1

Chapter 1: Introduction to the Study

Treatment modalities used with psychiatric patients are changing in the United

States, especially for psychotherapy groups in inpatient acute psychiatric units (Deering,

2014; Emond & Rasmussen, 2012; Evlat et al., 2021; Frazier et al., 2016; Mendelberg,

2018; Sabes-Figuera et al., 2016; Wood et al., 2019). Current practices for inpatient care

emphasize implementing cost-effective and evidence-based group (EBG) treatment

modalities and short hospital stays (Baumgardt et al., 2021; Bledin et al., 2016;

Burlingame & Jensen, 2017; Crowe et al., 2016; Van Veen et al., 2015). Furthermore,

there are legal mandates by governmental authorities to use evidence-based treatments in

acute inpatient settings (Evlat et al., 2021; Frazier et al., 2016; Moore et al., 2019;

Restek-Petrović et al., 2014; Unhjem et al., 2018; Wiemeyer, 2019).

However, despite the shift in expectations for clinical group sessions provided in

inpatient psychiatric units, there has been a dearth of research in the past 10 years on

group therapies for psychiatric patients in acute settings (Bendig et al., 2021; Bledin et

al., 2016; Cook et al., 2014; Deering, 2014; Emond & Rasmussen, 2012; Frazier et al.,

2016; Mendelberg, 2018; Sanchez Morales et al., 2018; Restek-Petrović et al., 2014;

Sousa et al., 2020; Vigo, 2021). Although group treatment is considered helpful (Deering,

2014; Evlat et al., 2021), the practitioner responsible for delivering therapy in an acute

inpatient setting is also at a loss regarding the selection of relevant scientifically studied

treatment modalities for this population and environment (Mendelberg, 2018; Sousa et

al., 2020).
 2

The purpose of the current study was to explore, capture, and describe the lived

experiences of hospital staff who have facilitated Yalom focus group therapy for acute

psychiatric patients in inpatient hospital settings. Yalom (1983) described a model for a

lower level therapy group for acute psychiatric patients, namely the focus group. The

Yalom focus group is a structured approach to group psychotherapy designed to help

patients admitted to psychiatric hospitals reconstitute from psychotic and severely

regressing ego states. The main objectives of Yalom focus groups are to provide a safe

and trusting environment for group participants to begin to work on improving

concentration, to model active listening, to increase patients’ awareness of interpersonal

strengths and challenges, and to help patients develop appropriate social skills (Yalom,

1983).

The current study involved psychiatric inpatient hospital staff and interns who

conducted group sessions in this setting at least twice. The participants’ experiences of

facilitating the Yalom focus group experience were explored, captured, and described by

conducting a thematic analysis of semistructured interview responses. This analysis

identified meaningful units of participants’ experiences based on their facilitation groups

(see Bledin et al., 2016; Cook et al., 2014).

Qualitative research methods are used to better understand individuals’

experience of a phenomenon (Askew et al., 2019). The current qualitative investigation

aimed to enhance the understanding of staff’s experiences in leading Yalom focus

groups. The social implications of this study include insights into the appropriate
 3

selection of group treatment in inpatient psychiatric units in the future. The study also

serves as a starting point for prospective quantitative research.

Chapter 1 contains information regarding the research problem, nature of the

study, purpose of the study, and research question. The theoretical framework,

definitions, assumptions, delimitations, limitations, and significance are also described.

The chapter ends with a summary and an introduction to Chapter 2.

Background

Sanchez Morales et al. (2018) indicated that, as of the time of their writing, there

continued to be a shortage of data discussing, describing, and assessing the quality and

efficacy of therapeutic intervention provided in psychiatric inpatient settings. Mendelberg

(2018) echoed this claim by arguing that it is imperative that scientific research efforts be

employed to assess therapeutic interventions provided in inpatient psychiatric units to

ensure that patients are receiving psychological treatments that are symptom appropriate.

Vigo (2021), supporting society’s recent recognition of the importance of mental health,

suggested it is even more imperative that the therapeutic community begin to invest in

research informing interventions employed as more individuals begin to seek mental

health treatments.

To that end, I sought to explore, capture, and describe the lived experiences of

hospital staff who facilitated or had experience facilitating a Yalom focus group in a

psychiatric inpatient unit. The main objective of this study was to employ qualitative

methodology to gain a deeper understanding of Yalom focus group facilitators’ lived

experiences of conducting the group with inpatient psychiatric patients. Evlat et al.
 4

(2021) posited that adequate training of inpatient staff delivering treatments to patients is

essential to providing effective treatments. The current study was intended to fill a gap in

the field by providing more insight into selecting appropriate group treatment in inpatient

psychiatric units and serving as an inspiration for quantitative analysis in the future.

Problem Statement

Current practice in inpatient care underscores implementing cost-effective and

EBG treatment modalities and short hospital stays (Bledin et al., 2016; Burlingame &

Jensen, 2017; Crowe et al., 2016; Evlat et al., 2021; Frazier et al., 2016; Mendelberg,

2018; Moore, 2019; Van Veen et al., 2015). However, despite the shift in expectations of

clinical group sessions provided in inpatient psychiatric units, the recent literature

contained a dearth of research on group therapies for psychiatric patients in the acute

setting (Bledin et al., 2016; Cook et al., 2014; Deering, 2014; Emond & Rasmussen,

2012; Frazier et al., 2016; Mendelberg, 2018; Sanchez Morales et al., 2018; Restek-

Petrović et al., 2014; Sousa et al., 2020; Vigo, 2021). Although evidence suggested that

group treatment is effective (Deering, 2014, Sanchez Morales et al., 2018; O’Donovan &

O’Mahony, 2009; Visagie et al., 2020; Wood et al., 2019), group facilitators responsible

for conducting sessions in acute inpatient settings have few available resources to guide

them in selecting appropriate group treatment interventions (Evlat et al., 2021;

Mendelberg, 2018; Sousa et al., 2020). The problem to which the current study responded

was the lack of recent literature regarding hospital staff’s lived experiences of facilitating

the Yalom focus group in a psychiatric inpatient unit.

 5

A review of the available literature indicated no studies of the lived experiences

of group facilitators of the Yalom focus group in an inpatient acute psychiatric unit.

Findings from the current study may yield insight into the selection of appropriate group

treatment for hospitalized inpatients patients by understanding staff members’ lived

experiences of facilitating the group. Furthermore, the results may serve as an inspiration

for future quantitative research addressing the identified challenges with the paucity of

literature on the subject (see Bledin et al., 2016; Burlingame & Jensen, 2017; Crowe et

al., 2016; Evlat et al., 2021; Frazier et al., 2016; Mendelberg, 2018; Moore, 2019; Van

Veen et al., 2015).

Purpose of the Study

The purpose of this study was to explore the hospital staff members’ lived

experiences of facilitating the Yalom focus group treatment model with inpatient adults

in psychiatric hospital units. The experiences of staff participants with the focus group

were explored by capturing, describing, and interpreting their facilitation of the group.

This objective was achieved by having participants share their experiences of facilitating

the Yalom focus group and conducting a thematic analysis of participants’ semistructured

interview responses. This analysis identified meaningful units of participants’

experiences of facilitating the group (see Bledin et al., 2016; Cook et al., 2014). The

motive for conducting this study was to provide in-depth and meaningful information

about Yalom focus group facilitators’ perceptions of facilitating the group.

The objective was to gain access to the meaning the group facilitators ascribed to

their lived experiences of guiding and managing the Yalom focus group. A further
 6

objective was to understand group facilitators’ lived experiences of the outcomes of

facilitating the group after two or more group sessions. The outcomes of group therapies

have been the focus of many studies to improve care efficiencies and address challenges

to the quality treatment of patients (Sanchez Morales et al., 2018; Visagie et al., 2020).

The need for the current study was supported by research showing a need for more

literature on the subject of providing treatment for patients in inpatient psychiatric

hospital units (see Espinosa et al., 2015; Harvey & Gumport, 2015; Marmarosh, 2018;

Snyder et al., 2012; Sturgeon et al., 2018).

Furthermore, although group therapy is a well-adopted psychosocial treatment

modality in many acute psychiatric settings, previous researchers focused on patients’

perceptions regarding the impact of the approach (Digby et al., 2020). No recent research

existed regarding staff’s experiences using Yalom focus groups, particularly for shorter

inpatient hospital stays (Palmer Kelly et al., 2020). Wood et al. (2019) described the

clinical necessities of providing group therapies on psychiatric inpatient units specific to

the population by indicating the complexity and uniqueness of presenting symptoms as

well as the current trend of short hospital stays being a hindrance at times in providing

adequate and effective treatments. Additionally, Sanchez Morales et al. (2018) attested to

the limited available literature on inpatient psychiatric group therapy use and

acknowledged the importance of conducting more studies not only to update literature but

also to begin to improve the quality of psychological care on inpatient psychiatric units.

The aim of the current study was to understand psychiatric inpatient group

facilitators’ lived experiences during group facilitation in terms of their perceived

 7

meaning of the group experiences, mainly based on patient interactions. Considering the

recent trend for inpatient psychiatric admission to hospital units to be a shorter stay with

the expectation of more innovative, efficient care, it is essential to identify effective

therapeutic intervention for this population (Kullberg et al., 2018; Sanchez Morales et al.,

2018; Wood et al., 2019). The results of the current study may be helpful in training and

enhancing psychiatric hospital staff’s knowledge of group treatment for inpatient

psychiatric clients, as well as motivating them to consider using the group modality

provided that is designed for that population. This study may also encourage future

quantitative research and inspire modification of the group structure to meet current

treatment standards, given the foundational nature of this research.

Research Question

The purpose of this study was to explore, describe, and interpret the lived

experiences of facilitators who had experienced conducting the Yalom focus group in an

inpatient setting. A phenomenological approach was used to understand the meaning

participants attached to their experiences of conducting the Yalom focus group with acute

inpatient patients. At the time of this study, there was no identified peer-reviewed

evidence available concerning the lived experiences of group facilitators conducting the

Yalom focus group with inpatients in a psychiatric unit. Therefore, the following research

question was developed to explore the lived experiences of participants in this study:

What are the lived experiences of facilitators who conducted the Yalom focus group on

an inpatient psychiatric hospital unit?

 8

Theoretical and Conceptual Framework

A theoretical framework and conceptual framework, according to Kivunja et al.

(2018), are two different but essential frameworks employed for conducting educational

research. A theoretical framework is a formal theory researchers use to explain a

phenomenon or research results. A conceptual framework is the researcher’s identified

plan of action or the lens to approach the problem under study (Grant & Osanloo, 2014;

Kivunja et al., 2018). The theoretical foundation that I used for this research was

existential theory; the conceptual framework was a phenomenological approach.

Theoretical Foundation

Existential theory served as the theoretical framework for this study because it

helped me explain and identify how group facilitators of the Yalom focus group ascribed

meaning to their group facilitation experiences. In addition, existential theory was used to

help frame whether participants felt that the members of the Yalom focus group exhibited

a change in behaviors or cognitive processing as a result of attending the group.

Existential theory is the basis for Yalom focus group because it is rooted in the

assumption that individuals experience emotional or behavioral suffering when they are

unwilling to accept the four main existential givens (Krug, 2009; Rice & Greenberg,

1992; Shannon, 201;). Existential givens are death, freedom, isolation, and

meaninglessness (Shannon, 2019; Spillers, 2007; Wilmshurt, 2019). This theory assumes

that a patient’s awareness and acceptance of one or more of these existential challenges is

a significant and necessary aspect of the recovery process of identified acute psychiatric

symptoms (Fernando, 2007; Krug, 2009). In the current study, staff members’ lived
 9

experiences of conducting the Yalom focus group were investigated based on the theory

that a positive shift in a patient’s awareness of deficits in one or more of the therapeutic

factors is indicative of progress in the recovery process (Krug, 2009; Shannon, 2019;

Wilmshurst, 2019).

