute to a focus group; written consent was obtained
from each participant. Participants were told that they
were free to withdraw from the study at any time (none
did). A local charity-funded music organisation supplied
the music facilitators and provided space for the singing
session and focus group/interviews. Participants were
reimbursed for their travel expenses.
2Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
Development of the group singing session
The singing session was designed with input from stroke
survivors with aphasia, music facilitators, a speech and
language therapist, health researchers and psychologists,
following principles of participatory design.
31 32
Two
design meetings were held. The first meeting produced
the outline of the singing session, with a focus on
describing group activities designed to encourage the
emergence of a social identity, as members of the singing
group, among the participants. Specifically, the outline
described structural (eg, seating arrangements, session
break), musical (eg, using familiar, upbeat songs to
maximise participant engagement) and facilitator-led
(acknowledging group progress and providing feedback)
initiatives to promote and reward interaction between
participants and create for them a shared perception of
commonality, and group commitment, consistent with
social identity theory principles.
17 24
The session outline
was refined in the second meeting, which additionally
focused on potential barriers to participant engagement
with the singing session (eg, lacking confidence in lan-
guage) and identifying procedures to minimise these
(eg, avoiding group member introductions at the session
outset). CC and a speech and language therapist advised
on potential barriers to participant communication and
contributed to the topic schedule used to guide the
focus group.
Research context and data collection
The singing session was led by two experienced music
facilitators and was observed by four of the authors (TS,
KW, KS and MT) who made independent session notes.
The session lasted 1.5 h and began with a brief introduc-
tion to the session by the facilitators and a short physical
and vocal warm-up activity. Participants then took part in
two focused singing blocks, led by the music facilitators,
separated by a short refreshment break. Participants
were each provided with a songbook containing lyric
sheets. The first singing block focused on singing songs
preselected by facilitators to take account of the antici-
pated musical preferences of participants on the basis of
their ages.
33
The second singing block continued in the
manner of the first block but additionally involved some
repetition of songs and rehearsal of different song ele-
ments, including introducing harmonies.
After the singing session, TS led a 45-min focus group
with the participants. The music facilitators were then
interviewed (45 min) by TS using a semistructured inter-
view guide to explore their reflections on the singing
session, focusing on activities within the session related
to the underlying theoretical aims. The interview guide
was reviewed and agreed by the authors prior to use.
The focus group and facilitator interviews were audio
recorded.
Data analysis
Audio recordings were transcribed verbatim. The
Framework Approach,
34
a widely used approach in applied
qualitative research, guided the data analysis. NVivo10
qualitative data analysis software was used to support data
management. TS and KW independently read the tran-
scripts numerous times to become familiarised with the
data. Initial ideas were then identified and coded using
both inductive and deductive processes. A thematic frame-
work was developed with the codes as columns and data
sourcesasrows(ie,focusgroup,facilitatorinterviews,
researcher observations). Through comparison of codes
and emerging themes, the framework was further refined,
and thematic charts were created incorporating the coded
data. The resulting themes and subthemes were then inde-
pendently verified by SD and, through discussion, inter-
pretation arising from the analysis was finalised.
RESULTS
Ten stroke survivors with aphasia (five males, five
females) took part in the singing session and focus
group. A carer of one participant also attended the
session but did not participate in any activities.
Participants’mean age was 58.60 years (SD=6.93). Stroke
type included four participants who had had an ische-
mic stroke, one a haemorrhagic stroke and one a sub-
arachnoid haemorrhage (the remaining participants did
not know their type of stroke). Mean time since stroke
was 7.70 years (SD=8.40).
As is reflected in the section below, some participants
appeared more willing (and able) to contribute to the
focus group discussion than other participants. However,
it was clear from other contributions (eg, non-verbal
communication) that these participants agreed with the
sentiments expressed in the focus group by more vocal
members. The researcher observations of the singing
session and the facilitator interviews corroborate this
interpretation: there was nothing to suggest that any of
the less vocal participants in the focus group experi-
enced the singing session differently from the more
vocal participants.
Two inter-related themes emerged from the analysis of
the focus group and facilitator interview data that con-
cerned participants’experiences of the singing session
(Developing a sense of group belonging) and their perceptions
of the session design and delivery (Creating the conditions for
engagement). Within these two themes, eight key features
were identified that could be used to design a framework
for developing social identity in new group interventions
(figure 1). These features are described in detail below,
supported by quotes from participants and music facilita-
tors, and also the researchers’observation notes.
