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The acceptability and feasibility of a cognitive behavioural therapy managing emotions group on a male psychiatric intensive care unit: a mixed methods evaluation

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Research suggests that the provision of psychological interventions within acute inpatient settings is effective and important for improving clinical outcomes. There remains limited research on the application of such interventions for individuals admitted to psychiatric intensive care units (PICU), and notably none for male-only PICU environments specifically. Two published protocols have been evaluated in female and mixed gender PICU settings, one a cognitive behavioural therapy (CBT) anger management group and one dialectical behaviour therapy (DBT) skills group. No studies have reported on a general CBT-based group in a male PICU. This study aimed to assess the acceptability and feasibility of a CBT-based managing emotions skills group, delivered in brief 30-minute sessions, within a 7-bed male PICU. All individuals admitted to the PICU during the study period were invited to attend a five-session group. A mixed methods design was used incorporating measuring attendance and retention, a pre–post quasi-experimental design and a qualitative component. Pre- and post-group self-report outcome measures of calmness, anxiety, recovery, and qualitative feedback were gathered and analysed. Pre- and post-outcome measures demonstrate significant improvements in calmness and reduction in anxiety following attendance. Attendance, retention and qualitative feedback data suggests that the group was acceptable and feasible for the participants. Initial findings suggest that adapted CBT skills group-based interventions tailored to the male PICU population are acceptable, feasible, and beneficial to participants. The clinical and research implications are discussed.
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Journal of Psychiatric
Intensive Care
BRIEF REPORT
The acceptability and feasibility of
a cognitive behavioural therapy
managing emotions group on a male
psychiatric intensive care unit: a mixed
methods evaluation
Meghan Davies1, Alastair Pipkin2
1Adult Inpatient Psychology Service, Berrywood Hospital, Northamptonshire Healthcare
NHS Foundation Trust; 2Adult Inpatient Psychology Service, Berrywood Hospital,
Northamptonshire Healthcare NHS Foundation Trust ORCID: https://orcid.org/0000-0001-
8202-6383
MD, https://orcid.org/0009-0008-2443-2365; AP, https://orcid.org/0000-0001-8202-6383
Correspondence to: Dr Alastair Pipkin, Berrywood Hospital, Berrywood Drive, Duston,
Northamptonshire, NN5 6UD; Alastair.Pipkin@nhft.nhs.uk
Research suggests that the provision of psychological interventions within acute
inpatient settings is effective and important for improving clinical outcomes.
There remains limited research on the application of such interventions for
individuals admitted to psychiatric intensive care units (PICU), and notably
none for male-only PICU environments specically. Two published protocols
have been evaluated in female and mixed gender PICU settings, one a cognitive
behavioural therapy (CBT) anger management group and one dialectical
behaviour therapy (DBT) skills group. No studies have reported on a general
CBT-based group in a male PICU. This study aimed to assess the acceptability
and feasibility of a CBT-based managing emotions skills group, delivered in
brief 30-minute sessions, within a 7-bed male PICU. All individuals admitted
to the PICU during the study period were invited to attend a ve-session group.
A mixed methods design was used incorporating measuring attendance and
retention, a pre–post quasi-experimental design and a qualitative component.
Pre- and post-group self-report outcome measures of calmness, anxiety, recovery,
and qualitative feedback were gathered and analysed. Pre- and post-outcome
measures demonstrate signicant improvements in calmness and reduction in
anxiety following attendance. Attendance, retention and qualitative feedback data
suggests that the group was acceptable and feasible for the participants. Initial
ndings suggest that adapted CBT skills group-based interventions tailored to the
male PICU population are acceptable, feasible, and benecial to participants. The
clinical and research implications are discussed.
Key words: acute mental health; psychiatric intensive care unit; group
psychological intervention; brief intervention; cognitive behavioural therapy;
male mental health
Journal of Psychiatric Intensive Care
doi: 10.20299/jpi.2023.008
Received 5 February 2023 | Accepted 19 October 2023
© The Author(s) 2023
This is an open access article under the terms of the CC-BY 4.0 license
2© The Author(s) 2023
Davies & PiPkin
Financial support: This research received no specic grant from any funding agency.