This theory aligned with my research for a couple of reasons. The Yalom focus

group was founded based on existential theory philosophy (Yalom, 1983). Additionally,

there was no identified literature regarding the lived experiences of group facilitators of

the Yalom focus group on inpatient psychiatric hospital units. To that end, the current

study was an introductory study. The main objective of this research was to contribute to

the literature on Yalom group therapy, specifically the Yalom focus group, and serve as

motivation for quantitative analysis in the future. According to Wodarski (1983),

existential theory as a qualitative research theory can be valuable to quantitative research

by providing vital information to develop research instruments. Existential theory was

appropriate for my study because it helped me explain and identify the subjective

experiences of group facilitators of the Yalom focus group in an inpatient unit through

their multiple interactions with Yalom focus group participants. I provide more details

about existential theory in Chapter 2.

Conceptual Framework

The conceptual framework to explore and interpret the lived experiences of

Yalom focus group facilitators was phenomenology. Phenomenology is a qualitative

approach that was originated by Husserl (1962/1977, as cited in Finlay, 2014; Neubauer

et al., 2019). Heidegger, a student of Husserl, expanded the methodology, which led to
 10

the concept of an interpretative approach to qualitative research (Converse, 2012;

Peredaryenko & Krauss, 2013). There are various examples of using the

phenomenological framework to understand the lived experiences of wellness and mental

health (Tuohy et al., 2013; Valandra, 2012).

Various studies attested to the dearth of literature regarding the facilitation of

psychological groups in psychiatric inpatient units (Bendig et al., 2021; Bledin et al.,

2016; Cook et al., 2014; Deering, 2014; Emond & Rasmussen, 2012; Frazier et al., 2016;

Mendeberg, 2018; Sanchez Morales et al., 2018; Restek-Petrović et al., 2014; Sousa et

al., 2020; Vigo, 2021). There is also a current trend of governing mental health agencies

mandating the use of scientific therapeutic approaches with acute psychiatric inpatients

despite lower funding for treatments and shorter hospital stays (Sousa et al., 2020; Vigo,

2021). The challenge was that there was limited literature on the use of group therapeutic

intervention as an effective, inexpensive therapeutic instrument for hospital-based acute

psychiatric patients (see Kullberg, 2018; Morant et al., 2021). The phenomenological

methodology is a foundational research approach that explores how individuals

experience different phenomena in terms of their way of perceiving, knowing about, and

having expertise related to a phenomenon (Donalek, 2004; Groenewald, 2004; Holroyd,

2007; Ornek, 2008; Neubauer et al., 2019).

According to Heidegger (1927/1962, as cited in Neubauer et al., 2019; Patton,

2002), phenomenology is used to qualitatively explore different ways research

participants experience, conceptualize, and attach meaning to aspects of the phenomenon

they have experienced. The phenomenological approach allows a researcher to make a

 11

meaningful theoretical contribution by observing an unnamed or identified experience

and providing an identity for it (Edward & Welch, 2011; Groenewald, 2004). A

phenomenological conceptual framework was compatible with the current study because

it provided the opportunity to use an inductive approach to answer the research question:

What are the lived experiences of group facilitators of the Yalom focus group on an

inpatient psychiatric hospital unit? Additionally, phenomenology offered a framework to

understand the lived experiences of Yalom focus group facilitators and the process they

used to describe the meaning of their experiences (see Donalek, 2004; Kwon, 2017;

Ramsook, 2018). Finally, Yalom’s existential theory and phenomenology allowed for the

investigation of the subjective meaning of the participants’ lived experiences as Yalom

focus group facilitators. This framework permitted exploration of how the meaning of an

individual’s experiences was ascribed and interpreted (see Edward & Welch, 2011;

Kwon, 2017).

Nature of the Study

A phenomenological qualitative design was used for the study. This approach was

appropriate to answer the study’s research questions because it allowed for the

exploration and interpretation of the lived experiences of group facilitators of the Yalom

focus group in an inpatient psychiatric unit, including their perceptions, beliefs, and

attitudes (see Finlay, 2014). According to Creswell (2009), phenomenological studies

seek to capture the essence of lived experiences. Qualitative interviewing enabled me to

commence a research process by assuming that Yalom focus group facilitators’

experiences of facilitating the group were meaningful and could be made explicit (see
 12

Ayres, 2007; Donalek, 2004; Neubauer et al., 2019; Redsecker, 2005). A

phenomenological design chiefly concentrates on the essence of a lived experience

(Donalek, 2004; Groenewald, 2004; Holroyd, 2007; Ornek, 2008; Neubauer et al., 2019).

Donalek (2004) postulated that people could attach different meanings to similar

experiences or phenomena.

Nine medical center staff and student interns who had facilitated the Yalom focus

group in a psychiatric hospital unit were recruited. The number of participants was

appropriate because previous qualitative researchers used a similar sample size (see

Ayres, 2007; Gentles et al., 2015). Dworkin (2012) stated that qualitative samples need to

be large enough to obtain feedback on most participants’ perceptions. Five to 10

participants are generally considered acceptable for this type of study (Ayres, 2007).

Dworkin postulated that five to 50 research participants would suffice for qualitative

research, but Al-Busaidi (2008) suggested a no minimum rule to sample size, noting

sometimes it would suffice to have one participant depending on what is being studied.

The sample size is contingent on the object of the study, research participant availability,

time, and funds (Al-Busaidi, 2008).

Purposeful sampling was used for the current study. Purposeful sampling is

compatible with the qualitative research design to obtain information from a population

(Ayres, 2007; Gentles et al., 2015). Purposeful sampling allows for selecting research

participants who are members of a group with knowledge of the phenomenon of interest

(Ayres, 2007; Gentles et al., 2015; Pedreira & Gonzalez. 2019).

 13

Current participants included nine social workers, hospital staff, and student

interns who had conducted the Yalom focus group in an inpatient acute psychiatric unit.

To understand the experiences of recruited participants, I used open-ended interview

questions related to the research question. Each interview was recorded and lasted

approximately 15 to 30 minutes. NVivo was used to study the data collected. NVivo is

software that enables a researcher to sort and arrange gathered information into

meaningful files (Ranney et al., 2015). Coding was used to develop themes that emerged

from the interviews. Information was collected through software, personal notes, and

index cards. The interviews were conducted virtually via Zoom.

Researchers had conducted qualitative research with designs such as narrative,

ethnographic, and grounded theory. However, these approaches were not chosen for the

current study. A narrative design is appropriate for studying the life of a single person to

establish their experiences. An ethnographic design was not appropriate for this study

because of the focus on analyzing and interpreting data from one source. Similarly, the

grounded theory design was inappropriate because my purpose was not to identify a

particular theory. After considering various designs, I selected the phenomenological

approach as the most suitable to answer the research question. This qualitative design

allowed for capturing participants’ observation of group participants’ and patients’

change in or lack of change in behavioral or cognitive presentations based on the Yalom

focus group’s therapeutic factors (see Vagle, 2014).

Definitions

The following terms were used operationally in the study:

 14

Psychiatric hospital: A psychiatric hospital is designed to provide psychiatric

treatment relative to the provision of medication management and other psychotherapy

for individuals who have been deemed a danger to themselves or others (Gambino,

2013). The medical center where the current study participants worked or interned is a

hospital located in New Jersey. The behavioral health department of the hospital has 21

beds in its involuntary inpatient unit and 27 beds in its voluntary inpatient unit.

Psychosocial treatment: Psychosocial treatment entails focusing on individuals in

a social environment and psychological factors concerning their mental and physical

wellness and their ability to function (Kircanski et al., 2018).

Yalom focus group: In the mid-1970s, Yalom designed the focus group model for

treatment during acute psychiatric inpatient extended stay, which was approximately 28

days in the hospital at the time (Restek-Petrović et al., 2014). Groups can be as small as

three or four people, but group therapy sessions often involve eight to 12 individuals,

although more participants can be included. The group typically meets once or twice each

week for 1 to 2 hours (Wiemeyer, 2019). The medical center where current study

participants gained the experience of facilitating the Yalom focus group was similar in

structure; however, given the significantly shorter hospital stays now advocated,

attendance varied between 2 and 7 days. Group size was approximately six to eight

patients.

Assumptions

Creswell (2009) defined assumptions as the culmination of a researcher’s

worldviews, paradigms, and beliefs in a study. Creswell described qualitative studies as

 15

initiating assumptions, world views, and keenness of research problems involving

individuals or people acquainted to social or human issues. Researchers must be

cognizant of their beliefs when conducting their research (Creswell, 2009). As a result, I

made the following assumptions for the current study:

1. The study participants would meet the requirements to participate in the study;

therefore, they would be familiar with critical terms associated with the

investigation.

2. The participants in the study would provide honest responses to the interview

questions.

3. The participants’ option to participate in the interview via a virtual platform

was likely to be more appealing because of the ongoing COVID-19 pandemic.

4. The interview questions would elicit accurate information.

Scope and Delimitations

Delimitations are factors that can be controlled by the researcher (Theofanidis &

Fountouki, 2019). The scope of the current qualitative phenomenological study was

limited to hospital staff, clinicians, interns, and psychiatric inpatient staff who had

conducted the Yalom focus group in an inpatient unit. Individuals who may have

experienced conducting the group outside of a hospital setting were not included. The

study aimed to address the following issues: (a) What are the meanings that Yalom focus

group facilitators with experience of facilitating the group attached to their experiences of

conducting the group? (b) How did group facilitators arrive at the meaning that they

ascribed to their group facilitation experiences?

 16

Limitations

Limitations are factors that may affect the study that the researcher does not

control (Theofanidis & Fountouki, 2019). Qualitative research has limitations that must

be considered and addressed when conducting research (Al-Busaidi, 2008; Nicholls,

2009). Creswell (2009) posited that qualitative research requires credibility and

trustworthiness. Credibility is the truth of the study and the researcher’s diligence in

ensuring that study was processed and interpreted accurately (Polit & Beck, 2006).

Furthermore, the credibility of a study is determined by the recognition of the study by

other individuals who have experienced the phenomenon (Sandelowski, 1986). The

reliability of a study is based on the credibility and trustworthiness of its investigative

process (Polit & Beck, 2006). According to Lincoln and Guba (1985), reliability and

validity are intertwined with dependability in qualitative research. Credibility, reliability,

and transferability are essential ingredients for a qualitative study.

A researcher is responsible for ensuring that their research process is conducted in

a manner that ensures credibility and reliability (Creswell, 2009). To provide credibility,

validity, and reliability for my study, I did the following:

• Given that I was a novice and single researcher, an intercoder was used. The

objective of doing this was to ensure that two coders agreed on the codes used

for this research.

• All collected data were judiciously screened to validate the themes.

• A follow-up interview was conducted with participants to receive feedback on

the findings to ensure that they were accurate.

 17

• As an individual who also conducted Yalom focus groups for approximately

12 months, I used the hermeneutic methodology of reflection to help me to

identify my biases, which I documented as part of my results.

• I used peer debriefing to ensure the accuracy of the study.

The limitations that I encountered were the following:

• Some research participants did not designate a quiet space during the

interview and had limited access to technology and reliable internet servers;

these factors affected the interview quality when using a virtual platform.

• Participants who preferred to interview face-to-face did not want to

participate.

• My study was limited to a small number of hospital staff with experience

conducting the Yalom focus group on a hospital unit. As a result, my research

outcomes cannot be generalized to most inpatient hospital units on a global or

national level.