Participant and facilitator names below are pseudonyms.
Theme 1: Developing a sense of group belonging
This theme described how the singing session provided
the foundations for developing psychological connec-
tions between group members and a sense of belonging,
characterised by being comfortable in the group and
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 3
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
interacting with others. Three key features that emerged
within this theme are as follows:
(i) Homogenous nature of the group: Sharing a
health condition (in this case, aphasia) with every other
member of the singing group was described by partici-
pants as critical to them feeling at ease, or comfortable,
with the group. Homogeneity of condition also pro-
moted a sense of common understanding between parti-
cipants and was seen as a starting point for forming
connections with one another.
…because we all have had brain problems it connects
you all. [Megan]
I think it is a good thing because everybody here under-
stands what’s going on in your head and you can talk to
people about it …if I talk to Julie or Rob about it or
Ben, then they understand, don’t you? Understand
what’s happened to you and what the pitfalls are or the
obstacles are. [Jack]
(ii) Member familiarity: Each participant knew at least
one other group member in advance of attending the
singing session, and everyone knew the local aphasia
network co-ordinator, Julie. This was regarded as con-
tributing positively to participants’engagement with the
session and appeared to influence the rapid emergence
of a positive group dynamic.
Because most of us know at least a few people here and
we talk to them, so it is not mainly a problem. [Ben]
…they actually settled very quickly. There was a common
understanding perhaps between them. [Beth, music
facilitator]
Notably, presession member familiarity was described
by some participants as a factor which would determine
their decision to attend a group programme such as
this.
If you have got a group who didn’t know anybody, then I
don’t think anyone would turn up. You would have to get
a certain type to get them to turn up initially. I came
because Julie asked me, not because of any other reason.
[Ben]
…Julie really brought everybody here together, so she
knows everybody that solves it, it makes it fairly easy
really. [Ben]
(iii) Member interactions: There were numerous
instances of interpersonal interaction during the singing
session (including non-verbal interaction such as eye
contact and the expression of emotions). Beth, the
music facilitator, was of the view that ‘they [the partici-
pants] had a lovely way of being with each other too.
There was a lot of support in there, just by little glances,
encouraging glances here and there from people or
laughter and quite spontaneous things that went on’.
Interaction often occurred between participants previ-
ously unfamiliar with each other: Ben felt he had
‘spoken to people who I have not spoken to before’.
Interaction also occurred between the group members
and the music facilitators. This interaction was experi-
enced positively by the participants and encouraged
further engagement with the singing session. Indeed,
member–facilitator interactions were deemed essential
for participants to provide feedback, for facilitators to
adapt and make changes accordingly and, overall, to
motivate participation.
…they were very responsive …I was very aware at the
start, it was quite hard to get any eye contact with
anybody in the circle because everybody was so fixated
on that song book …So I initiated a conversation with
somebody about a song and the words and, …So they
weren’t saying it is not something they want to do but
[it] brought our attention to the fact that reading the
lyrics and the singing was a bit of [a] thing which is why
we kind of adapted to try and suggest that they shut their
song books. That’s when we invited them to shut the
Figure 1 Key features reflecting
participant experiences of an
introductory session of a new
group singing intervention for
people with aphasia.
4Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
books and do some work off the song book and trying to
join in. [Susan, music facilitator]
By coming to feel more comfortable with the group,
participants felt able to relax and reported reduced
anxiety. Indeed, it was apparent that participants and
facilitators were initially anxious about the singing
group, and this anxiety was reflected in individual
contributions to the session, especially at the beginning
of it.
I think it will be [like this] in the first session …I was a
little bit embarrassed singing but I did do it but it was
very quiet singing I think. I don’t think we sang as we
should do because we were a little bit self-conscious.
[Jack]
We work a lot with people who are nonverbal in different
contexts and we have worked with people with aphasia
but not a group of people with aphasia, so it was a differ-
ent thing and we were worried, a little bit worried about
people feeling uncomfortable and how we might …
avoid that happening. [Beth, Music facilitator]
Well, you know that [there is] always is going to a bit of
anxiety…at the start of the session, may be as to know
what to expect and as to what is expected of them.
[Susan, Music facilitator]
However, the inhibitions that participants reported
largely dissipated as the session progressed. Participants
and facilitators referred to the positive interactions as
possible reason for this.