Ethics: The authors assert that all procedures contributing to this work comply with
the ethical standards of the relevant national and institutional committees on human
experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Declaration of interest: None
Introduction
Individuals who present to psychiatric intensive care
units (PICUs) often experience severe mental health dif-
culties and high levels of emotional distress and would
likely benet from psychological intervention. Hence,
national PICU standards advise that psychological inter-
ventions should be accessible within these environments
(Penfold et al. 2019). However, there are identied bar-
riers to implementing psychological interventions in
acute inpatient and PICU settings, including a signicant
need for adaptation, high levels of acuity, high staff and
patient turnover, and practical challenges such as space
(Kerfoot et al. 2012; NHS England 2016). A common
narrative exists that those accessing inpatient services are
‘too unwell’ to benet from psychological intervention
(Mullen 2009), with patients admitted to PICU environ-
ments often presenting as acutely unwell with impaired
functioning and high levels of psychological distress
(Garcia et al. 2005).
Despite identied barriers, evaluations of individual
psychological interventions within acute inpatient set-
tings have shown positive effects on treatment outcome
for a wide variety of diagnoses and presentations. This
includes helping patients cope during crises (Araci &
Clarke 2017) and reducing distress and symptoms for
those experiencing psychosis, trauma and depression
(Jacobsen et al. 2011; Oud et al. 2016; Mc Glanaghy et
al. 2021). There is a growing body of evidence for group-
based psychological interventions in acute inpatient set-
tings, with research demonstrating that adaptations to
standard protocols make group interventions acceptable,
feasible and effective. Stroud & Grifths (2021) found
signicant improvements in patient outcomes for those
who attended a compassion focused therapy (CFT) group
facilitated across three acute wards, when compared to
those undertaking treatment as usual. Similarly, a fur-
ther study found that a CFT group within an acute ward
signicantly reduced attendees reported level of distress
and increased ratings of calmness (Heriot-Maitland et
al. 2014). Furthermore, Boynton & Sanderson (2022)
explored the effectiveness of an open group cognitive
behavioural therapy (CBT) on inpatient wards. The use
of an open group design was adopted in order to adapt to
the inpatient environment, allowing members to join and
leave as they wish, for attendees to select a therapeutic
goal at the start of the session rather than adhering to a
strict psychoeducational structure or manualised content,
and for the focus to be on common difculties shared
amongst a range of disorders (e.g. emotion dysregula-
tion). Furthermore, the use of an adapted CBT approach
demonstrated self-reported increases in self-efcacy and
ability to manage emotions in acute inpatient settings
(Durrant et al. 2007; Clarke & Nicholls 2018). CBT-based
group interventions with adaptations therefore appear to
be suitable for inpatient settings.
There remains a lack of empirical evidence concern-
ing the needs of those requiring admission to a PICU
and the implementation of psychological therapy for this
population (Archer et al. 2016). The authors are aware
of only two published studies evaluating the effectiveness
of psychological therapy groups in a PICU environment
specically. These included the implementation of a CBT-
informed anger management programme on a mixed
gender ward (Wilson et al. 2011) and a dialectical behav-
iour therapy (DBT)-informed recovery skills group on a
female PICU (Walsh-Harrington et al. 2020). Both groups
focused on developing problem solving and coping skills
and reported positive outcomes for those attending, with
patients rating the groups as ‘worthwhile’ and ‘helpful for
the future’ and a reduction in risk incidents pre- and post-
group identied. Keeping groups shorter in duration, ex-
ible in approach, and focused on skills practice and devel-
opment appeared efcacious in both articles. A notable
research gap remains for how and whether psychological
interventions are acceptable, feasible and benecial in
male-only PICU settings. The present study was further
informed by research-led recommendations for adapta-
tions for male-friendly psychological interventions, nota-
bly maintaining an action-focus, transparency, increased
collaboration and an awareness of male socialisation
such as rearing around emotions (Seidler et al. 2018). It
remains unknown whether such an adapted male-friendly
CBT group intervention is viable, acceptable, and feasible
to individuals admitted to a male-only PICU.
The present study reports a pilot evaluation of a CBT-
based managing emotions skills group for males on a
PICU. The aim of the group was to assess the accept-
ability, feasibility and preliminary self-reported outcomes
of the group to inform the literature and further group
developments. The study aimed to answer the following
research questions:
1. How acceptable and feasible is a 30-minute, skills-
focused psychological intervention on a 7-bed male
PICU regarding session attendance and completion?
Managing eMotions grouP in Male PiCu
3© The Author(s) 2023
2. Does the intervention improve participants’ self-
reported sense of threat, anxiety, calmness and gen-
eral recovery?
3. What are attendees’ experiences of the intervention?
Method
Design
A mixed methods design was used with a repeated meas-
ures pre-post quasi-experimental design and qualitative
evaluation. An opportunity sampling method was utilised.