Qualitative studies also have limitations because results cannot be generalized; however,

patterns among participant responses can be used for further research (Creswell, 2009). A

larger pool of participants was not included in my small qualitative study because it was

meant to inspire more extensive scientific study with a broader range of participants in

the future.

Significance

This qualitative study was intended to add to the body of literature regarding the

understanding of clinicians and other medical staff members’ lived experience of

 18

delivering Yalom focus groups in an in-patient psychiatric hospital unit. In addition, the

results have the potential of inspiring future quantitative research, which may contribute

to or improve the current challenges of limited availability of literature on group therapy

for inpatient psychiatric patients in acute hospital units. Last, the information gathered

may help promote awareness of the Yalom focus group as a potential therapeutic group

for more psychiatric in-patient units across the United States and globally.

Summary

Chapter 1 included an overview of the background, problem statement, purpose

statement, methodology, research question, and limitations of the study. In addition, the

chapter provided theoretical and conceptual framework for the analysis, definitions of

terms, assumptions, the study scope, delimitations and limitations, and a summary. This

topic was selected to address a gap in the literature regarding the dearth of literature

relevant to the provision of group therapy modalities in psychiatric inpatient hospital

units. There was no recent literature identified on the subject. Addressing this gap in the

literature may have implications for practice in the field because it could inspire future

quantitative research to add to the body of literature on the subject. This study could also

bring awareness to using a group therapy that is designed for this population. Chapter 2

includes a review of the literature supporting the investigation of the lived experiences of

staff members’ facilitation of the Yalom focus group Chapter 2 includes the literature

search strategy, theoretical foundation and conceptual framework, and a literature review

to synthesize results related to this research.

 19

Chapter 2: Literature Review

Treatment practices used with psychiatric patients are changing for several

reasons including pressures due to financial and governmental regulations. The treatment

practices affected include inpatient psychiatric patients’ psychotherapy groups (Deering,

2014; Emond & Rasmussen, 2012; Evlat et al., 2021; Sabes-Figuera et al., 2016).

Recently, psychiatric programming has emphasized the application of cost-effective and

EBG treatment modalities (Bledin et al., 2016; Burlingame & Jensen, 2017; Crowe et al.,

2016; Evlat et al., 2021; Mendelberg, 2018; van Veen et al., 2015, Visagie et al., 2020).

Despite the recent shift in expectations of clinical group sessions provided in

inpatient psychiatric units to be effective and manageable, there is minimal research or

literature on the issue, especially group therapies for psychiatric patients admitted to

acute inpatient settings (Cook et al., 2014; Bledin et al., 2016; Burlingame & Jensen,

2017; Deering, 2014; Emond & Rasmussen, 2012; Evlat et al., 2021; Frazier et al., 2016;

Restek-Petrović et al., 2014; Sousa et al., 2020). Although group treatment is considered

helpful (Deering, 2014; Sanchez Morales et al., 2018; True et al., 2017), the practitioners

responsible for delivering treatment in an acute inpatient setting are often without

resources for selecting relevant EBGs or relevant literature on the subject, despite the

evidence that mainly processed group therapies are suitable for this particular population

setting. Curtis et al. (2007) stressed the importance of researching clinical functionality

and therapeutic programming outcomes in inpatient psychiatric units.

To that end, the purpose of the current study was to explore, capture, and describe

the lived experiences of hospital staff who facilitate or had facilitated the Yalom focus
 20

group therapy in an inpatient psychiatric unit as an attempt to contribute to the literature

on the subject. A qualitative study involving thorough exploration of hospital staff’s

perception of their experience of facilitating the Yalom focus group was conducted to add

to the body of knowledge on group therapies designed for inpatient psychiatric hospital

units by allowing research participants to voice their opinions or identify the meaning

that they attached to their experiences of the group they conducted. This chapter provides

the literature search strategies that were used to conduct my literature review, the

theoretical and conceptual lenses that this research was founded on, a review of related

literature that supported the need to investigate the lived experiences of staff facilitation

of the Yalom focus group, a summary.

Literature Search Strategy

The objective of this literature review was to explore and identify research related

to the use of psychotherapy groups in inpatient acute psychiatric units in the United

States and beyond. The literature search strategy focused on peer-reviewed journal

articles retrieved from databases such as Psych INFO, Psych Articles, Psych books, Soc

INDEX with FULL TEXT, American Psychiatric Publishing, Google Scholar, Google,

and ProQuest Central. I also used Yalom’s textbooks on group therapy. Searches

occurred for sources published between 2015 and 2022.

This literature review consists of primary journal articles written within the last 30

years. The literature review was extended to 30 years due to the paucity of recent

research on the subject. The search included these extended publication dates due to the

minimum availability of recent documentation on the topic. Key terms used for this
 21

literature search were psychotherapy group, psychodynamic group therapy, history of

psychotherapy, group therapy, inpatient, group therapy in psychiatric inpatient units,

acute psychiatric inpatient unit, and Yalom’s therapeutic factors. Furthermore, inpatient

units, history of inpatient units, perceptions of the staff of inpatient units, psychiatric

inpatient nurses’ perception, framework for group therapy, phenomenology,

phenomenological methods, qualitative research, phenomenology research, and

existential theory were key terms used.

Theoretical Foundation

Existential Theory

Existential theory evolved out of humanistic psychology originating from Europe

and was presented in the United States in the 1940s (Frokedal et al., 2017; Krug, 2009;

Greenburg & Rice, 1992; Watson & Schneider, 2016). The existential-phenomenological

theory was introduced in the United States by Tillich in 1944 (Shannon, 2019; Watson &

Schneider, 2016). May and Angel were credited for making it relevant in the field of

psychiatry in America (Rice & Greenberg, 1992; Watson & Schneider, 2016). Bugental,

Yalom, and Schneider, who were students of May, are acknowledged as recent leaders

and contributors to existential theory (Rice & Greenberg, 1992; Watson & Schneider,

2016). The existential theory is a client-focused phenomenological theory with four main

approaches: client-centered, experiential, Gestalt, and existential (Rice & Greenberg,

1992; Spiller, 2007; Watson & Schneider, 2016; Wilmshurst, 2021). These four

approaches are similar in that they stress the importance of an individual’s subjective

experiences as a vehicle for self-actualization via the process of self-awareness, self-

 22

determination, and healthy interpersonal relationships (Fernando, 2007; Rice &

Greenberg, 1992; Spillers, 2007; Watson & Schneider, 2016). Existential theory states

that humans are in search of a meaningful existence through consistent work on self-

improvement to achieve this goal (Huguelet, 2014; Shannon, 2019; Winston, 2016).

Existential theory states that human suffering is a result of lack of awareness or

acceptance of four core existential realities: anxiety surrounding death, freedom,

isolation, and meaninglessness (Bates, 2016; Fernando, 2007; Huguleet, 2014; Krug,

2009; Rice & Greenberg, 1992; Shannon, 2019; Spillers, 2007; Watson & Schneider,

2016; Wilmshurst, 2021). Furthermore, all of the human existential approaches share four

main ideologies: the importance of individual subjective experience, the ability for self-

development, autonomy to make a decision that can lead to growth, and the importance

of interpersonal relationships (Fernando, 2007; Rice & Greenberg, 1992; Watson &

Schneider, 2016). The principle that stresses the importance of an individual’s subjective

experiences speaks to the significance of evaluating one’s feelings, value system, and

worldview through reflective processing and using this expertise to effect positive life

changes (Rice & Greenberg, 1992; Watson & Schneider, 2016). The self-development

principle presumes that all humans have the innate desire and ability for self-

improvement through reflective processing. Self-development occurs through the

searching for purpose in life (Rice & Greenberg, 1992; Watson & Schneider, 2016).

The third principle asserts that every individual is biologically programmed to

analyze personal experiences, choices, needs, and desires and use these to make decisions

that can lead to healthy self-development. Thus, through self-awareness of feelings,

 23

wants, needs, and values, one can make a decision that creates meaning and fulfillment in

one’s life (Rice & Greenberg, 1992; Watson & Schneider, 2016). The last principal

focuses on the importance of interpersonal relationships. The idea that everyone is

valuable and deserving of being treated with respect calls for a need for interactions with

patients that are nonjudgmental with unconditional regard and devotion to develop

trustworthy and equal relations as key to positive change (Rice & Greenberg, 1992;

Shannon, 2019; Watson & Schneider, 2016; Wilmshurst, 2021).

The existential theory is founded on the premise that patients’ ability to recognize

and accept the four universal givens can lead to recovery from psychological distress

even through the use of group therapy treatments (Huguelet, 2014). Yalom identified

therapeutic factors to operationalize group participants’ experience of the group. Since

the evolution of group therapy as a treatment modality, researchers have made several

attempts to pinpoint the therapeutic value of group treatment (Bloch et al., 1979). Corsini

and Rosenberg (1955) identified nine therapeutic factors based on their review of

approximately 300 journals on group therapy. To measure or identify how existential

psychology effects change in the client, specifically in a group setting, Yalom followed

up on the work of Corsini and Rosenberg by modifying and adding to their nine

therapeutic factors (Bloch et al., 1979). Through his classic work, Yalom developed 11

well-recognized therapeutic factors that are the therapeutic benefits of group therapy

participation (Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014). The

11 therapeutic factors are altruism, instillation of hope, universality, information

imparting, corrective recapitulation of the primary family group, development of social

 24

techniques, imitative behavior, interpersonal learning, group cohesion, catharsis, and

existential factor (Bledin et al., 2016; Caruso et al. 2013; Restek-Petrovic et al., 2014).

Yalom suggested that the identified 11 therapeutic factors do not co-occur in one

group session but rather at different times in different sessions depending on the different

stages of change in the group’s development over time and the patient’s psychological

state (Behenck et al., 2017; Hastings-Vertino et al., 1996; Restek-Petrovic et al., 2014).

Altruism is the process whereby group participants can shift focus from themselves to

helping other group members gain insight into subjects to which they may be oblivious.

The benefit for the member assisting is the ability to fulfill the human need to assist

others in need, thereby improving their self-esteem, interpersonal coping, and adaptivity

(Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014). The feeling of

hopelessness is a common experience for individuals with chronic mental health

challenges. Installation of hope is a curative factor that recognizes the power of a group

member to observe improvements in other group participants as well as minor

improvement in themselves, and as a result restores hope for the individual (Behenck et

al., 2017; Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014). Yalom

asserted that change occurs in group attendees when they witness others with similar

mental health challenges. This observation shows that the challenges are not exclusive to

them. This therapeutic factor is universality. Furthermore, witnessing others with similar

issues leads participants to experience a decrease in negative mental health symptoms,

generating a feeling of hope and motivation to remain engaged in the therapeutic process
 25

(Behenck et al., 2017; Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al.,

2014).

The next therapeutic factor is impacting information. This process involves the

sharing of treatment information or resources that are useful to the healing process by

group members or the group facilitator. The process of exchanging information creates

connectivity (Behenck et al., 2017; Bledin et al., 2016; Caruso et al., 2013; Restek-

Petrovic et al., 2014). Corrective recapitulation is a therapeutic factor that refers to the

potential for a group participant to consciously or subconsciously identify or ascribe

feelings or relationships (negative or positive) that they may have with group members

and/or group facilitators. The process of assisting the group member in recognizing the

projection on others also has the benefit of the facilitator and/or group members

identifying and assisting the member in correcting the dysfunctional relationship with the

family member via constructive feedback. The feedback alerts group members to the

dysfunctional relationship with the family member and possibly teaches the member

coping skills to correct identified ill family relationships (Behenck et al. 2017; Bledin et

al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014). The next therapeutic factor is

the development of social techniques. Patients admitted to an inpatient psychiatric unit

often exhibit deficiency in social skills (Mahon & Leszcz, 2017). This curative factor

identifies group therapy as a safe and supportive social environment for group

participants to sharpen their social skills.