…the body language has changed, they were moving
more, the feet were going up, a bit more wriggling about,
and lots of smiling, nice body movement along with the
poses and the music …. [Beth, music facilitator]
we have got to be at ease in any group, in any situation,
but particularly a group that may be anxious, just maybe
that would help. It did feel that as soon we had that inter-
action, then …it was different. [Beth, Music facilitator]
The three features of this theme (group homogeneity,
member familiarity and interaction) contributed to the
emerging sense of belonging and connection, or shared
social identity that participants experienced as a result of
taking part in the singing session. These features also
underpinned their beliefs about the potential longer-term
health impacts of the intervention. Participants were
unanimous in their belief that a programme of singing ses-
sions like the current one had the potential to positively
influence quality of life. Some participants elaborated on
this belief by describing other health benefits that may
arise from belonging to and participating in groups like
this, including improved confidence and coping with daily
stressors. Expectations about health benefits appeared to
influence participants’engagement with the session.
I think in a small group like this, we are so involved when
we are singing and you got to put yourself up and I think
because of that you are you get more comfortable with
other people, because of that you get more confident
with people. [Jack]
Theme 2: Creating the conditions for group engagement
Theme 1 was concerned with how participants experi-
enced the singing session and identified factors that con-
tributed to an emerging sense of shared social identity.
Theme 2 reflected participants’and facilitators’percep-
tions of the session features that created the conditions
for establishing the psychological connections underpin-
ning this identity. There were two subthemes within this
theme, one reflecting fixed, or planned, features of the
singing session, and one reflecting flexible, or responsive,
features of it.
Fixed features
(i) Group size: Participants suggested that intervention
groups like this should involve a maximum of around 15
people. They felt that interventions with larger groups
than this would inhibit one-to-one interaction with the
facilitators—interaction that they regarded as contribut-
ing to the group’s success.
Well, the more person you put in, you don’t reach the
purpose of it because you can’t talk, and …if you [are]
trying to talk to the people here, you would want to talk
to everybody, won’t you? And the facilitators would need
them and this meeting would not be the same because
some people would not be able to say what they wanted
to say. [Jack]
(ii) Mid-session break: The 15–20-min mid-session
break presented an opportunity for further interaction.
The positive dynamic this created spilled over into the
second half of the singing session. Participants and facili-
tators valued highly the mid-session break.
…you need that, have that to say ‘hi, how are you’and
that was good as well …and then we came back, our
singing I think went up after [that]. [Julie]
…we have a rapport built between participants and our-
selves, and also with each other there was a lot of discus-
sion and lot of hustle and bustle going on really in the
break time and it became more visible in the second part
that people were more joking and laughing with each
other across the room more so than in the first half.
[Beth, music facilitator]
This narrative resonates with the researchers’observa-
tions of the singing session. Early in the session, several
participants were observed to be hesitant in contributing
to the group singing; however, after the break, it was
apparent that the group dynamic had shifted such that
those whose contributions were previously muted were
now fully participatory.
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 5
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
Flexible features
(1) Session delivery: Although certain aspects of the
singing session, such as the break and the group size,
were planned in advance of the session, the facilitators
adopted a flexible approach to the session delivery that
was based on their own judgement as to how the session
was progressing and in response to verbal and non-
verbal feedback from participants. For example, while
the mid-session break was initially scheduled for 10 min,
this was allowed to over-run because of the high level of
interaction that was occurring between participants.
The facilitators emphasised the necessity of this flexi-
bility in order to respond to the needs of the group.
Every group is going to be different and dynamic and
you need to be able to respond to the groups as they are
[Susan, music facilitator]
It is important to have a kind of awareness of things that
might happen …that might be an issue so that you can
plan for it. But aside from that, it is good to have that
opportunity, those windows to explore because then you
get that nice surprises of things, you just try that and
then you just might hit on something really really positive
and really powerful for somebody. [Beth, music
facilitator]
Participants valued this approach too, although at the
same time emphasised the importance of the interven-
tion meeting their expectations. Expectations that were
not met could negatively influence participants’motiv-
ation to attend subsequent group sessions.
Personally I would like to have some achievement by the
end of some sorts if that is a possibility and I don’t know
something like a choir or with progress. [Rob]
I think what they [facilitators] did was very good but
yeah if you did that every week and not anything else,
then I wouldn’t come as there would not be anything for
me. I think the first couple of weeks would be alright but
after that you know. [Jack]
For Jack to continue in the programme, the intervention
would need to focus on speech development: he said he
would not attend if the intervention comprised only
“sing along”sessions.