Participants
During the ve-week evaluation period, 13 patients were
admitted to the PICU. Of those admitted, seven attended
at least one group session. Participants ages ranged
between 25 and 60 years, three were diagnosed with
schizophrenia, one with acute and transient psychotic
disorder, two with bipolar and one did not have a formal
diagnosis at the time of the group. Six were White and
one Black British.
Procedure
The group was designed based on previous research. It
consisted of ve, stand-alone, 30-minute-long sessions
with a focus on experiential exercises and group discus-
sions, drawing on CBT principles of understanding and
managing emotions. It drew upon providing psychoedu-
cation about emotions, identication of a participant’s
appraisals of their emotions and primarily developing
skills to manage emotions. It was delivered weekly over
ve weeks. Each session followed the structure of: revis-
iting the group rules; recapping previous session content
and learning; initial skill practice; facilitated group dis-
cussion around the session content and psychoeduca-
tion; skill practice; giving handouts and setting goals.
The main skills practiced were variations of mindfulness
practices, relaxed breathing, visualisations, progressive
muscle relaxation, and naming or labelling emotions.
Session content included exploring the meaning of emo-
tions, understanding appraisals of emotions, identifying
physiological and behavioural responses to emotions,
and ways to manage emotions. Group sessions were led
with a focus on facilitating peer discussions and skills
practice.
On the day of each group, the facilitators (a member
of the psychology service and an occupational therapy
team member) invited all patients admitted to the PICU to
attend, subject to risk assessment by the nurse in charge
on the day. Patients were informed that they would be
asked to leave the group if they presented substantial
disruption, and group rules were developed collabora-
tively. Participants were supported to complete the group
outcome measures prior to the session and again at the
end where consent had been provided.
Measures
Attendance was tallied per session and per participant.
When a participant left a session early this was noted to
measure in-session retention.
Self-report quantitative measures were designed
based on previous inpatient group evaluations (Stroud
& Grifths 2021) using a 10-point Likert scale ranging
from ‘Not at all’ (1) to ‘Extremely’ (10). The questions
asked participants to rate how they felt right now for each
of: ‘I feel threatened’, ‘I feel calm’ and ‘I feel anxious’.
Measures were completed immediately before and after
each group session. Higher levels of threat and anxiety
denoted worse threat and anxiety, while higher levels of
calm denoted more calmness.
For participants who attended all ve sessions, the
Recovering Quality of Life-10 (ReQoL-10) scale was
administered at the rst session and again after the fth
session. The ReQoL-10 is a 10-item self-report scale
assessing perceived recovery. It contains 10 statements
which are scored in relation to the past week on a 0–4
Likert scale, ranging from ‘None of the time’ (0) to ‘Most
or all of the time’ (4). Example statements include ‘I
found it difcult to get started with everyday tasks’ and
‘I felt like a failure’. Higher scores reect higher per-
ceived recovery. It demonstrates excellent internal reli-
ability (Cronbach’s alpha = 0.92) and validity (r = 0.90)
(Keetharuth et al. 2018).
Two written open-ended qualitative questions were
also provided for participant feedback, asking what, if
anything, they had gained from attending the session and
what, if anything, they thought could be improved for
future sessions.
Analysis
Descriptive statistics were used for all quantitative meas-
ures, with session-by-session tallies, average attendance,
the range of attendees per session, and the number and
percentage of sessions left early compared to social num-
ber of sessions attended, all being used to answer the
rst research question. To examine the second research
question, paired sample t-tests were used to ascertain any
statistically signicant differences with post-hoc mean
comparisons where differences were found. The qualita-
tive feedback forms were subjected to a content analysis
(Krippendorff 1980), whereby each statement within a
response was given a code to reect its meaning, these
were then grouped and reported as themes.
Ethics
The study underwent ethical review and approval with
the hosting NHS Trust’s Psychology Research Group.
4© The Author(s) 2023
Davies & PiPkin
The project was deemed to be a service evaluation of rou-
tine clinical practice. All participants provided informed
consent and were assured that attendance and completion
of outcome measures and feedback forms were com-
pletely optional and anonymised, and refusal would not
affect their care delivery. No adverse events were noted
or reported.
Results
How acceptable and feasible is the intervention regard-
ing attendance and completion?
Session-by-session attendance and retention within ses-
sions are displayed in Table 1.
The range of attendees per session was 1–6, with
the average number of attendees per session being 2.8.