Exposure to group members is another means of developing meaningful

relationships that can be maintained beyond the hospital unit walls (Behenck et al. 2017;
 26

Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014). Imitative behaviors

as a therapeutic factor are an important source of learning in group therapy. The process

of modeling can be effective. Patients learn innovative strategies to handle difficult

emotions without resorting to dysfunctional coping skills. Facilitators must be highly

cognizant of their vital role in this context; patients typically look to the therapist to

model new behaviors as they experience new situations within the group context.

Learning also occurs when group members imitate other members who effectively

address difficult relational issues. It is useful for a new group member to witness an

ongoing group member confront challenges appropriately, transcending dysfunctional

patterns and establishing new relationships that support change. This process and other

therapeutic factors support self-awareness and transformation (Behenck et al., 2017;

Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014).

Interpersonal learning is a process whereby members learn about relationships

and intimacy. The group environment becomes a space where members feel safe enough

to honestly share intimate emotional challenges and receive constructive feedback from

other group members. Interpersonal learning is enabled by appropriately sharing personal

information (Behenck et al., 2017; Bledin et al., 2016; Caruso et al., 2013; Restek-

Petrovic et al., 2014). Humans naturally long for a sense of belonging. As a result, group

cohesion is sometimes presented as the main therapeutic factor. A cohesive group is

defined as a group in which members feel a sense of belonging, acceptance, and

validation. Having a sense of belonging leads to the feeling that is meaningful and

valuable. The ability to take the risk of self-disclosure typically becomes easier, leading
 27

the patient to being open to feedback and change. (Behenck et al., 2017; Bledin et al.,

2016; Caruso et al., 2013; Restek-Petrovic et al., 2014). Catharsis is the group member’s

experience of relief from psychological challenges through an unconstrained expression

of feelings due to membership in a cohesive group. Release of painful emotions in an

environment where the group facilitator encourages and acknowledges the patient’s

bravery in sharing and also invites group members to give emotional meaning and

support to the member’s emotional release can help patients support and obtain relief

from constant feelings of shame and guilt (Behenck et al., 2017; Bledin et al., 2016;

Caruso et al., 2013; Restek-Petrovic et al., 2014).

Lastly, the existential therapeutic factor occurs when members learn through

group interactions to take responsibility for their decisions and the consequence of a

decision made by them, whether good or bad. The shortness of the group sessions and

treatment experience also contributes to real realization limits. Expression of this

awareness and corroboration from other group members that they are the captains of their

lives leads to a change in perception and behavior (Behenck et al., 2017; Bledin et al.,

2016; Caruso et al., 2013; Restek-Petrovic et al., 2014).

Rationale for the Theoretical Framework

Wood et al. (2019) employed the existential theoretical framework to explore the

necessary protocol for the provision of psychological group therapy in psychiatric

inpatient hospital units from the perspective of the clinician’s services. A qualitative

investigation including the existential theory was used to determine the required

adaptations of providing effective group intervention for the population being studied.
 28

Similarly, my objective was to conduct a study to add to the body of knowledge

regarding Yalom focus group facilitators’ perception of facilitating the group in a

psychiatric inpatient hospital unit. This study focused on the meanings that the

participants attached to their experience with the hope that their perspectives would aid in

gaining an understanding of the advantages and disadvantages of conducting a group

therapy modality that is designed for inpatient psychiatric patients.

The first objective of this study was to add to the body of literature to help address

the reported dearth of literature on the experiences facilitating group therapies in

psychiatric inpatient hospital units (see Deering, 2014; Emond & Rasmussen, 2012; Evlat

et al., 2021; Frazier et al., 2016; Restek-Petrović et al., 2014; Sousa et al., 2020). The

second objective was to inspire future researchers to consider conducting quantitative

research to determine the effectiveness of the Yalom focus group. The third objective was

to provide insights for training future group facilitators on how to conduct a focus group

more efficiently. It has been documented that psychiatric inpatient staff are sometimes at

a loss for appropriate treatment resources and guidance (Wood et al., 2019).

According to Creswell (2009), a theory can explain why behaviors occur. The

existential approach was selected for this current study because it relates to the role that

Yalom group facilitators play in facilitating their groups. The existential theory was

applicable to the analysis of the outcome of this current research project because the

information gathered was new information about the group facilitation experience, which

is typically critical to foundational studies such as this one.

 29

The research question for this study is based on the premises of existential theory,

which states that humans have the capacity to alter maladaptive behaviors and emotional

processing based on their willingness to be cognizant and accepting of the four existential

challenges (see Frokedal, et al, 2017; Krug, 2009; Greenburg & Rice, 1992; Watson &

Schneider, 2016). People’s motivation to identify, acknowledge and accept one or more

of the existential challenges is essential to recovery from psychiatric distress (Rice &

Greenberg, 1992; Shannon, 2019; Spiller, 2007). This current study was structured on

existential theory to help explain and identify how facilitators of the Yalom focus group

experienced the social interaction of conducting the group with inpatient psychiatric

patients. The goal was to use this theory to shed light on how the Yalom focus group

impacted or did not impact patients who attended the group sessions.

Conceptual Framework

Phenomenology is the conceptual framework for this study. Phenomenology was

utilized by Heidegger to gain insight into the lived experiences of many research

participants’ experiences of various phenomena (Neubauer et al., 2019; Ramsook, 2018).

Similarly, phenomenology can also be used to describe, interpret, and understand Yalom

focus group facilitators’ perception of their group facilitation. Phenomenology purports

that people have different ways of experiencing different phenomena (Van Manen, 2014).

Though the experiences of conducting the Yalom focus group could be associated with

various treatment dynamics, this study focused on how and what the group facilitators

experienced while facilitating the group with patients on the hospital unit.
 30

A phenomenology framework is generally used to explore and gain an

understanding of how individuals experience events or occurrences as well as how they

relate to them (Neubauer et al., 2019). More specifically, this framework assists with

understanding group facilitators’ perceived benefits or detriments of utilizing the Yalom

focus group therapy model with inpatient group participants after attending a minimum of

two group sessions. The use of the phenomenology framework requires that the

researcher employ intuition, reduction, and intersubjectivity to understand the meaning of

the event that is being investigated (Kinsella, 2006; Neubauer et al., 2019; Ramsook,

2018). I employed intuition, reduction, and intersubjectivity by seeking to understand

Yalom focus group facilitators’ perceptions of the impact or lack of impact of beneficial

therapeutic factors on patients who participated at least twice while admitted for

psychiatric treatment on the unit.

Literature Review Related to Key Variables and Concepts

Group psychotherapy is the therapeutic process of addressing emotional disorder

symptoms in a group setting with the primary objective of creating awareness and

positive change in social, psychological, interpersonal, and behavioral deficits for

participants (Burlingame & Baldwin, 2011; Burlingame & Jensen, 2017). Historically,

the first documented group therapy was psychoeducational and conducted by a medical

doctor, Pratt, in 1905 for tuberculosis patients. The purpose of Pratt’s group was to

provide education on effective management of tuberculosis to a significant fraction of his

patients in an affordable way (Burlingame & Baldwin, 2011; Kemp, 2010; Razaghi et al.,

2015). After conducting this educational group for several years, Pratt observed some
 31

therapeutic factors among these participants, such as relatedness and optimism for

recovery. As a result, Pratt extended group therapy treatment to patients with

psychosomatic illnesses (Burlingame & Baldwin, 2011; Kemp, 2010). Henceforth, Marsh

(2007) provided educational and inspiring speeches to mental health patients (Kemp,

2010).

Marsh’s (2007) group therapy presentation was distinct from others in using

reading, singing, role-playing, question and answer, and testimonial techniques to engage

group participants (Kemp, 2010). Similar to Pratt, Lazell was a psychotherapist who

provided educational information to psychiatric inpatient clients via a group forum.

Lazell noted the therapeutic benefits of the group sessions, including universality and

hope because of support from peers, and found reduction of some psychiatric symptoms

among the group members (Burlingame & Baldwin, 2011; Kemp, 2010). Although Freud

did not formally use group therapy as an intervention, in 1921 he released a publication

on group psychology and the function of the ego (Kemp, 2010). Approximately fifteen

years later, Lazell emerged with psychotherapy as an instructional instrument for acute

psychiatric patients. Lazell attested to the positive therapeutic effects of group therapy

with patients and having a forum for them to share experiences and gain a sense of

solidarity and hope (Burlingame & Baldwin, 2011). Lazell also indicated that staff

reported a reduction in requests for sleeping aids from patients who participated in group

sessions (Burlingame & Baldwin, 2011; Kemp, 2010).

In 1920, Burrow developed and utilized group analysis with patients who

struggled with symptoms, including irrational thoughts. Early in his career, Burrow
 32

emphasized the importance of social interaction as an essential focus of treatment for

psychotic patients. He was a proponent of group interventions that focus on patients’

experiences of the “here and now” and suggested that psychotic patients typically have

interpersonal skills impairment that contributes to psychological disorders. Burrow

identified the openness of group members, universality, and existential factors as

essential therapeutic interventions for neurotic patients given their poor social skills

(Burlingame & Baldwin, 2011). Overall, Burrow indicated that social skills training is a

unique psychotherapy treatment and imperative in the healing process for patients

diagnosed with psychotic disorders because the format facilitates teachings of appropriate

social and interpersonal skills (Burlingame & Baldwin, 2011; Kemp, 2010). In 1928, Syz

extended Burrow’s school of thought and introduced the concept of existential theory to

address interpersonal dysfunction. Consistent with Burrow, Syz focused on the here and

now interactions in group sessions and how these interactions lead to decreasing

irrational thoughts and increasing self-awareness. Syz’s group process stressed group

members’ shared struggles with poor social and interpersonal skills and how they can

approach change (Burlingame & Baldwin, 2011).

In the 1930s, Moreno formally began using the term “group therapy” and was

credited for developing psychodrama groups (Burlingame & Baldwin, 2011; Gambino,

2013; Kemp, 2010). Building on previous research, Moreno promoted group therapy by

identifying the therapeutic benefits of group interactions, including universality and

interpersonal skills training. In 1943, Slavson extended group therapy to children with

mental health challenges and extolled the benefits of social interactions as a source of
 33

treatment for common social challenges experienced by most mental health patients

(Burlingame & Baldwin, 2011). Consequently, the success of group therapy as a

treatment modality for group organizations emerged in the 1940s. The first group therapy

organization, the American Group Psychotherapy Association, was created in 1942

(Burlingame & Baldwin, 2011; Kemp, 2010).

Group Therapy Acceptance and Recognition

Group therapy gained acceptance in the 1940s when mental health professionals

from various fields began to consistently identify therapeutic benefits (Gambino, 2013).

Before recognition in the 19th century, group therapy was perceived as inferior to

individual therapy. Individual therapy was more respected due to societal perceptions of

individuals as the agent of change (Montgomery, 2002) and the abundance of empirical

backing for individual therapy as an effective treatment model (Burlingame & Baldwin,

2011; Montgomery, 2002). However, more recently as of the time of this writing,

psychotherapy groups have been recognized as an economical and efficient vehicle to

deliver treatment, typically ascribed to individual therapy sessions but for multiple

patients simultaneously. Thus, a psychotherapy group is a form of treatment with unique

benefits for patients (Burlingame & Baldwin, 2011; Gambino, 2013; Kemp, 2010).

