Inpatient Group Psychotherapy: Improvement through Group Skills Training and Outcomes Tracking

Jennifer Ellsworth, BS, and Matthew Hoag, PhD

The Utah State Hospital (USH) offers group psychotherapy as a primary form of treatment for adults and adolescents. Several types of group programming are offered, ranging from large milieu to traditional psychotherapy groups. However, internal and external reviews identified a need to strengthen the group treatment program and to establish a more rigorous outcome tracking system. The majority of staff at USH had little or no formal training in comprehensive group work, despite the utilization of group as a primary treatment format.

Based on these needs, two specific aims were identified for this study. The first goal was to improve staff skills/competencies in the delivery of group treatment, including introducing staff to empirically supported group treatments for target populations. The second goal was to improve the quality of outcomes tracking. This research was supported by funding from the State Academic Collaborative Committee and the Brigham Young University Comprehensive Clinic. 

Although there is little research on the direct effect of training on group processes and outcomes (Fuhrman & Burlingame, in press), there is some evidence that manual based training and supervision can have significant effects on the process and outcome of individual therapy (Burlingame, Paul, Fuhrman, & Ogles, 1989). It was expected that group leaders who received general and specific training in the delivery of group treatment would run more effective groups as demonstrated by higher levels of therapeutic interaction, curative factors, and group functioning. 

Design of the Study
The clinical staff at USH includes psychiatrists, psychologists, social workers, nurses, occupational and recreational therapists, and psychiatric technicians. Staff from all disciplines received training in group treatment. One youth unit and one adult unit were targeted to receive staff training. Two approximately analogous units, one youth unit and one adult unit, received no training and served as a comparison. Seven groups from the adult target unit and six groups from the adult comparison unit participated. Three groups were monitored on each of the youth units. The number of patients per group varied between four and 10, and approximately 100 patients participated. Many of the patients are severely and chronically mentally ill, and a high percentage suffer from schizophrenia. The staff was targeted for intervention, however data on group processes were collected from patient questionnaires and behavioral observations of group sessions.

The staff skills enhancement program extended across a six-month time frame and consisted of several inter-related phases. The first segment of training was participation in a one-day workshop by a leading international authority on group treatment, K. Roy MacKenzie, MD, CGP, DFAGPA. This workshop introduced participants to the basic skills necessary to run effective psychotherapy groups. Special focus was given to group development, leadership strategies, therapist interventions, and a general paradigm for conceptualizing a group service program. The workshop included observing Dr. MacKenzie utilize a variety of these skills in leading a group of current USH patients.

Further staff skills enhancement was based on Conyne, Wilson, and Ward’s (1997) model for comprehensive group work and occurred during a training meeting that met weekly over the six months. The content of this 300-page manual was broken into the knowledge and skill components associated with effective management of task, psychoeducational, counseling, and psychotherapy groups, as well as considerations related to general group dynamics. Staff members were provided with a descriptive matrix categorizing the hospital’s current group offerings on three dimensions (type of group X patient diagnosis X developmental competencies). This tool, developed by the investigators, assisted staff in linking the MacKenzie and Conyne concepts with the groups they run on a daily basis.

Finally, a weekly group consultation service was provided for the duration of the six-month program. Three psychologists, all experts in group psychotherapy and research, led this training. Group leaders were able to obtain feedback on problems with their groups and ask for direct observation. Further, the consultants facilitated group skills acquisition through various means, including discussion of readings and handouts and role-playing difficult interactions with patients.

The Instruments
A baseline assessment of group climate, therapeutic dynamics, and patient satisfaction with current group offerings was obtained on the target units and the comparison units prior to the introduction of staff skills enhancement. The instruments used to obtain this assessment included the Group Climate Questionnaire (GCQ) (MacKenzie, 1983), the Self-Report of Satisfaction Scale (SSS) (Kochendorfer, 1974), and the Hill Interaction Matrix-G (HIM-G) Hill, 1965).

The GCQ allows those involved in group therapy to express their views regarding their group experience. Three areas of the group therapy experience are tapped by the GCQ: the positive working climate of the group (engagement); anger and rejection expressed in the group (conflict); and personal responsibility for making a meaningful contribution to the group (avoidance). The SSS assesses participants’ satisfaction level, as well as their problems with the group. 

The quality of both patient and therapist interaction was measured by the HIM-G, which provides observer ratings of several dimensions of group process. Eight undergraduate and graduate students participated as HIM-G raters after being trained on videotaped inpatient group therapy sessions.

