Audit of group-based activities in an inpatient assessment and treatment unit for individuals with...

O R I G I N A L A R T I C L E

Audit of group-based activitiesin an inpatient assessment andtreatment unit for individualswith learning disabilities

Philip Reynolds and Lauren Field Intensive Support Services for Adults with Learning Disabilities,

Vale Assessment and Treatment Unit, Berrywood Hospital, Northampton, NN5 6UD, UK (E-mail: philip.

[email protected])

Accessible summary d A series of stand-alone groups were offered on an assessment and treatment ward

for adults with learning disabilities.

d The group ran for 9 weeks and involved session themes of relaxation, sensory and

physical activities.

d All individuals involved reported to have found the sessions useful and enjoyable.

d All staff involved reported that the sessions were helpful for the participants.

d The sessions helped individuals to improve their mood following the session.

d The sessions provided a practical way of introducing therapeutic activity to the

ward and developing therapeutic relationships.

Summary This audit is intended to investigate the effectiveness of a series of stand-alone

groups delivered on an inpatient unit for individuals with learning disabilities. Our

ward is a specialist assessment and treatment unit that provides brief admissions for

clients with a learning disability, mental health difficulties and/or challenging

behaviour. The aim of the unit is to develop an understanding of the presenting

difficulties, formulate an appropriate intervention plan and implement this with the

aim of successfully discharging the client back into the community following the

shortest possible admission. Group interventions facilitated on the unit were drawn

from a variety of evidence and best practice guidelines relating to specific

interventions for individuals with a learning disability (Adv Psychiatr Treat, 11,

2005, 355) and more general interventions within inpatient settings (Clin Psychol

Forum, 2009, 200). Nine sessions focused on a variety of relaxation, sensory and

physical activity tasks. The objective of the audit is to investigate to what extent these

interventions are perceived as helpful and enjoyable by clients and by staff, to

investigate any positive effect on client’s mood and to determine whether any

particular activities were rated more favourably than others. Additional aims of the

audit are to further understand some of the practical issues related to delivering

group-based interventions in an inpatient environment, to engage ward staff in the

delivery of therapeutic activity and to investigate the use of groups as an effective

way of developing therapeutic relationships.

ª 2012 Blackwell Publishing Ltd, British Journal of Learning Disabilities

British Journal of

Learning DisabilitiesThe Official Journal of the British Institute of Learning Disabilities

Keywords Groups, inpatient, learning disabilities, physical, relaxation, sensory

Introduction

The inpatient environment

The evidence base for provision of therapeutic groups

offered and delivered in acute inpatient environments is

currently limited. Tickle et al. (2009) state that such settings

can often pose potential difficulties and challenges owing to

the rapidly fluctuating populations and the degree of

disturbance of the individuals on the ward. More recently,

however, there has been recognition and positive focus

upon improving access to therapeutic groups available

within the ward setting. Clarke & Wilson (2009) believes

that individuals who access such services are often amongst

those least likely to receive psychological interventions and

that it is often assumed that the outcome of direct contact

and intervention may be limited. Another consideration is

the unpredictability of length of stay and the high proba-

bility that individuals may arrive in a state of crisis often

unable to engage in early therapeutic interventions. It may

also be the case that when an individual becomes more

settled and amenable to treatment, they are relocated or

discharged back into the community (Clarke & Wilson

2009). Furthermore, it is important to consider the poten-

tially complex mixture of individuals within the ward

setting who, at any one time, will inevitably be at different

stages of treatment, recovery and rehabilitation.