Furthermore, acceptance of group therapy has been based on recognizing its

unique benefits and therapeutic factors. The unique therapeutic factors that contributed to

group therapy’s recognition are installation of hope, universality, information imparting,

imitative behavior, altruism, the corrective recapitulation of the primary family group,

socialization skills, and altruism among group participants (Burlingame & Baldwin,
 34

2011; Kemp, 2010). The development of various psychoanalytic groups added a layer to

the therapeutic process instead of individual functioning as a new treatment engagement.

The expansions of competing group therapies, such as humanistic, behavioral, cognitive

impersonal, and Gestalt, were crucial in solidifying group therapy’s acceptance as a

respected form of treatment (Emond & Rasmussen, 2012). The emergence of social-

psychological studies that advanced various group sessions used in non-clinical areas,

such as encounters and focus groups, was also a contributing factor for group therapy

acceptance in the mid-1940s. One of the most influential factors that strengthened group

therapy in mental health practice was the need to meet the demand to provide mental

health services to World War II veterans and the limited federal funding for mental health

services (Kemp, 2010).

History of Inpatient Psychiatric Group Therapy

In this section, I review the history of inpatient psychiatric treatments focusing on

group therapy; specifically, I discuss the relevance of group therapy in current treatment

practices on inpatient psychiatric units. I then review Yalom’s 11 therapeutic factors and

their relevance to the Yalom focus group and inpatient group therapy, past evaluation of

Yalom focus groups, and the importance of investigating hospital staffs’ perspectives of

facilitating the Yalom focus group as a treatment modality on an inpatient psychiatric

hospital unit. Finally, I discuss the purpose and importance of researching staff and

clinician perceptions of group therapy.

 35

History of Psychiatric Treatment

Historically, individuals struggling with mental illness were perceived as “crazy”

in American society; hence, they were relegated to religious leaders to explain behavior

and treatment. In the 18th century, family members addressed mental health issues

privately with assistance from the community. Mentally challenged individuals from low-

income families were sometimes incarcerated or sent to shelters. In 1773, the United

States’s first asylum was created in Virginia (Osborn, 2009). During this period, asylums

or psychiatric institutions were the primary forms of care for chronically mentally ill

patients (Chow & Priebe, 2013; Talbott & Glick, 1986).

In the mid-20th century, however, psychiatric hospitals were commonly used.

From a sociological perspective, Goffman (1961) studied the experiences of psychiatric

patients in federal psychiatric hospitals. The conclusion was that psychiatric patients’

experiences were comparable to those of prison inmates in program structure and patient

treatment (Chow & Priebe, 2013). These findings and the reduced availability of

psychiatric inpatient services versus community-based services, along with legal

mandates requiring effective rehabilitative services and programming on psychiatric

inpatient units, led to increased usage of group-oriented services (Snyder et al., 2012).

Additionally, more extensive use of psychotropic medications contributed to less

institutionalization of chronically mentally disabled patients (Watanabe-Galloway et al.,

2015).
 36

Current Practices in Inpatient Psychiatric Settings

Acute psychiatric units are staffed with nurses, psychiatrists, medical physicians,

case managers (social workers), mental health providers, psychologists, and therapists

(Cromwell & Maier, 2006). Current practices in the inpatient psychiatric unit mandate

evidence-based treatment programs (Snyder et al., 2012). Treatment interactions focus on

adjustment in social interaction, perceptive reasoning, and emotional regulation in

patients (Delaney, 2006). General treatment protocols include assessment and intake of

the patient, diagnosis of mental health challenges, creation and implementation of the

treatment plan, and discharge planning (Talbott & Gick, 1986). Therapeutic interventions

involve using psychotropic medications as a significant component of managing acute

psychiatric patients admitted to an inpatient unit (Chow & Priebe, 2013). The second

most crucial aspect of the treatment modality used in inpatient psychiatric units is various

group therapies (Allen et al., 2017; Emond & Rasmussen, 2012; Kemp, 2010).

Implementing group therapies on an inpatient unit for chronically ill patients aims

to help patients learn coping skills, regulate their emotions, and promote appropriate

social interactions (Burlingame & Jensen, 2017; Connors & Caple, 2005; Emond &

Rasmussen, 2012). Specific objectives of group therapies are divided into five major

categories: curative, therapeutic, ward stability, psychological, and social goals (Emond

& Rasmussen, 2012).

Description of the Yalom Focus Group

The Yalom focus group was founded in 1983 by Irving Yalom, a psychiatrist who

has been credited with significant contribution to the development of group therapeutic
 37

factors, hence his reputation as the father of group therapy (Grandison et al., 2009; Hejk,

2017). One of his popular group therapy models for inpatient psychiatric patients is

namely the focus therapy group (Yalom, 1983). The Yalom focus therapy group is a

specialized and highly structured approach to group psychotherapy to help psychiatric

inpatients admitted on the psychiatric hospital unit to reconstitute from psychotic and

severely regressed ego states (Grandison et al., 2009; Yalom, 1983). The main objective

of the group model is to create an environment for patients that allows for interpersonal

communication among patients themselves and with hospital staff and group facilitators.

The group is also designed to assist group attendees in understanding their mental health

difficulties while admitted to the hospital as well as independent of the hospital unit

(Grandison et al., 2009; Yalom, 1983). The ultimate goal of the group sessions is to

provide a positive and supportive group psychotherapy experience for patients with

serious psychiatric disorders during an acute phase of the illness (Grandison et al., 2009;

Yalom, 1983).

The group is designed to be conducted daily, initially for approximately 75

minutes (the current length of time that the group is facilitated at The Medical Center

where the study participants worked or completed their internship is 30 to 45 minutes).

The recommended number of group participants is six to eight patients (Grandison et al.,

2009; Yalom, 1983). The Medical Center, however, typically accommodates

approximately 12 to 15 patients per group session. The group is typically facilitated by

nurses, internship students, social workers, psychologists, etc.

 38

The recommended treatment goals for group sessions are to provide a safe and

trusting group climate, an experience of success for patients, and the necessary structure

and group climate that ameliorates high states of anxiety. Furthermore, group sessions

seek to improve concentration, active listening, and basic conversation skills as well as

increase awareness of interpersonal strengths and weaknesses. The group is designed also

to provide introductions to group therapy and psychoeducation that will promote

engagement in group treatment in post-discharge settings (Grandison et al., 2009; Yalom,

1983). The criteria for admission for prospective inpatient group participants are the

ability to tolerate 30 to 45 minutes of group treatment; no history of assault, precautions,

or disruption to the group; and responsiveness to redirections (Yalom, 1983).

The focus therapy group typically takes place three to four times a week for 30 to

45 minutes in a designated quiet group room. The group is usually facilitated by two

therapists, with one sitting at each end of the table where group participants are sitting for

the session. The group commences with orientation and preparation of patients (5–10

minutes), which involves gathering patients for the group, introduction of the group

facilitators, explanation of group goals and structure to group participants to help reduce

anxiety or concern about not knowing what to expect from the session. The next process

is a warm-up (5–10 minutes), an ice breaker activity that can include light physical

exercise, therapeutic relaxation, and the introduction of members by tossing a ball to each

other. The person who receives the ball will introduce themselves, briefly comment on

their experience on the unit thus far, state one good and or bad thing that happened over

the past day, and then toss the ball to whomever they would like to hear from next. This
 39

process continues until every group participant gets the opportunity to introduce

themselves. This exercise is followed by the main event of the session, which includes

structured exercises (20–30 minutes). This structured portion involves exercises that

focus on the following key themes: self-disclosure, empathy, here and now interactions,

didactic discussion, personal change, and tension-relieving games. The session is

concluded by summarizing and reviewing the session (5–10 minutes). The process

involves temporal reconstruction of the group, evaluation of the session via solicitation of

feedback from group participants, review of meaningful interaction during the group

session, and then dismissal of the patients (Yalom, 2003).

Significance of Evaluating Staff and Clinician Perceptions

Meltzer et al. (2020) surveyed psychology directors and psychologists engaged as

group therapists in inpatient psychiatric hospitals across the country to obtain their

opinions about the use of EBG (evidence-based guidelines) treatment modalities and

changes they prefer for the group therapy to support applicability and benefits for their

client populations. The staff members also provided information about factors supporting

or obstructing EBG practices in their facilities. The results indicated that although most

of the group therapies in use were evidence-based, they reflected a paucity of EGB

modalities from which to choose. The results also contained information about techniques

to support and ensure the quality of group provision.

Sousa et al. (2020) evaluated therapist-identified intentions in group and

individual treatments. Using Yalom’s (1995) therapeutic factors, these authors theorized

that therapists involved in individual sessions were expected to use intention dimensions
 40

that comprise direct, that is, therapeutic, work and structure intention dimensions with

their patients. Conversely, group therapists were theorized to use intentions reflecting an

indirect focus of work with their patients, that is, interpersonal and safe environment

intentions. The findings showed that therapists are more prone to subscribe to therapeutic

work intentions in individual treatment, while in group therapy, they are more likely to

employ interpersonal and safe atmosphere intentions.

Summary

This chapter comprised a synopsis of the relevant research literature, including

empirical research to justify the appropriateness of existential theory as an appropriate

theoretical framework for this study. The gap in research concerning inpatient group

therapy is the scarcity of current research on staff and facilitators’ perspectives about the

effectiveness of inpatient group therapies conducted by hospital staff members and

recognition of the importance of having this information (see Clapp et al., 2014; Gordon

et al., 2018; Kool et al., 2014; Lothstein, 2014; Meltzer et al., 2020; Morgan et al., 1999;

Sousa et al., 2020).

The objective of this research was to fill the gap in the reported empirical research

concerning the efficacy of interpersonal inpatient group therapy in an acute psychiatric

unit. In addition, it sought to provide an assessment of identified medical hospital centers

staffs’ perceived effectiveness of the Yalom focus group on inpatient wards to support

understanding of the benefits or lack of benefits of group therapies in this setting. The

intention was to inspire quantitative research in the future that may contribute to a
 41

solution for current government and insurance companies’ demands for the provision of

EBG (Espinosa et al., 2015; van Veen et al., 2015).

Chapter 3 is a description of the qualitative design for this study. The design

supports the aim of obtaining staff descriptions of their lived experience while facilitating

Yalom focus groups with acute inpatient psychiatric patients. The chapter contains an

introduction along with details of the research design and rationale for the study, a

description of my role as the researcher and details of the methodology, the rationale for

sampling and research participant selection, and the data collection and analysis plan. I

also discuss the study’s reliability and ethical considerations. Finally, Chapter 3

summarizes the main points and offers an overview of Chapter 4.

 42

Chapter 3: Research Method

The aim of this phenomenological study was to explore the potential benefit or

lack of benefit of the delivery of the Yalom focus group in an inpatient psychiatric unit.

The social implications include providing inspiration for quantitative research in the

future on the subject as well as possibly gaining insights into selection of appropriate

group treatments for acute inpatient psychiatric patients. This chapter includes the study

design; the rationale for the study; the participants, population, and sampling method; the

research question; the role of the researcher; data collection instruments and procedures;

data analysis procedures, reliability, and validity; and ethical considerations. This

qualitative phenomenological study addressed the phenomenon of group facilitation of

the Yalom focus group to increase insight about the group facilitators’ experiences of

facilitating the group. This investigation included virtual interviews with Yalom focus

group facilitators who had experience facilitating the group.

Research Design and Rationale

The selection of an appropriate research design enables a researcher to choose the

right method for a study (Creswell, 2009). I used a qualitative phenomenological design

for the current study. A qualitative method facilitates open-ended explorations of

phenomena, allowing the identification of themes and insights not anticipated by the

researcher, making qualitative methods suitable for understanding a phenomenon’s

characteristics to serve as a framework for future study (Nicholls, 2009; Vagle, 2018).