During the six-month treatment phase, groups on all four units were monitored on a monthly basis using the GCQ, SSS, and HIM-G. Patient outcome was also monitored on a three-month basis with the Severe Outcome Questionnaire (S-OQ) (Lambert & Burlingame, 1995), Youth Outcome Questionnaire (Y-OQ) (Burlingame, Wells, & Lambert, 1996) and the Brief Psychiatric Rating Scale (BPRS) (Overall & Klett, 1983). The S-OQ and Y-OQ are semi-parallel child/adolescent and adult self-report instruments used to track the symptomatic improvement of patients receiving mental health services. The BPRS is designed to assess the severity of psychiatric symptoms. It is administered in an unstructured interview by a qualified rater and was developed to provide a rapid assessment of patient change.

Results
While the target youth unit was considerably less engaged and more avoidant at the beginning of the study when compared to the comparison youth unit, these differences were not present after four to five months of group supervision and training. This suggests that the staff skills enhancement successfully helped the target youth unit to engage in the group process more consistently. Furthermore, the youth on the target unit reported more satisfaction with their groups than the comparison group. Both units demonstrated similar HIM-G results over the course of the study, indicating similar levels of quality within the therapeutic interaction in group therapy. After three months of staff training, outcome measurement revealed no significant difference between the two youth units. However, at the conclusion of the six-month treatment phase, outcome scores on the target youth unit had improved significantly while scores on the comparison youth unit remained static.

Important findings were also obtained on the adult units. Shortly after the initiation of training (one month), the target adult unit experienced an increase in the amount of conflict and avoidant behavior, which fits the pattern predicted by MacKenzie’s developmental theory (MacKenzie, 1997). Groups in the early stages of development are likely to experience avoidant and conflictual behavior. However, differences in conflict and avoidant behavior between the target and control groups were not present after the second month of the study. 
Target adult unit members also became more open to therapeutic types of interactions over the course of the study, as assessed by the HIM-G. The Total Resistance Index (TRI) on the HIM-G is a measure of how open the group is to therapeutic interaction between the members. The adult target unit demonstrated decreasing levels of resistance while the comparison unit demonstrated a more erratic pattern of resistance. 

There were no reliable differences between the two units in their overall satisfaction with the groups being offered (as measured by the SSS). There were also no reliable differences in patient improvement between units as measured by the S-OQ and BPRS. However, the anxiety/depression and thinking disturbance scales on the BPRS and the S-OQ total did provide some evidence for a general pattern of patient improvement that favored the target unit. 

Implications of the Study
Results suggest optimism regarding the overall impact of this training program. Improvement in staff skills and knowledge was paralleled by improved engagement in group and decreased avoidant behavior on the youth unit, improved quality of therapeutic interactions on the adult unit, and improved outcomes on both units, relative to comparison units. These promising results provided the impetus to make staff skills training and outcomes tracking available on a more widespread basis throughout USH. The same six-month treatment program that was available for the target units has been employed on other units. Data collection and analysis remains to be completed for these additional treatment phases.

Follow-up assessment of group process and outcome on the target units indicates some decline in gains achieved during the treatment phase. A busy unit climate is a likely contributor to this decline. When the unit is no longer a target for study, it proves difficult to maintain the same level of commitment and provide the same staff resources necessary to maintain group skills excellence. A solution to this problem has taken the form of appointing unit Group Coordinators. A staff member on each unit has committed to become his or her unit’s Group Coordinator. The Group Coordinators meet on a weekly basis with one of the group experts responsible for the group consult service. The focus of these meetings is the development of group treatment protocols and ways to continually enhance staff skills in group therapy. The group consult service is available to other staff on a limited basis. By shifting the emphasis of the group skills training from outside experts to current members of the USH staff, it is expected that commitment to group skills excellence will become a permanent element of the USH community.

This research was funded by the State Academic Collaborative Committee and the Brigham Young University Comprehensive Clinic.
Jennifer Ellsworth, BS, is affiliated with Brigham Young University, and Matthew Hoag, PhD, is with the Aspen Achievement Academy.

References

Burlinghame, G.M., Paul, S., Fuhriman, A., & Ogles, B.M. (1989). Implementing a time-limited therapy program: Different effects of training and experience. Psychotherapy, 26(3), 303–313.

Coyne, R., Wilson, F., &Ward, D. (1997). Comprehensive Group Working: What It Means and How To Teach It. American Counseling Association, Alexandria, VA.

Fuhriman, A. & Burlingame, G.M. (In press). The Hill Interaction Matriz: Therapy through dialogue. In A.P. Beck & C. Lewis (Eds.) Handbook of group psychotherapy (pp 3–40). New York: Wiley.

MacKenzie, K.R. (1997). Time-Managed Group Psychotherapy: Effective Clinical Applications. Washington, DC: American Psychiatric Press, Inc.

This article was published in the October/November 2000 issue of The Group Circle.