Despite these difficulties, it is acknowledged that the

inpatient environment can provide an opportunity for the

facilitation of shared group work. A potential benefit of such

group therapy is that it can remove the sometimes daunting

experience of one to one therapy and may assist in creating

multiple opportunities for action and interaction in a

situation which, as the group develops, is safe and

supportive (Peck et al. 1989). The presence of others within

the group may also provide the opportunity for shared

learning and for individuals to help one another, working

more effectively as a team to complete specific tasks in a

supportive environment. This is particularly important as

clients within an inpatient environment may have limited

opportunities for effective sharing, developing feelings of

acceptance and the practice of interpersonal skills. Yalom

(1983) describes a study that involved qualitative analysis of

former group psychotherapy clients. Results indicated that

more than half of those involved considered mutual support

to be the primary mode of help in group therapy. The

concept of modelling may also be utilised in such a shared

environment and this technique has been found to be

particularly useful for people with learning disabilities who

may experience difficulties in following verbal instructions,

explanations or prompts. Modelling enables the demonstra-

tion of skills and techniques so that individuals may further

understand the actions and sequences involved in specific

tasks. It also helps in the positive reinforcement of pro-social

behaviours and activities.

Taking group work of this nature into consideration,

whilst also acknowledging the aforementioned difficulties

and challenges of the inpatient environment, the idea of

‘stand-alone’ groups was developed. Yalom (1983) identified

important and beneficial functions of stand-alone groups,

such as providing a shared, positive and hopeful experience

that may encourage engagement in future therapeutic work.

Tickle et al. (2009) offered a ‘rolling’ programme of stand-

alone sessions and developed a programme of five-1-h

groups that involved psycho-educational discussion of

topics such as motivation, anxiety, emotions and in later

groups, psychosis. Results of this study reflected that overall,

participants found attending the groups ‘useful’, ‘helpful’

and ‘friendly’. Other beneficial factors included feelings of

cohesiveness, relaxation, decreased isolation and the allevi-

ation of some hospital-related anxiety (Tickle et al. 2009).

Despite such encouraging findings, there remains limited

research into the use of stand-alone groups offered within

inpatient environments.

Learning disabilities

Given the above evidence regarding the inpatient environ-

ment and the nature of the groups being offered, similar

considerations and adaptations must be acknowledged

when working with individuals with a learning disability.

Therapy content may often require tailored modification to

promote a person-centred approach and accommodate

individual differences and intellectual ability. Rigid adher-

ence to established groups, models and guidelines could

potentially exclude individuals with a learning disability

from receiving the appropriate and tailored support they

may require.

Traditional interventions for people with learning disabil-

ities often involve the teaching of appropriate and useful

skills necessary to maximise personal abilities to instil a

sense of confidence and empowerment within the individ-

ual. An example of a tailored program specifically devel-

oped for use with individuals who have a learning disability

is Tacpac (Tactile Approach to Communication). This is a

structured play format that was developed primarily to be

used to assist teachers working with children with special

educational needs. Tacpac combines the sensory use of touch


2 P. Reynolds and L. Field

and music to heighten awareness and intentional commu-

nication through responses to stimuli. This is particularly

important as, for many individuals with a learning disabil-

ity, touch and responding to touch may be the primary mean

of communication and expression. Tacpac also allows the

opportunity to develop turn taking, socialisation and antic-

ipation skills Murray et al. (2007). Panter (2004) reports that

regular use of Tacpac with clients with a learning disability

can enable professionals to build a greater understanding of

the individuals they are working with. Although it is

difficult to assess the lasting effects of such a stimulating

sensory environment, previous studies have shown that it

can offer ‘enjoyable and valuable experiences’ to the partic-

ipants involved (Ashby et al. 1995).

Another method that has shown to be particularly

beneficial for individuals with a learning disability is

relaxation. This could involve the use of relaxation and

breathing techniques using progressive muscular relaxa-

tion, guided imagery and autogenic relaxation. Studies in

which relaxation techniques have been utilised for individ-

uals with a learning disability have, overall, shown positive

results, particularly when adaptations were made to proce-

dures to incorporate the client’s strengths and needs

(Hegarty & Last 1997). Yuen Fung & Chan (2000) investi-

gated the effectiveness of muscle relaxation in the reduction

of the frequency of aggressive behaviour for individuals

with a learning disability. Results from this study high-

lighted a 14.7% reduction in aggressive behaviour after

muscle relaxation training. Behavioural relaxation training

has also shown to be advantageous physically as well as

psychologically, for example in the reduction of chronic

headaches (Michultka et al. 1988) and in the reduction of

hyperventilation and seizures (Kiesel et al. 1989).