Researchers use a qualitative design when conducting a human experience study

(Nicholls, 2009; Vagle, 2018). Qualitative approaches also consider the context of a
 43

phenomenon and participants’ perceptions of contextual influences (Ramsook, 2018).

The phenomenological design was chosen for the current study because it provided an

inductive approach that allowed for exploring, analyzing, and understanding how staff

experienced facilitating the Yalom focus group in an inpatient psychiatric unit. This

design allowed me to address the phenomenon that I investigated and to answer my

research question.

In this qualitative study, interview questions were designed to explore the lived

experiences of the participants. The interview questions were designed to focus on the

what, how, and why of the phenomenon being investigated. To ensure objectivity in the

data analyzes process, I took precautions to decrease biases and human error (see Levitt

et al., 2017). To adhere to the phenomenological model, I made sure interview questions

were nonleading, open-ended questions focusing on the participants and encouraging

them to freely expand on their story or experience (see Levitt et al., 2017). Interviews

were conducted through the encrypted virtual system Zoom. This method was employed

for multiple reasons, including the COVID-19 pandemic ongoing at the time of the study

and the need to maintain social distancing as well as the opportunity to take advantage of

recording the conversation (see Cater, 2011). Additionally, the use of a virtual platform in

the qualitative process was convenient for participants who lived far away or were

immobile.

The rationale for this study was the need to explore hospital staff members’ lived

experience of facilitating the Yalom focus group and to capture the story of their

experiences. The qualitative phenomenological design was used because the goal was to
 44

explore individual experiences of the phenomenon in the natural setting. The

phenomenological design was consistent with thematic analysis of participants’

experiences and data from the group sessions (see Ramsook, 2018). A phenomenological

design was consistent with seeking an understanding of participating staff members’

ascribed meaning of their experience of facilitating the Yalom focus group. In

phenomenological research, a researcher uses a design based on the humanities, human

sciences, and arts to describe the meanings of participants’ experiences and elucidate

first-person experiences of phenomena (Donalek, 2004; Kruth, 2015). The results of the

current study may provide helpful information regarding the phenomenon, which may

inspire quantitative research in the future regarding selection of group therapy for acute

psychiatric patients admitted for psychiatric treatment. This research may also serve as an

instrument to inform selection of appropriate group treatments for acute inpatient

psychiatric patients.

Research Question

The research question for this research was developed to investigate the use of the

Yalom focus group as a clinical instrument with acute psychiatric patients. The research

question was developed to explore the lived experiences of Yalom group facilitators:

What are the lived experiences of group facilitators who conducted the Yalom focus

group on an inpatient psychiatric hospital unit?

My Role as Researcher

For this qualitative research, I was the chief researcher who recruited and selected

participants, interviewed participants, gathered all data, and completed the analysis and
 45

interpretation of the data. Researchers have the obligation of disclosing any personal or

professional relationships with study participants as well as any experience or familiarity

with the subject of study (Van Manen, 2014, Vagle, 2014). I worked with some of the

participants as an internship student. I, however, did not have a supervisory or instructor

relationship with any of the potential participants. Therefore, there was no power

relationship to be managed. I was a formal facilitator of the Yalom focus group as an

internship student. According to Fischer (2009), bracketing facilitates researchers’ ability

to disclose a personal interest, investigate personal beliefs or expectations regarding the

study, and evaluate the same while conducting the research.

Reflexivity is essential in decreasing bias as researchers use it to evaluate their

beliefs and attitudes associated with the problem and research questions. I evaluated my

preconceptions systematically and mindfully concerning my personal experiences and

perceptions of having facilitated Yalom focus group for approximately 1 year. I

acknowledged that I had biases regarding my belief that the group format is impactful or

beneficial to group participants. Therefore, I mindfully examined how my biases affected

the data and implemented means to mitigate bias. I used reflexivity and bracketing to

address potential sources of bias in an effort to enhance accuracy in reporting (see Fisher,

2009).

Methodology

Participant Logic Selection

Phenomenological research typically includes one primary data collection source

and people as informants for the phenomenon being studied (Gentles et al., 2015). Also,
 46

one of the differences between quantitative and qualitative research is the sampling

process; that is, quantitative researchers use random sampling versus purposeful

sampling, respectively (Ayres, 2007). Purposeful sampling is used in qualitative research

so that the participants are experts on the phenomenon and research problem; data are

collected from individuals who are intentionally chosen based on aptitude or expertise

useful for the study (Ayres, 2007). In the current study, purposeful sampling was used to

select participants. Participants were required to have experience in facilitating the Yalom

Group at least twice to be qualified to participate in this study. Participants were recruited

by sending invitational letters to current and previous clinicians, student interns, and staff

members who had or were still facilitating the group session in the hospital units.

Sample Size

In a phenomenological study, the sample size is determined by the type of study

being conducted (Palinkas et al., 2015). According to Creswell (2009), a sample of five to

20 participants is sufficient when using a phenomenological design. Furthermore, Morse

(1994) suggested that a sample of six participants is adequate for a phenomenological

investigation. Based on these recommendations, I recruited nine participants in this study.

It is common knowledge among many qualitative researchers that sample size is

subject to the researcher’s judgment. There are no prescribed rules on sample size

(Creswell, 2003). According to Vagle (2014), there is no specific required number of

participants for a phenomenological study. The focus is not on the amount of data

gathered but the richness and depth of the information gathered (Mason, 2010; Tuckett,

2004). The sample size is related to data saturation, which stipulates that enough data
 47

need to be gathered to gain insight into the depth of participants’ lived experiences that

are being investigated (Mason, 2010). Saturation or redundancy is used to describe the

data collection phase when no new information of significance is provided by the data

collected, or there is no new information in situations where the data collection is through

interviewing (Patton, 1999). Van Manen (2014) indicated that the chief objective of a

phenomenological study is to find meanings and lived experiences that do not depend on

data saturation but on capturing detailed descriptions and interpretations of the

phenomenon being investigated. The sample size for the current study was nine

participants. My sample size was small enough that the likelihood of having repetitive

information was low to nonexistent.

Instrumentation

Central to a phenomenological inquiry is the gathering of data via interviews

(Vagle, 2013; Van Manen, 2014). Interviewing is an exchange of views between two

individuals (interviewer and interviewee) regarding a topic in which both have a common

interest or knowledge (Kvale, 2007). Interviewing as a research instrument grants the

interviewer an opportunity to enter into the participants’ lived experience and allows the

interviewee to share their perception of the phenomenon (Vagle, 2013).

Because the current study was conducted during the COVID-19 pandemic, I used

one-on-one semistructured interviews via encrypted virtual platforms as the research

instrument for data collection. This decision was based on safety reasons for myself and

the research participants. The interviews were conducted in a calm and nondistracting

environment; participants were encouraged to select a quiet space to be interviewed (see

 48

Ivey, 2000). The purpose of the interview, the rule of confidentiality, and the estimated

interview time were explained to all participants. Participants were encouraged to provide

their contact information to allow me to contact them after this study was completed for

further inquiry.

I was time conscious by considering the interviewee’s time while allowing for

sufficient time to gather necessary information. No interview took more than 60 minutes.

Each interview was conducted individually. As Moustakas (1994) recommended,

questions were open-ended to allow participants to share their experiences, feelings, and

thoughts freely. The questions were focused on the participants’ lived experiences of

facilitating a Yalom focus group in the hospital unit of an urban medical facility in New

Jersey. Furthermore, I used the following interview guidelines suggested by Creswell

(2009): The researcher must understand the philosophical understanding of the research

participant, data can only be collected from participants who have experienced the

phenomenon being investigated, a phenomenological approach must be used to analyze

the data when the interview is being conducted, and a researcher must use a reduction

method to analyze the data.

Field Notes

Patton (2002) suggested that the use of field notes is essential to ensure efficient

data collection. In the current study, field notes were used to help provide supplemental

data (see Creswell, 2009). Patton cautioned against gathering irrelevant data. To ensure

compliance with this recommendation and to document each participant’s response to the

interview inquiry, I used field notes as a tool. Using field notes also allowed me to
 49

categorize common themes related to the research inquiry (see Patton, 2002). Appropriate

field notes should consist of reflective and descriptive information (Creswell, 2009). I

documented factual information gathered during the interview.

Researcher-Developed Instruments

I developed open-ended questions to aid in obtaining a comprehensive

understanding of Yalom focus group facilitators’ perceptions of their lived experiences of

conducting the group with in-patient psychiatric patients. The questions were developed

based on those used in similar studies. The interview questions for this study are provided

in Appendix A.

Content validity was established by communicating with research participants in

an effort to access and comprehend their perceptions relevant to the research question and

research topic (see Creswell, 2009). Qualitative content analysis indicates patterns,

themes, and categories for a study in which coding becomes the essential analytic process

in qualitative analysis (Patton, 1990). On the other hand, Van Manen (2017) postulated

that phenomenological inquiry is more concerned with the search for an in-depth

understanding of a phenomenon that an individual experienced and not the

instrumentalities and technicalities of the process.

Procedure for Recruitment, Participation, and Data Collection

Data collection began once approval from the Walden University Institutional

Review Board (IRB) was received (approval #52249915). This process was needed to

ensure the ethical responsibility of minimum risk, minimal harm, confidentiality, and fair

treatment of the researcher participants was observed (see Yin, 2014). I conducted all of
 50

the interviews. All participants were required to sign a consent form indicating their legal

permission to participate in this study. I contacted a medical center in New Jersey and

requested volunteers from the current Yalom Group facilitators to participate, which

included student interns and staff.

I used purposeful sampling to recruit nine participants. I interviewed them

virtually via Zoom in a private and quiet conference room to allow for a calm and

distraction-free interview. Participants were recruited through the use of invitations

letters (see Appendix B). I obtained contact information from all selected participants. I

used interviews to collect data for the study. Whiting (2008) defined an interview as a

form of information gathering by asking questions of another person. A semistructured

interview, the most common form of interview, involves preset questions that were asked

in the same order with all participants (Rowley, 2015; Whiting, 2008). In addition,

interviews can support a deep understanding of the interviewees’ lived experiences,

perceptions, and expertise (Rowley, 2012).

I arranged to interview participants at their designated date and time. I allowed a

maximum of 1 hour per interview so participants could communicate their thoughts,

feelings, and beliefs on the topics with ease. The justification for the allotted time for

interviews included that the interviewees should answer without feeling unnecessary

pressure due to time constraints.

Once the participants were selected, I first read the informed consent script and

obtained the participant’s signature on the consent form. Once the form was signed, the

recording of the interview began. At the beginning of the interview, I explained the
 51

purpose of the interview, the rules of confidentiality, and the anticipated length of the

interview. I also explained the theoretical and conceptual framework guiding this

investigation and answered the interviewee’s questions.

I asked a set of open-ended questions (see Appendix A) to each participant. The

interviews were audio-recorded to ensure accurate data transcription and capture all

interviewees’ responses. I took notes during the interviews to facilitate collecting as

much information as possible. Follow-up and clarifying questions were asked as needed

to ensure the participant’s experiences were understood and assumptions about

experiences did not infiltrate the data. This was a necessary part of the process and was

essential to minimize the possibility of bias on my part.

Data Analysis Plan

The primary objective of data analysis is to provide a comprehensive description

of the experiences and perceptions of research participants (Polit & Beck 2006).

Phenomenological research often relies on developing understanding through the

hermeneutic circle. As Grondin (2016) described, researchers examine possible meanings

of presuppositions through the back-and-forth interpretation that allows findings to

emerge. In therapeutic research they give an example of how therapeutic research uses

the circle to find meaning.