(2) Encouraging different forms of participation:
Relatedly, the flexibility of the session allowed facilitators
to introduce new activities that enabled different forms
of participation. At one point in the session, facilitators
encouraged participants to use a kazoo. The session
observers noted participants’enjoyment of this non-
singing activity, a view also expressed in the focus group
and facilitator interviews.
…anybody who is feeling a bit …something else they
can concentrate on. [Cath]
It is an excellent breathing exercise I think. [Megan]
…quite empowering for them, they were waiting for the
end of the song so that they could make that noise.
[Beth, music facilitator]
Use of instruments in this way was felt to create an
additional form of participation in the group beyond
singing, and this was seen as particularly valuable for
participants with more severe aphasia who are less able
to vocalise.
Yes everybody did really enjoy it [the kazoo]. They took
risks themselves and for the lady that had quite profound
aphasia, she …and the gentleman next to her in the
end, for them it was very marked, because they were
making the big noise. They both really liked that I think.
They were really into it. [Susan, music facilitator]
(3) Empowering participants: Facilitators also sought
opportunities for providing participants with some
control over the session content, through collectively
choosing the songs that the group would sing.
Facilitators felt that this sense of participant control was
important and contributed to a feeling of collective own-
ership over the group and its direction.
We were probably also trying to promote some more choice
making, so that the participants would perhaps decide …
we can introduce new material but choose the one [song]
they are most comfortable with and the ones they would
want to spend time on. [Beth, music facilitator]
Another way in which participants were empowered
within the session was by allowing singing/musical mis-
takes to happen and by encouraging participants to take
singing ‘risks’.
…for the participants to be able to make mistakes and
think not to be a problem, nobody is judging them, so
it’s ok to kind of expose yourself to those kind of …chal-
lenges [Susan, music facilitator]
In summary, the above five features in combination
reflected the perceived design and delivery elements of
the singing session which allowed for the emergence of
shared social identity between participants described in
Theme 1.
DISCUSSION
We designed and delivered an introductory session of a
new group intervention for people with aphasia. Data
from a focus group with intervention participants, an
interview with group facilitators and direct observations
of the session highlighted an emerging sense of group
belonging and social identity among participants. This
emerging social identity was underpinned by shared per-
ceptions of group homogeneity, member familiarity and
social interaction (figure 1). The findings from this study
support previous research that has established social
identity as an important determinant of a range of health
6Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
outcomes.
18 28
Our research extends that earlier work by
showing how social identity can be actively nurtured in
new group interventions. This contribution is important
given the increasing frequency with which new patient
groups are assembled for the purposes of delivering
health interventions. Understanding how new social iden-
tities emerge, and knowledge of the factors that can
inhibit or facilitate this emergence, is an important first
step in developing a new guidance framework to
enhance group-based interventions for health.
Our study highlights some potential benefits of estab-
lishing early psychological connections and a sense of
group belonging among intervention participants.
Principally, the study shows that actively shaping interven-
tion participants’experiences of new groups can encour-
age engagement with an intervention, partly because it
can reduce the anxiety that participants experience in
new group settings; nurturing shared social identity can
provide the foundation for effective delivery of interven-
tion content. Accordingly, to the extent that participants
feel comfortable in engaging with an intervention group,
it is possible that the health potential of the given inter-
vention will be better realised. Participants in the current
study were clear about the potential health benefits of
this intervention, namely increasing confidence and
quality of life—outcomes especially pertinent to their
health condition (aphasia). These anticipated benefits
were attributed to the reported ease with which partici-
pants interacted with other members.
While our study has focused on a bespoke group inter-
vention for a specific health condition, we suggest that the
basic principles needed to establish belonging and psycho-
logical connections—shared social identity—that have
been documented here should be core features of a
general framework for group interventions, including
those targeting health outcomes beyond psychosocial
health.
8
By way of an example, recent research with baria-
tric surgery candidates has highlighted the role of shared
social identity in motivating engagement with a group
dietary education programme and subsequent lifestyle
behaviour change (Tarrant et al, 2015: unpublished observa-
tions). Similar to the findings from the current study, social
identity in that study was shown to be an emergent prop-
erty of facilitated interaction that was based on perceptions
of group member similarity and shared experience.