Activities involving physical exercise have also shown to

be beneficial for individuals with a learning disability. It is

thought that participation in such activities may enhance

motor control, co-operation and the ability to respond to

verbal instructions (Peck et al. 1989). Landers (2006) exam-

ined six different meta-analyses investigating the relation-

ship between exercise and anxiety and concluded that there

was a small to moderate relationship, highlighting that

exercise can reduce anxiety. Furthermore, Landers (2006)

suggested that exercise is not only related to a relief in the

symptoms of depression and anxiety but that it also appears

to be beneficial in enhancing self-esteem, producing more

restful sleep and helping people to recover more quickly

from psychosocial stressors. Gruber (1986) compared self-

esteem scores in children and found that the positive effect

of physical activity was larger for children with a learning

disability compared to children without a learning

disability.

Combining the aforementioned information, this audit is

intended to investigate the effectiveness of a series of

stand-alone groups delivered on an inpatient unit for

individuals with learning disabilities. The objectives are to

explore to what extent these interventions are perceived as

helpful by clients and by staff, to investigate any positive

effect on client’s mood and to determine whether any

particular activities (physical, relaxation and Tacpac) were

rated as more helpful or useful than others. Additional

aims of the audit are to further understand some of the

practical issues related to delivering group-based interven-

tions in an inpatient environment, to engage ward staff in

the delivery of therapeutic activity and to investigate the

use of groups as an effective way of developing therapeutic

relationships.

Method

The intensive support environment

Hargrave House in Rushden is a five-bedded unit and

admits both male and female individuals with a learning

disability, who are in need of intensive assessment and

treatment. The ward admits both informal clients and those

detained under the Mental Health Act; therefore, the ward

door is routinely locked, although individuals who are not

under section are able to access the community freely.

Inpatient treatment and support is offered and delivered to

clients who may be experiencing mental health problems

and/or exhibiting challenging behaviour. The average

length of admission on the unit is approximately 6 months;

however, many admissions are for shorter periods of time.

Through a period of multidisciplinary assessment, the

team seek to assist and support individuals, families and

carers to develop plans for long-term solutions and goals.

Person-centred interventions and assessments are delivered

by members of the team including a psychiatrist, psychol-

ogist, learning disability and mental health nurses, support

workers and limited sessions from an occupational thera-

pist. Intervention plans typically involve the development

of behaviour management guidelines, the review and use of

medication to treat mental health problems or help with

challenging behaviour and the use of adapted psychother-

apy typically based on a cognitive behavioural framework

to treat mental health problems and aid with anger

management.

Whilst staff do offer activities within the ward setting,

these are often on an ad hoc rather than systematic basis and

are not routinely monitored and evaluated for their out-

come. Patients are offered activities on a daily basis such as

opportunities to go into the local town to have a drink or a

meal. They are also offered a range of activities on the ward

or in the hospital grounds such as board games, computer-

based games and physical activity including ball games in

the unit garden. Clients are also supported to be as

independent as possible in their self-care and activities of

daily living. Group-based activities are limited and specific

ª 2012 Blackwell Publishing Ltd, , British Journal of Learning Disabilities

Learning disabilities, sensory, groups, inpatient 3

therapeutic activities such as relaxation and sensory activ-

ities are not a routine part of daily activity. The time needed

to plan more detailed therapeutic activity and the lack of

experience in delivering group-based activities are con-

straining factors on the availability of regular and predict-

able therapeutic activity within the unit.

Hargrave House is part of a wider Intensive Support

Service which includes the inpatient assessment and

treatment unit and a community-based support team.

The aim of the service is to provide intensive assessment

and intervention in the least restrictive environment,

preferably in the client’s home. Members of the commu-

nity Intensive Support Team are able to work with the

client, their family and carers to prevent admission, assist

transition periods, offer specified training to staff teams

and to monitor the client’s well-being and support

through continued therapeutic engagement and observa-

tions.