A researcher gains an in-depth understanding of a phenomenon by identifying

patterns and themes relating to participants’ experiences in the process of data analysis

(Zhong, 2018). The steps for data analysis include preparation of the data from each of

these three sources, data analysis, triangulation, and the presentation of the data and
 52

results. The first process is preparing interview data, where the audio-recorded interviews

are transcribed using Gee’s transcription key (see Gee, 1999). For this study, the

transcripts included literal statements and offered coding for paralinguistic emphasis as

indicated. Once an interview was transcribed, I checked the transcript against the audio to

determine accuracy and corrected as needed. I imported transcripts into NVivo 12

computer-assisted qualitative data analysis software.

Data preparation is the second major phase where data are exported to an Excel

spreadsheet for analysis. For this study, the spreadsheets were imported into the NVivo

12 software. The analysis and triangulation process were done using Braun and Clarke’s

(2006) six-step, inductive, thematic analysis procedure. An inductive analysis procedure

allowed for the emergence of unanticipated themes and insights and was appropriate for

the exploratory research conducted in this study (see Braun & Clarke, 2006). A thematic

procedure enhanced the trustworthiness of the study findings by allowing common

themes to be identified across all or most participants’ responses, thereby minimizing the

influence of individual participants’ biases or errors in the findings (see Braun & Clarke,

2006).

The six steps included reading the data transcripts several times to gain familiarity

with the data and then coding the data by grouping statements that expressed similar

ideas, perceptions, or experiences and theming the data by grouping codes into a smaller

number of broader categories. I then triangulated data by running an NVivo matrix query

in which all codes and themes were cross tabulated with the three data sources to indicate

commonalities or discrepancies in the themes and codes to which the different data
 53

sources contributed. After that, I reviewed and refined themes by comparing them to the

original data to ensure they accurately represented the patterns in the data. Finally, I

named and defined the themes and presented the results. The presentation stage was the

concluding phase where NVivo outputs, such as the codebook and exported matrix query

results, facilitated the comparison of data across the three data sources.

Issues of Trustworthiness

Reliability and Validity

To ensure the quality of research findings, a researcher establishes a study’s

reliability and validity, the goal of which is to reduce biases (Yin, 2014). Establishing

trustworthiness regarding validity and reliability is crucial in ensuring qualitative research

quality (Ang et al., 2016). Reliability and validity are corresponding concepts consisting

of four criteria: credibility, transferability, dependability, and confirmability. For this

study these criteria were expanded to include authenticity (see Ang et al., 2016). I used

the strategies and techniques in the following discussion to ensure the study’s

trustworthiness.

Credibility

Credibility is based on how viable the study being investigated is (Patton, 1999).

My objective for this current research project was to provide rich descriptions and

interpretations of the information provided by my research participants. Credibility was

achieved in my investigation by ensuring validity. I ensured that I measured what I set

out to measure by understanding hospital staff members’ lived experiences of facilitating

Yalom focus groups with inpatient adults at a medical hospital’s psychiatric unit. To
 54

ensure internal validity I used the following strategies. First, I had my research

participants review my interpretation of the information they provided to ensure that I

captured it accurately, a practice suggested by Creswell (2009). When checking in with

my participants, I also provided them an opportunity to remove any information that they

would not like to have published. Participants were also required to indicate their consent

for release of obtained information by signing a consent form. I reflected on my own

personal experiences, presumptions, understanding, and biases relevant to this

investigation. Finally, I collected data through interviews and field notes, practices

discussed by Creswell (2009).

Transferability

Transferability is the generalizability of study results to other populations (Ang et

al., 2016). I provided a complete description of the population for the study, which

readers could use as guide to understand whether the results of my research could be

generalized to other populations or situations (see Denzin & Lincoln, 1994). I also

ensured that other researchers looking to read my research or conduct research on the

lived experiences of group facilitators of the Yalom focus group were able to fully

comprehend the results of my study.

Dependability

The goal of achieving dependability, which is analogous to reliability, is to

minimize errors and biases (Yin, 2014). Dependability speaks to how consistently other

researchers are able to use the same research process that I used and arrive at comparable

findings. Therefore, I maintained an audit trail or inquiry audit as a strategy to enhance

 55

the reliability, credibility, external validity, and confirmability of this study, as suggested

by Ang et al. (2016). I also worked with my chair and committee members to make sure

that the results of this study reflect Yalom focus group facilitators’ perspectives rather

than my perspective.

Confirmability

Confirmability speaks to the researcher’s personal biases, experiences, and

training that may influence the phenomenon being studied (Patton, 1990). As previously

stated, I acknowledged that I facilitated the Yalom focus group for approximately six

months during my internship at a medical center in New Jersey. To ensure objectivity, I

used three techniques. I provided research participants with information about the focus

of my study, my position as a researcher, and how I collected data (see Creswell, 2009). I

also guaranteed that my data collection and data analysis process provided a detailed

depiction of what is being investigated and conducted a final audit at the end of my study

to ensure that my research was done appropriately (Patton, 2002). In addition, my study

was supervised by an experienced qualitative methodologist. Reliability via repetition of

this study will also help with ensuring confirmability. According to Lincoln and Guba

(1985), confirmability is created when transferability, dependability, and credibility are

accomplished.

Ethical Procedures

In the context of international research norms and practices, the 1979 Belmont

Report remains critical. The Belmont Report protocol outlines the basic ethical principles

for researchers to follow when conducting research involving human subjects. The
 56

principles ensure that a researcher meets the participant’s right to privacy and treats

participants with dignity. As required by the Belmont Report, a researcher must ensure

justice through attention to the significance of the study purpose and careful choices in

the research design to generate findings without unduly burdening subjects (National

Commission for the Protection of Human Subjects of Biomedical and Behavioral

Research, 1979). I followed the ethical guidelines of the protocol.

I obtained approval from the Walden University IRB before proceeding with data

collection (approval #52249915). The IRB requires that a study include the protection of

human subjects by following the IRB procedures. Therefore, participation in this study

was entirely voluntary. Participants were asked to read and sign the informed consent

form, the terms of which included their right to withdraw at any time, with or without

giving a reason, without any negative consequences. There were no incentives to

participate in the study other than knowing the results may provide insights to contribute

to future projects to help improve the selection of group intervention on inpatient

psychiatric hospital units. Participants were informed that the risks of participation were

not expected to exceed those associated with participants’ everyday activities, although

there was a possibility that they would feel some vulnerability when discussing the

interview questions.

Participants’ identities were kept confidential. Real names were replaced with

alphanumeric codes in interview transcripts and compiled questionnaire data (e.g., PM1,

PM2). Other potentially identifying information was redacted. Information in archival

data that could be used to identify specific organizations or individuals was also redacted.
 57

Audio-recorded interviews, unredacted questionnaire data, unredacted archival

documents, and a key indicating the alphanumeric code assigned to each participant were

stored on password-protected flash drives to which only I have access. The flash drives

and signed informed consent forms are stored in a locked file cabinet at my workplace.

These materials will be stored for three years and then destroyed.

Summary

This chapter outlined the methods for this qualitative phenomenological inquiry.

First, I outlined the phenomenological inquiry approach as a lens for this methodology.

Next, I identified the recruitment, sampling, and data analysis process required for the

study. This research methodology allowed me to study the phenomenological questions

in reference. The objective was to recruit participants for one-on-one interviews that were

used to generate data. The data were coded utilizing qualitative methods to unveil themes

and meanings. Finally, the results were used to answer the research question. Findings

were considered dependable, trustworthy, and credible, because they were returned to

participants for corrections and endorsement. Chapter 4 will discuss the results of this

study in detail with examples from the participant data to justify the themes. Chapter 5

will explain those findings.

 58

Chapter 4: Results

Current practice in inpatient care underscores the need to implement cost-

effective and EBG treatment modalities and short hospital stays (Bledin et al., 2016; E.

M. Burlingame & Jensen, 2017; Crowe et al., 2016; Evlat et al., 2021; Frazier et al.,

2016; Mendelberg, 2018; Moore, 2019; Van Veen et al., 2015). However, despite the

shift in expectations for clinical group sessions provided in inpatient psychiatric units, the

recent literature contained a dearth of research on group therapies for psychiatric patients

in the acute setting (Bledin et al., 2016; Cook et al., 2014; Deering, 2014; Emond &

Rasmussen, 2012; Frazier et al., 2016; Mendelberg, 2018; Sanchez Morales et al., 2018;

Restek-Petrović et al., 2014; Sousa et al., 2020; Vigo, 2021). The purpose of the current

study was to explore hospital staff members’ lived experience of facilitating Yalom’s

focus group treatment model with inpatient adults in psychiatric hospital units. The

research question to address this purpose was the following: What are the lived

experiences of group facilitators who conducted the Yalom focus group on an inpatient

psychiatric hospital unit?

A comprehensive analysis of interview data was used to identify themes regarding

participants’ lived experiences. The interviews helped me gain a better understanding of

how Yalom group facilitators experienced running the Yalom focus group with inpatient

hospital patients regarding the perceived beneficial or nonbeneficial effect of the group

experience. This chapter includes a description of the participants, setting, thematic

findings, and data analysis process used. Data collection, data analysis, and evidence of

trustworthiness are also discussed. The chapter ends with a summary.

 59

Setting

The participants for this study were recruited using purposeful selection from staff

and student interns from an inpatient psychiatric unit of a hospital in New Jersey that

conducted Yalom focus groups. Most participants were located in New Jersey, but two

participants were located in New York City. The interviews were conducted virtually in

my home office via the Zoom platform, which allowed for audio recording. I also used

my iPhone 12 to record the interviews as a backup to the Zoom recordings. All

participants chose an environment that was comfortable and convenient for them to

ensure that there were no disruptions or external interference with the collection of data.

All recordings were done in a quiet and private environment. Participation in the study

was voluntary and confidential. I did not have any personal or professional connections

with participants that may have influenced the data collected. The study was IRB

approved in addition to following the guidelines of the Belmont Report (Department of

Health, Education, and Welfare, & National Commission for the Protection of Human

Subjects of Biomedical and Behavioral, 1979). In addition, I received NIH certification

on October 22, 2022.

Demographics

The participants were required to have experience facilitating the Yalom Group at

least twice to be qualified to participate in this study. Participants were recruited by

outreach to current and previous clinicians, student interns, and staff members who had

or were currently facilitating the group session on the target hospital units. Participants

were recruited using invitational letters (see Appendix B) via social media platforms such
 60

as Linkin and Instagram. A total of nine participants participated in semistructured

interviews. To maintain confidentiality of the participants, I used prescribed identifiers as

pseudonyms (e.g., P1, P2). The participants included one man and eight women. The

ages ranged from 40 to 56 years. The duration of participants’ experience in facilitating

the Yalom focus group ranged from 1 to 2 years. Five of the participants were partial-

licensed psychologists, and the other four were masters-level clinicians. All partial-

licensed psychologists were individuals who had completed their externship and were

studying to sit for their state licensing examination to become fully licensed

psychologists. All masters-level clinicians were licensed clinicians. There were no

prospective candidates who were excluded from the study.

Data Collection

Research showed that rapport development is enhanced when emails are

exchanged before conducting an interview with an interviewee (Seitz, 2015). I

established rapport with all participants by ensuring that they felt comfortable with asking

me questions before the interview. I was able to develop a positive rapport during the

screening process. I also spoke to the participants via telephone after confirming that they

were willing to participate in my study after notifying them on social media. I connected

with all participants over the phone and confirmed that they understood the study. I

provided all participants the opportunity to ask me clarifying questions before completing

the consent form. The screening process lasted 15 to 30 minutes, depending on the

questions asked by the participants. There were no prospective participants excluded.