Participants and group facilitators in the current study
identified several features relating to the design of the
intervention session (figure 1) that highlight how the
above basic principles of establishing social identity can be
implemented in group interventions. In line with recent
Medical Research Council guidance on process evaluation
in complex interventions,
11
these features can be seen as
reflecting fidelity issues (eg, delivery of group interven-
tions) and also mechanisms of impact (eg, how participant
engagement and group interaction are achieved). Some of
the design features participants identified were regarded as
‘fixed’features, or what might be termed form issues,inthe
sense that they could be planned in advance of the session
(eg, group size, mid-session breaks). Of particular note is
the finding that involving a member of the target popula-
tion in the organisation of the session (eg, recruitment)
contributed to participant engagement with the interven-
tion. Employing a group ‘champion’in this way may
encourage a more rapid ‘settling in’of participants and
promote early social interaction leading to feelings of
belonging. Other features related to the perceived critical
role of the group facilitators—both in terms of their provi-
sion of key content relative to the intended health out-
comes (in our case, leading musical activities) and their
‘flexible’delivery of the session, for example, by managing
the expectations of group members and responding to
their needs in situ. This flexibility (or function issues)was
strongly valued by participants and reflects other research
that has considered the role of group facilitators in man-
aging groups
22
(Tarrant et al, 2015: unpublished observations).
It also highlights the importance of ensuring that those
who are responsible for delivering group interventions are
appropriately skilled in group leadership: facilitators may
require specific training to become entrepreneurs of identity.
21
A clear strength of the current study is its triangulation
of findings, drawing on data from three sources (focus
group, interviews and researcher observations). While
the conclusions drawn here about how to nurture social
identity in group interventions are based on data from a
single session of an intervention for people with a spe-
cific long-term health condition, they accord with some
of the general processes pertaining to group formation
that have been discussed elsewhere.
35
Our findings also
resonate with those from other research programmes
that have started to explore the role of social and psy-
chological connections between participants in interven-
tion groups,
8
and the potential of music to facilitate
these connections.
36
Nonetheless, future research
should seek to test our conclusions in other healthcare
contexts, particularly those where there are fewer pre-
existing similarities between group members or lower
levels of initial homogeneity. Relatedly, while participants
here were clear about the potential benefits of partici-
pating in a group intervention that is underpinned by
shared social identity between group members, it is not
possible to conclude that this participation actually
impacted participants’health. Finally, we have articu-
lated group processes conducive to the initial formation
of social identity in an intervention group. How these
processes evolve over time across the context of an inter-
vention is an important consideration and is likely to
depend both on the specific health condition and group
members’individual experiences of the intervention
and interactions with others receiving it.
37 38
Our
ongoing research is building on the work here to finalise
the intervention specification such that it can be the
subject of a randomised controlled trial with clear out-
comes of value to people with aphasia.
This study should therefore be seen as a starting point
for understanding the ways in which participants in new
group interventions form psychological connections with
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 7
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
one another, and it provides a guide to how these con-
nections might be deliberately nurtured by creating the
conditions for early active participant engagement.
Facilitating the development of a positive and meaningful
shared social identity among intervention participants
may pave the way for the delivery of key intervention
content pertinent to the intended health outcomes.
Author affiliations
1
University of Exeter Medical School, University of Exeter, Exeter, UK
2
Peninsula Collaboration for Leadership in Applied Health Research and Care
(PenCLAHRC), South West Peninsula, UK
3
Department of Psychology, Centre for Clinical Neuropsychology Research,
University of Exeter, Exeter, UK
4
Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth
University, Plymouth, UK
Twitter Follow PenCLAHRC at @PenCLAHRC
Acknowledgements The authors thank Jane Adamson, Ian Parsons, Bev
Snowden, Rachel Thame and Anna Batson for their contributions to the
development of the intervention session plan, a local aphasia network
chairperson for assistance in participant recruitment and Plymouth Music
Zone for providing music facilitators and use of their facilities for the singing
session and focus group/interviews.
Contributors MT was a project lead; and involved in the study conception and
design; intervention development; data collection; interpretation of results;
manuscript write-up. KW was involved in the data collection; data analysis
and interpretation of results; manuscript write-up. CC was involved in the
intervention development; study design; interpretation of results; manuscript
write-up. SD was involved in the study design; data analysis; interpretation of
results; manuscript write-up. VAG was involved in the intervention
development; interpretation of results; manuscript write-up. KS was involved
in the study conception and design; data collection; interpretation of results;
manuscript write-up. TS was involved in the study design; data collection; led
focus group and interviews; transcription of interview/focus group data; data
analysis; interpretation of results; manuscript write-up.