Structure of the group

The groups were offered over an 11-week period, every

Thursday afternoon and ran for 45 min per session. The

group did not run on two occasions owing to clients

having other appointments and so not being free for the

group. In total, nine sessions were run over the 11-week

period. The groups alternated in their focus each week

between relaxation, Tacpac and physical activities so that

three groups of each were run over the nine sessions. Each

session was facilitated by two members of staff, with a

clinical psychologist, trainee psychologist or an occupa-

tional therapist present for each session. Ward staff were

also encouraged to attend the sessions and become

integrated and involved as active participants, role models

and to eventually lead sessions. This was also carried out

to encourage and empower ward staff to feel confident to

independently offer a variety of activities and sessions on

the ward on a more routine basis.

The relaxation sessions involved progressive muscular

relaxation, guided imagery and autogenic relaxation. These

sessions were delivered from a CD in one session and then

by the facilitator from a script in later sessions. The Tacpac

sessions were pre-prepared multisensory activities includ-

ing music on CD and a variety of sensory items based

around the beach and woodland themes. The physical

activity sessions were planned activities such as the use of

a parachute, a variety of ball games, bean bags and hoops,

and instruction games involving activities such as jumping

and hopping. The members of staff participating in the

sessions were actively involved as role models in all the

sessions and there were no passive observers.

Owing to the nature of inpatient assessment and treat-

ment units, the sessions were kept as open groups and

offered to all clients who were resident on the unit at the

time the sessions were running. The content of each session

was also intended to be stand alone with no requirement to

have attended previous sessions or commitment or obliga-

tion to attend future sessions.

Participants

As the sessions were of a stand-alone nature, data were

collected from each participant for each session attended,

giving 24 sets of data in total. All participants were male,

representing the cohort of patients admitted at that time.

Participants ranged from 19 to 67 years of age. Full

evaluation measures were missing for three of the sets of

data so that data have been excluded from the evalua-

tion.

Individual support was offered to all participants taking

part in the sessions and this also included assistance

when completing the easy read evaluation forms. Further

assistance and communication support was also offered to

one of the participants who had a hearing impairment. At

the beginning of each session, all participants were aware

that they could withdraw from the activity at any time

should they wish to do so and that they were under no

obligation to attend future sessions if this was their

choice.

Data collection

The audit was approved by the local Clinical Effectiveness

and Audit Department. All data collected were routine

clinical data looking at group effectiveness and have been

anonymised for the purpose of audit. The audit was open to

all clients on the inpatient unit and so promotes an equality

of opportunity. If the groups are found to be of benefit, they

will also be included in routine practice on the unit, and so

will further improve therapeutic opportunities and

engagement.

Evaluation forms for clients were used at the beginning

and end of each session and looked at client’s perceptions of

how helpful and how enjoyable the group was, and their

self-rated mood pre- and post-group and included open-

ended comments about the group. Clients were supported

to rate the helpfulness of the group using a visual rating

scale and to rate their mood pre- and post-group using

emotion faces (happy, sad, angry and worried) and a visual

rating scale.

Evaluation forms were also completed by staff to give an

external rating of mood pre- and post-group and of how

helpful and enjoyable the clients appeared to find the group.

All staff attending the group were also invited to comment

on the group at the end using feedback sheets. It is hoped

that information taken from these feedback sheets will help

to positively inform future groups and offer potential

recommendations for future practice.



Results

Overall feedback from the evaluation forms was positive

and suggested that 100% of the clients reported to have

found the sessions helpful and 100% of clients reported to

have enjoyed the sessions. Furthermore, 85% of clients rated

themselves as happy before the sessions and 95% rated

themselves as happy after the sessions (Figs 1 and 2); (Table 1).

This reflects an overall improvement in mood. Clients

reported that they liked the group activities, particularly the

music and games and another client wrote ‘I really enjoyed

myself’ on their evaluation form.