Attendance as a percentage of the total bed stay therefore
ranged from 14–86%, with the average being 40%. Of
the seven total participants who attended, three left one
session each early, spending 10–15 minutes in the session
before leaving. In-session retention as a percentage was
therefore 79%.
Regarding repeat attendance, four of the seven par-
ticipants attended more than one session, with the aver-
age number of sessions attended being two. Three par-
ticipants attended one session (with two of those leaving
the session early), three attended two sessions (with
one leaving the session early) and one attended all ve
sessions.
Does the intervention improve self-reported threat, anxi-
ety, calmness and general recovery?
One-tailed paired sample t-tests were conducted on the
self-reported pre- and post-session data. Table 2 contains
the means of the pre- and post-group measures with sig-
nicance levels. There was a signicant difference in
self-reported anxiety before (mean= 3.00, SD = 2.57) and
after the group (mean = 2.27, SD = 2.68), (t(10) = 3.37,
p = 0.002) with participants reporting lower anxiety after
the group compared to before. There was a signicant
difference in self-reported calmness before (mean = 6.46,
SD = 4.11) and after the group (mean = 9.00, SD = 1.41)
(t(10) = −1.91, p = 0.042) with participants report-
ing higher calmness after, in comparison with before,
the group. There was no signicant difference in self-
reported threat before and after the group (t(10) = 1.206,
p = 0.128).
Only one participant completed all ve sessions and
therefore completed a pre- and post-group ReQoL-10.
There was no change in the total score from the rst to
fth session attendance.
What are attendees’ experiences of the intervention?
A total of 14 written evaluation forms were received, with
10 of those containing written feedback. A content analy-
sis identied four themes amongst the written responses:
Expressed appreciation; Finding the group helpful; Gets
you thinking; and Recommendations for future sessions.
Indicative quotes are provided verbatim, with context
added using [ ] where required.
Expressed appreciation. Participants expressed gratitude
and appreciation for group content, with comments such
as ‘thank you’, ‘perfect’ and ‘awesome’ provided in feed-
back. One patient commented: ‘[I] enjoyed mindfulness
tasting the sweets and meeting new staff’. Another fed
back: ‘[it was] good to have a healthy chat with support-
ive staff’.
Finding the group helpful. Comments also referenced the
sessions as being helpful, with participants listing what
they would be taking away such as ‘tips for dealing with
anxiety’. One participant noted that: ‘[the session] pro-
vided words of advice and help managing for the future’.
Another commented: ‘helpful course, gets you to realise
certain psychological reactions’.
Gets you thinking. Reference to the sessions being thought-
provoking were reected in patient feedback. One patient
stated the session was: ‘brain ticking, exercised my brain
Table 1. Numbers of attendees per session, and participants who
left a session early, with time spent in the session before leaving
in minutes.
Session
number
Participants in
attendance
Participants leaving early
(time spent in session in
minutes)
1 2 0
2 6 1 (15)
3 3 1 (10)
4 2 1 (15)
5 1 0
Average 2.8
Table 2. Pre- and post-group means with standard deviation for measures of anxiety, calmness and threat.
Measure Anxiety Calmness Threat
Pre-group
mean (SD)
Post-group
mean (SD)
p-value
Pre-group
mean (SD)
Post-group
mean (SD)
p
Pre-group
mean (SD)
Post-group
(SD)
p-value
3.00 (2.57) 2.27 (2.69) 0.002 6.45 (4.11) 9.00 (1.41) 0.042 3.18 (3.82) 2.00 (2.72) 0.128
Statistical signicance shown in bold
Managing eMotions grouP in Male PiCu
5© The Author(s) 2023
[and] helped communicating with others’. Another com-
mented the session was: ‘fun [and] exercised my mind [as
the] skills help in all different ways’.
Recommendations for future sessions. Participants pro-
vided feedback on how the intervention could be devel-
oped or be of more use to those accessing it. Requests
were made for ‘more activities’ and for activities to be
‘more constructive’. Additionally, suggestions were given
for more space to ‘talk about my past and my experience
in hospital’ and ‘more about what we have struggled with
throughout our lives’. One participant also noted that
having the option of ‘using an online form’ to provide
feedback would be useful.
Discussion
This study explored the acceptability and feasibility of
a CBT-informed managing emotions intervention on a
7-bed male PICU. A signicant difference was found in
the self-reported levels of anxiety and calmness before
and after session attendance, with both improving after
attendance. No signicant difference was found in the
immediate levels of threat participants experienced.