Funding This research was funded by the National Institute for Health
Research (NIHR) Collaboration for Leadership in Applied Health Research and
Care South West Peninsula. The views expressed are those of the authors and
not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests None declared.
Ethics approval University of Exeter Psychology Ethics Committee, Ref:
2014/514.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/4.0/
REFERENCES
1. Lacasse Y, Goldstein R, Lasserson TJ, et al. Pulmonary
rehabilitation for chronic obstructive pulmonary disease. Cochrane
Database Syst Rev 2009;18:CD003793.
2. Paul-Ebhohimhen V, Avenell A. A systematic review of the
effectiveness of group versus individual treatments for adult obesity.
Obes Facts 2009;2:17–24.
3. Wakefield JR, Bickley S, Sani F. The effects of identification with a
support group on the mental health of people with multiple sclerosis.
J Psychosom Res 2013;74:420–6.
4. Beesley K, White JH, Alston MK, et al. Art after stroke: the
qualitative experience of community dwelling stroke survivors in a
group art programme. Disabil Rehabil 2011;33:2346–55.
5. Code C, Torney A, Gildea-Howardine E, et al. Outcome of a
one-month therapy intensive for chronic aphasia: variable individual
responses. Semin Speech Lang 2010;31:21–33.
6. Greaves CJ, Campbell JL. Supporting self-care in general practice.
Br J Gen Pract 2007;57:814–21.
7. Borek AJ, Abraham C, Smith JR, et al. A checklist to improve
reporting of group-based behaviour-change interventions. BMC Pub
Health 2015;15:963.
8. Gessel SB, Barkin SL, Valente TW. Social network diagnostics:
a tool for monitoring group interventions. Implement Sci
2013;8:116.
9. A framework for development and evaluation of RCTs for complex
interventions to improve health. Medical Research Council, 2000.
http://www.mrc.ac.uk/documents/pdf/rcts-for-complex-
interventions-to-improve-health/ (accessed 28 Jul 2015).
10. Craig P, Dieppe P, Macintyre S, et al.Developing and evaluating
complex interventions: new guidance. Medical Research Council,
2008. http://www.mrc.ac.uk/documents/pdf/complex-interventions-
guidance/ (accessed 28 Jul 2015).
11. Moore GF, Audrey S, Barker M, et al. Process evaluation of complex
interventions: Medical Research Council guidance. BMJ 2015;350:
h1258.
12. Cruice M, Worral L, Hickson L. Quantifying aphasic people’s social
lives in the context of non-aphasic peers. Aphasiology
2006;20:1210–25.
13. Hilari K. The impact of stroke: are people with aphasia different to
those without? Disabil Rehabil 2011;33:211–18.
14. Auerbach J, Benezra A. Therapeutic recreation and the rehabilitation
of the stroke patient. Loss Grief Care 1998;8:123–8.
15. Cruwys T, Haslam SA, Dingle GA, et al. Feeling connected again:
interventions that increase social identification reduce depression
symptoms in community and clinical settings. J Affect Disord
2014;159:139–46.
16. Gleibs IH, Haslam C, Jones JM, et al. No country for old men? The
role of a ‘Gentlemen’s Club’in promoting social engagement and
psychological well-being in residential care. Aging Ment Health
2011;15:456–66.
17. Tajfel H, Turner JC. An integrated theory of intergroup conflict. In:
Austin WG, Worchel S, eds. The social psychology of intergroup
relations. Monterey, CA: Brooks-Cole, 1979:33–47.
18. Haslam SA, Jetten J, Postmes T, et al. Social identity, health, and
well-being: an emerging agenda for applied psychology. Appl
Psychol-Int Rev 2009;58:1–23.
19. Sani F, Madhok V, Norbury M, et al. Greater number of group
identifications is associated with healthier behaviour: evidence
from a Scottish community sample. Br J Health Psychol
2015;20:466–81.
20. Tarrant M, Hagger MS, Farrow CV. Promoting positive orientation
towards health through social identity. In: Jetten J, Haslam SA,
Haslam C, eds. The social cure: identity, health, and well-being.
New York: Psychology Press, 2012:39–54.
21. Haslam SA, Postmes T, Ellemers N. More than a metaphor:
organizational identity makes organizational life possible. Br J
Manage 2003;14:357–69.