Overall, 95% of staff reported that they believed

the clients found the sessions helpful and 95% believed

that the clients found the sessions enjoyable. Staff rated 81%

of the clients as happy before the sessions and 100% of the

clients as happy after the sessions (Figs 3 and 4); (Table 2).

The group that clients reported to have found most useful

was the physical activity session with 71% of clients having

rated that they found the group to be ‘a lot’ useful (the

highest point on the scale). Similarly, the group that clients

reported to have enjoyed the most was the physical activity

session with 57% of clients having rated that they enjoyed

the sessions ‘a lot’.

Qualitative outcome includes the observation that clients

would often decline the sessions initially but would then join

the group as the session progressed, thus suggesting that the

group set-up and use of role modelling had a positive impact

on increasing engagement in therapeutic activity. Whilst the

physical activity sessions were rated most positively, it

should be noted that the relaxation sessions aimed to teach a

specific skill and relaxation often became a part of the client’s

management strategies suggesting some generalisation

beyond the group sessions. Clients who had been reluctant

to engage in individual sessions often engaged in individual

work following the group sessions, suggesting that it also

provided a vehicle in which to develop a therapeutic

relationship.

Conclusions and implications

This audit intended to investigate the effectiveness of a

series of stand-alone groups delivered on an inpatient unit

for individuals with learning disabilities. The objective was

to investigate to what extent these interventions were

perceived as helpful by clients and by staff, any positive

effect on the clients mood and to determine whether any

particular activities were rated more favourably than others.

Additional aims of the audit were to further understand

some of the practical issues related to delivering group-

based interventions in an inpatient environment, to engage

ward staff in the delivery of therapeutic activity and to

investigate the use of groups as an effective way of

developing therapeutic relationships.

The delivery of stand-alone groups with a variety of

content was found to be achievable and can provide a

positive addition within a learning disability assessment

and treatment unit. The addition of the therapeutic groups

added a reliable and predictable source of therapeutic

activity; the study showed that it was possible to plan,

organise and deliver a therapeutic activity even within an

inpatient environment where clients changed and the ward

environment could be unpredictable. As expected before the

Table 1 Client’s overall self-rated mood – pre- and post-group

Rating Percentage

Before Happy 85

Worried 5

Sad 5

Angry 5

After Happy 95

Sad 5

85%

5%

5%5%

Happy

Worried

Sad

Angry

Figure 1 Client’s self-rated mood – overall pre-group rating.

95%

5%

Happy

Worried

Sad

Angry

Figure 2 Client’s self-rated mood – overall post-group rating.



groups, the membership of the group varied each week and,

as such, the stand-alone nature of the groups was essential

in this environment.

The use of routine outcome measurement was also found

to be possible, as part of the group process and modifica-

tions to the measure used are suggested below. The groups

were well received by clients and staff on the unit. All

participants reported to have found the groups enjoyable

and useful. Furthermore, both the clients and staff involved

reported an improvement in mood, or the maintenance of a

positive mood, following the session. This would suggest

that activities were found to be useful and helpful. The

ward staff were also given an experience of being involved

in group-based activities and the study demonstrated that

these planned activities were possible. Many members of

staff were involved in the groups and gained experience of

co-facilitating, and on two occasions, facilitating a group

under supervision.

The group sessions also demonstrated their use as an

effective vehicle to develop therapeutic relationships with

clients. As highlighted by Yalom (1983) and Peck, Killen &

Baumgart (1989), there are additional benefits to group-

based intervention. Qualitative findings from the groups

suggested that clients would often engage in activities

which were taking place and then rate them positively

even when they had initially declined the session. This is

likely to be linked to the predictability and reliability of the

session as apposed to ad hoc sessions and also to factors

such as modelling by staff who took the role of active

group members and then the modelling of other clients

who became involved in the activities. Clients who

engaged in the group sessions often went on to engage

in individual sessions with ward therapy staff such as the

clinical psychologist and occupational therapist when they

had initially been reluctant to engage. The factors and

processes involved in this could be further investigated

through research to establish optimum ways of engaging

with clients with a learning disability.