Session attendance ranged from one to six participants
per session, with four of the seven total attendees attend-
ing two or more sessions. This equated to a range of
14–86% of the total bed stay attending the group at any
one time. Completion of a session once in the room was
high, with only three participants leaving a session early
once each. Qualitative feedback contained positive com-
ments on the sessions being helpful and informative,
with recommendations for improvements predominantly
around further space to talk about their experiences and
more activity-based exercises.
The ndings suggest that offering group psychologi-
cal therapy in the form of a brief skills-based managing
emotions group for males on a PICU is acceptable and
feasible, with qualitative ndings suggesting that par-
ticipants found the sessions and their content benecial
and engaging, and were grateful for the opportunity to
access psychological intervention on the ward. This cor-
roborates previous research which emphasised the value
patients placed on accessing psychological intervention
in the PICU environment (Durrant et al. 2007; Walsh-
Harrington et al. 2020). Moreover, it appears to be fea-
sible given that each session had at least one participant,
taking into consideration recruitment from a single 7-bed
unit, and that more than half of the participants continued
to attend for more than one session. The structure of this
group protocol being stand-alone sessions, only lasting
approximately 30 minutes and focusing on experiential
and discussion-based exercises may have contributed to
the continued attendance, as found in previous research
(Walsh-Harrington et al. 2020). The qualitative feed-
back also highlighted that the males who attended valued
engaging activities and a structured space to talk about
their experiences. Participants’ comments reected liking
the active nature of the group to learn coping skills and to
engage their brains through thinking and reecting. This
relates to prior research on psychologically-informed
ward-based environments, incorporating additional staff
training and time to provide such spaces through groups
and individual psychologically-informed interven-
tions (Raphael et al. 2021). The experiences, outcomes
and utility of such spaces warrant further investigation,
though this preliminary investigation suggests that such
groups on male PICUs are acceptable, feasible and val-
ued by participants.
Regarding outcomes, completion of a formal psycho-
metric test was not possible for the majority of the par-
ticipants in the study, and one participant demonstrated
no improvement on the ReQoL, a measure of perceived
recovery. Ascertaining the value of therapeutic groups
in PICU warrants further exploration with a variety of
assessment methods due to this limitation in the present
study. However, participants self-reported Likert scales
demonstrated improvements in anxiety and calmness
immediately after the group, which reects prior nd-
ings in acute inpatient ward settings (Stroud & Grifths
2021). This study adds to the ndings of a previous
CBT-based anger management intervention and DBT
skills groups in PICU environments (Wilson et al. 2011;
Walsh-Harrington et al. 2020) suggesting that trans-diag-
nostic, CBT-based ‘bite-sized’ emotion regulation skill
group-based interventions are likely to be acceptable,
feasible and benecial and warrant further evaluation in
PICU settings. Further evaluation of outcomes is needed.
Specic adaptations for males in acute and PICU settings
warrant further investigation as, although the protocol
was informed by male-friendly adaptations, this was not
specically evaluated beyond attendance retention data
(Seidler et al. 2018). It is notable that some participants
reported desiring a space to discuss their past experiences
and difculties, so a wider range of possible psycho-
logical interventions for males in these settings could be
explored further.
Limitations and future research
Although the study found improvements in some of the
here-and-now measures post-group, it is limited by a lack
of follow-up measures. Additionally, the lack of psycho-
metric tests and follow-up beyond immediately after the
group limits the broader conclusions that can be drawn.
Future research would also benet from the use of a con-
trol group who do not attend the group to further gauge
any likely benets, as well as a larger sample to ascertain
6© The Author(s) 2023
Davies & PiPkin
whether this group benets more people. Further stud-
ies would benet from exploring psychometric and other
measures, such as risk incidences, well-being and skill
development, though further thought is needed for appro-
priate measures in the PICU environment. Qualitative
enquiry into the needs and experiences of men in a PICU
environment may add further value in understanding the
suitability and acceptability of psychological interven-
tions. Practitioners in PICUs can consider the possible
benets of employing psychologically-informed environ-
ments by offering structured, supportive spaces to learn,
reect and practice coping skills, and to share past experi-
ences, as the present participants reported desiring more
of such spaces in the PICU.
Conclusion
The present ndings suggest that implementation of an
adapted CBT skills-based managing emotions group on
a male PICU is acceptable and feasible, and that brief,
stand-alone sessions are perceived as benecial and
engaging. Preliminary data gathered supports existing
evidence that there is therapeutic value in delivering
psychological intervention within a PICU environment.
Further evaluation on a larger sample would be necessary
to determine any inuence on clinical outcomes.
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