22. Haslam SA, Reicher SD, Platow MJ. The new psychology of
leadership: identity, influence and power. Hove, UK: Psychology
Press, 2010.
23. Sani F. When subgroups secede: extending and refining the social
psychological model of schism in groups. Pers Soc Psychol B
2005;31:1074–86.
24. Van Vugt M, Hart CM. Social identity as social glue: the origins of
group loyalty. J Pers Soc Psychol 2004;86:585–98.
25. Clift S. Creative arts as a public health resource: moving from
practice-based research to evidence-based practice. Perspect Public
Health 2012;132:120–7.
26. Clift S, Hancox G, Staricoff R, et al.Singing and health: summary of
a systematic mapping and review of non-clinical research. Sidney
De Haan Research Centre for Arts and Health, 2008. http://www.
creativityaustralia.org.au/wp-content/uploads/2012/05/
Report-5-Systematic-Mapping-and-Review.pdf (accessed 28 Jul
2015).
27. Clift S, Hancox G. The significance of choral singing for sustaining
psychological wellbeing: findings from a survey of choristers in
England, Australia and Germany. Music Perform Res 2010;3:
79–96.
28. Dingle GA, Brander C, Ballantyne J, et al.“To be heard”: the social
and mental health benefits of choir singing for disadvantaged adults.
Psychol Music 2013;41:405–21.
8Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
29. Crotty M. The foundations of social research: meaning and
perspective in the research process. Thousand Oaks, CA: Sage,
2003.
30. Grbich C. Qualitative research in health: an introduction.St
Leonards, Australia: Allen & Unwin, 1999.
31. Clemensen J, Larsen SB, Kyng M, et al. Participatory design in
health sciences using cooperative experimental methods in
developing health services and computer technology. Qual Health
Res 2007;17:122–30.
32. Wherton J, Sugarhood P, Procter R, et al. Co-production in practice:
how people with assisted living needs can help design and evolve
technologies and services. Implement Sci 2015;10:75.
33. Holbrook MB, Schindler RM. Some exploratory findings on
the development of musical tastes. J Consum Res 1989;16:
119–24.
34. Ritchie J, Spencer L. Qualitative data analysis for applied policy
research. In: Bryman A, Burgess R, eds. Analyzing qualitative data.
London: Sage, 1994:173–94.
35. Postmes T, Haslam SA, Swaab RI. Social influence in small groups:
an interactive model of social identity formation. Eur Rev Soc
Psychol 2005;16:1–42.
36. Loersch C, Arbuckle NL. Unraveling the mystery of music:
music as an evolved group process. J Pers Soc Psychol
2013;105:777–98.
37. Cruwys T, Haslam SA, Fox NE, et al.“That’s not what we do”:
evidence that normative change is a mechanism of action in group
interventions. Behav Res Ther 2015;65:11–17.
38. Hornsey MJ, Dwyer L, Oei TPS, et al. Group processes and
outcomes in group psychotherapy: is it time to let go of
“cohesiveness”?Int J Group Psychoth 2009;59:267–78.
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 9
Open Access
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
session for people with aphasia
focus group evaluation of a group singing
intervention recipients: development and
Creating psychological connections between
Goodwin, Ken Stein and Thavapriya Sugavanam
Mark Tarrant, Krystal Warmoth, Chris Code, Sarah Dean, Victoria A
doi: 10.1136/bmjopen-2015-009652
2016 6: BMJ Open
http://bmjopen.bmj.com/content/6/2/e009652
Updated information and services can be found at:
These include:
References #BIBLhttp://bmjopen.bmj.com/content/6/2/e009652
This article cites 29 articles, 6 of which you can access for free at:
Open Access
http://creativecommons.org/licenses/by-nc/4.0/non-commercial. See:
provided the original work is properly cited and the use is
non-commercially, and license their derivative works on different terms,
permits others to distribute, remix, adapt, build upon this work
Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
This is an Open Access article distributed in accordance with the Creative
service
Email alerting box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in the
Collections
Topic Articles on similar topics can be found in the following collections
(374)Research methods (439)Qualitative research
(1397)Public health (867)Health services research
Notes
http://group.bmj.com/group/rights-licensing/permissions
To request permissions go to:
http://journals.bmj.com/cgi/reprintform
To order reprints go to:
http://group.bmj.com/subscribe/
To subscribe to BMJ go to:
group.bmj.com on February 23, 2016 - Published by http://bmjopen.bmj.com/Downloaded from