It should be noted that self-report in clients with a

learning disability is noted to be problematic but that

studies have shown that accurate self-report is possible if

consideration is given to a variety of factors (Kroese 1998).

These factors include making scales visual, which was

addressed in this study, making sure the questions are not

abstract, which is why the questions were kept simple in

this study and included emotion pictures, and it is also

important to make sure that you check the responses given

so that you can be confident that they are an accurate

reflection of the clients thoughts or emotions, again this

was considered within this study. Upon reflection, how-

ever, it was noted that the rating of emotions used in the

group evaluation forms lacked a neutral emotion and this

may have had an impact on the sensitivity of the measure

to changes in emotion, as clients were only able to pick a

happy face if they did not want to pick a negative emotion,

this may have meant that clients picked a happy face

because they were not experiencing a negative emotion but

they may not have been happy. Future groups will include

a neutral emotion as part of the measure in an attempt to

increase sensitivity of the assessment tool and give the

option of a non-negative emotion which is not just happy.

As mentioned previously, there was little structured

activity on the ward so there was limited opportunity to

compare these sessions with other activities at this time.

Sessions and activities that were available on the ward were

81%

9%

5%5%

Happy

Worried

Sad

Angry

Figure 3 Staff’s rating of client mood – overall pre-group rating.

100%

Happy

Worried

Sad

Angry

Figure 4 Staff’s rating of client mood – overall post-group rating.

Table 2 Staff’s overall rating of client mood – pre- and post-group

Rating Percentage

Before Happy 81

Worried 9

Sad 5

Angry 5

After Happy 100



often ad hoc in nature and were not regularly run on the

ward on a systematic basis. Examples of such ad hoc sessions

include self-care, board games, community access and

painting. However, any ad hoc groups or independent

activities that did occur on the ward were not routinely

monitored or evaluated in their outcome. Although this

particular research audit was not evaluated against other

groups, alternative activities or independent tasks at this

time, this presents a possible avenue of exploration for

future audits and research into this area that could further

explore other activities such as those generally available on

the ward and to no activity.

A further acknowledgement is that this audit was

somewhat limited as it had a small sample size and

participants were predominantly male. It is intended to

continue to offer stand-alone groups and to develop larger

data sets so that the results may prove more reliable and

valid. It is expected that more female participants will come

through the service so that their experience within these

groups can also be audited.

Further content for the groups is being considered whilst

maintaining a stand-alone model. Potential session content

could include groups focused on elements of well-being,

goal setting, social skills, understanding emotions, commu-

nication or elements of cognitive therapy as well as

continuing with the content used within this audit.

The implications for future practice are wide and the

positive benefits are already starting to be felt on the unit.

The sessions undertaken as part of this study gave a clear

message that it is possible to provide reliable and

predictable therapeutic activity even within an inpatient

assessment and treatment setting. Ward staff gained

experience and confidence in facilitating group work

and the content of the activities has been made available

to ward staff resulting in more therapeutic activity within

the ward. A much wider variety of planned activities are

now available on the ward drawing on the positive

outcome of this study and using increased input from

both occupational therapy and speech and language

therapy. Routine outcome measurement is now a feature

of these sessions and is used to evaluate new interven-

tions; physical activity is also used as a warm-up for our

weekly relaxation sessions owing to its positive rating in

this study.

Given the relative lack of research into this area, it is

hoped that other inpatient units that offer services to people

with a learning disability will explore and share their

experiences of offering therapeutic input. It appears that

there is a great opportunity to improve the therapeutic

experience of people with a learning disability who find

themselves within an inpatient unit and that stand-alone

groups may offer a positive way of increasing therapeutic

activity, mood and engagement.

Acknowledgements

We would like to thank all the clients who participated in

our groups, our colleagues from Hargrave House Assess-

ment and Treatment Unit (now Vale ATU), Faizia Pask

(Trainee Clinical Psychologist) and Lisa Dunkely (Occupa-

tional Therapist) who provided much of the input for the

sessions and helped develop the outcome measures.

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