 61

Data were collected through semistructured interviews with nine group facilitators

at the inpatient psychiatric unit of the target hospital. All interviews were conducted

virtually via Zoom. The interviews were recorded using Zoom’s built-in voice-recording

feature. The interviews were not video recorded. Each interview was approximately 15 to

30 minutes, though I allowed a maximum of 1 hour per participant interview so

participants would be able to expand their thoughts, feelings, and beliefs on the topics

with ease. The interviews were short for some of the participants due to having to

respond based on their recollection of their group facilitation experience. Participants

were allowed to determine a convenient time and place to conduct the interview. I was

flexible and tried to interview participants on their designated date and time. Participants

were recruited through the use of invitation letters (see Appendix B) that were sent via

social media platforms such as Linkin and Instagram. No unusual circumstances arose

during data collection that may have impacted the results of this study.

Data Analysis

Qualitative interviewing allows for the researcher to gather and evaluate all

acquired data that are unique about a phenomenon (Silverman, 2016). The nine

participants’ interviews in the current study were transcribed and imported into NVivo.

The data were structured according to the interview questions. I ran a word query to

organize the data into themes. The information was reviewed based on the results of the

word query to identified themes. Data analysis was performed using Braun and Clarke’s

(2006) thematic analysis process. The six steps included reading the data transcripts

several times to gain familiarity with the data; coding the data by grouping statements
 62

that expressed similar ideas, perceptions, or experiences; theming the data by grouping

codes into a smaller number of broader categories; reviewing and refining themes by

comparing them to the original data to ensure they accurately represented the patterns in

the data; and naming and defining the themes in this chapter.

After the initial coding process, I grouped codes into a smaller number of

categories. In this way, I was able to inductively move from coded units to larger

representations of themes. This process was completed by comparing and clustering

smaller coded units. Once I finished coding the transcripts into smaller units, I began

comparing those units to each other to identify patterns or similarities. During this

process, I looked for common themes, ideas, or concepts that emerged across different

coded units. As I noticed patterns, I clustered similar codes together to form preliminary

categories. I also practiced constant comparison throughout this process to refine the

larger themes that began to emerge. Throughout the theme refinement process, I revisited

previously coded data whenever new material was added to a theme. By comparing new

instances with what I had already coded, I was able ensure consistency and refine my

categories and themes further.

A total of 21 initial codes were identified from the interview transcripts of the

nine participants. These initial codes included identifying reality, discussing benefit

related to intent, instilling hope, connecting the topic to personal experience, having a net

positive perception, supporting agency, supporting coping skills, medication

management, being altruistic, reflecting, being self-aware, supporting socialization,

grouping appropriately, determining individual sessions needed, overstimulation, not

 63

being ready to participate, reducing jargon, maintaining confidentiality, discussing

icebreakers, addressing small groups, and discussing group structure. I grouped these

codes into four main themes and two main sub-themes during the final stages of the

coding process. The major themes that emerged from the data included (a) engagement

increased therapeutic benefit, (b) patients benefited from sharing common experiences,

(c) participating increased social skills, and (d) group structure was important. Within the

theme of patients benefited from sharing common experiences was a subtheme related to

instilling hope. Table 1 provides the codes and final themes.

 64

Table 1

Codes and Themes That Emerged During Data Analysis

Theme Contributing code Example quote

Engagement increased Identifying reality, benefit“It’s dependent on the person
therapeutic benefit related to intent, instilling
itself. Sometimes I saw a
hope, connecting topic to positive type of reaction… For
personal experience, net others they are literally in the
positive perception group because they were put
there, their goal was not to get
anything out of it to begin
with.”
Patients benefited from Supporting agency, “They were able to walk away
sharing common supporting coping skills, with benefits that included like
experiences medication management, shared experiences or a
altruism connection with someone.”
Participating increased Reflection, self-awareness, “I would say that with the
social skills supporting socialization patients that were on the unit
experienced positive
interactions as a result of the
group, especially for those
patients that were starting to
demonstrate social skills and
working on communication
skills.”
Group structure was Appropriate groupings, “I think some of the language
important individual session needed, [was confusing for patients].
overstimulating, not ready We were using different
to participate, reduce terminologies it was hard for
jargon, confidentiality, them to grasp.”
icebreakers, small groups,
group structure

The codes identifying reality, discussing benefit related to intent, instilling hope,

connecting the topic to personal experience, and having net positive perception were

grouped to create the theme of engagement increased therapeutic benefit. An example of

this theme is a quote from P1, a female partially licensed psychologist with 9 years of

experience as a therapist: “It’s dependent on the person itself. Sometimes I saw a positive

type of reaction. … For others they are in the group because they were put there; their
 65

goal was not to get anything out of it to begin with.” The theme of patients benefited

from sharing common experiences was a combination of the codes supporting agency,

supporting coping skills, medication management, and being altruistic. An example of

this theme was a statement from P3, a female clinician with 15 years in the field: “They

were able to walk away with benefits that included shared experiences or a connection

with someone.”

The theme of participating increased social skills was a combination of the

reflecting, being self-aware, and supporting socialization codes. An example of this

theme was a statement from P2, a female clinician with 10 years in the field: “I would say

that the patients that were on the unit experienced positive interactions as a result of the

group, especially for those patients that were starting to demonstrate improved social

skills and working on communication skills.” Finally, the theme of group structure was a

combination of the codes grouping appropriately, determining individual session needed,

overstimulation, not being ready to participate, reducing jargon, maintaining

confidentiality, discussing icebreakers, addressing small groups, and discussing group

structure. An example of this theme was a statement from P4, a female clinical director

and clinician with 18 years of experience in the field: “I think some of the language [was

confusing for patients]. We were using different terminologies; it was hard for them to

grasp.”

Although no participants gave responses that directly contradicted other

participants, some discrepant data emerged in the sense that some codes arose in certain

interviews that remained unsubstantiated among other participants. For example, one
 66

participant indicated that the Yalom focus group supported the personal agency of the

participants. However, another participant indicated that the Yalom focus group increased

the coping skills of the participants. Another participant indicated that discussing

medication management in a group setting was more effective than in individual settings.

These discrepant codes were discussed in one interview but did not arise in other

interviews.

Evidence of Trustworthiness

Accuracy in data collection and interpretation from participants is fundamental to

qualitative research (Levitt et al., 2017). To promote credibility in the current study, I

employed several methods to confirm the results. Credibility was achieved by ensuring

that each interview was transcribed. I checked the transcriptions a few times for errors

and returned the transcription to each interviewee for feedback and approval. To bolster

internal validity, I had participants review my interpretation of the information they

provided to check that I captured it accurately (see Creswell, 2009). When checking in

with my participants, I also provided them with an opportunity to remove any

information that they did not want to have published. Participants were also required to

indicate their consent for release of obtained information by signing a consent form. To

minimize bias, I made sure the results of this study were strictly based on the transcribed

interviews used during the coding process. Furthermore, I mindfully asked questions that

were approved for the study; I refrained from acknowledging or not acknowledging

information provided. I also presented the questions curated for this study and asked

open-ended questions when clarification was needed. Lastly, prior to the data collection
 67

phase, I documented my experiences and biases that may have impacted this research. By

listing these beliefs, I was more prepared to combat my preconceived notions and

potential biases during the data collection and analysis phases of this work.

The transferability of this study is restricted due to the small participant sample

and the fact that all participants were student interns who conducted the Yalom focus

group. Moon et al. (2016) showed that using a smaller sample size and atypical

participants (e.g., interns only) limits the transferability of the qualitative findings to

other contexts. Dependability is the process of recording accurate and detailed data to

allow for replication by other researchers. Dependability also requires that information

gathered can be interpreted and shared by other researchers (Ang et al., 2016). To ensure

dependability, I maintained an audit trail or inquiry audit as a strategy (see Ang et al.,

2016). This audit trail was created by using NVivo 12, a qualitative coding software that

allows researchers to code data in a way that leaves a clear audit trail (see Patton, 2002).

According to Lincoln and Guba (1985), confirmability is created when transferability,

dependability, and credibility are accomplished. Confirmability was addressed in the

current study by using the same interview questions for all participants. I also asked the

participants to review their transcriptions to ensure that their responses were accurately

captured.

Results

In this qualitative research study, I asked one research question: What are the

lived experiences of facilitators who conducted the Yalom focus group on an inpatient

psychiatric hospital unit? This research question was used to formulate the seven
 68

interview questions (see Appendix A). All interview questions were used in the same

sequence with all participants. The themes reported in this section were constructed from

the nine participants’ interviews.

Engagement Increased Therapeutic Benefit

The major themes that emerged from the data include the following: Engagement

increased therapeutic benefit, patients and group participants benefited from sharing

common experiences, participating in the Yalom focus group increased social skills, and

group structure was important. All research participants reported that the Yalom focus

group experience was therapeutic for all group attendees. The theme patients and group

participants benefited from sharing common experiences contains a sub-theme, instilling

hope. The group structure was important theme contains the subtheme called group

setting was inappropriate for some participants.

All nine study participants indicated that the Yalom focus group was a positive

experience overall for the majority of group participants. However, five of the study

participants also indicated that the therapeutic benefit from sharing common experiences

theme depended on participants’ willingness to engage in group activities. Group

attendees and patients who intended to get something out of the focus groups did ; patients

who did not expect or intend to get something from the groups experienced less benefit.

P1 explained this what by saying,

So, of course it’s dependent on the person itself. Sometimes I saw a positive type

of reaction because sometimes the person, in terms of them feeling hopeless in

that moment and we discussed that during group they felt as though it was
 69

something that really touched them that they were able to get a better

understanding of whereas though. For others, they are literally in the group

because they were put there; their goal was not to get anything out of it to begin

with. So, they’re a little bit more combative in that sense. So, whether it was

beneficial to them. I wouldn’t say it was because they didn’t intend on trying to

get anything out of the group to begin with.

Like P1, P5, a female clinician with 14 years’ experience in the field, also

reported that patients got more out of the sessions when they actively engaged in the

session. P5 commented,

Well, in my experience, what I observed during my group interventions is number

one, the individuals who had let’s say a higher level of participation, I believe

those were the ones that had the most positive impact. When they noticed that we

were gathering or calling them in order to participate, they willingly attended the

group and stayed for the entire duration of the group.

P9, a male, partially licensed psychologist with 15 years’ experience in the field,

also believed that participation was key for patient benefit. P9 indicated that when

patients did not want to change, they were less likely to find benefit from the therapy

session. P9 described this phenomenon by saying,

The experience was very rewarding. At times the majority of the patients that I

saw were receptive to group therapy. But some of them, they felt forced that they

had to be there, so it wasn’t as rewarding. [When patients say], ‘I’ve seen this

before. Nothing’s wrong with me, it’s everybody else.’ Everything is just the
 70

same old for [those patients], and they didn’t want to make that change. They felt

it was repeating, they were repeating themselves and doing the same thing. They

had a negative therapeutic experience. It just felt like it was the same thing and

nothing’s going to change.

Patients Benefited From Sharing Common Experiences

Eight of the nine participants indicated that patients benefited from sharing

common experiences. This theme suggests that patients benefited from the feelings of

camaraderie that came from speaking with other individuals who had similar common

experiences. P3 described this by saying,

In my experience a lot of group members walked away even after the first one,

including the second one with a positive experience. They were able to walk away

with benefits that included like shared experiences or a connection with someone.

I remember a shared experience that someone had at the group would be maybe

someone building their confidence level up in regard to being able to speak in a

space where there’s multiple people. Someone indicated that they were shy but

when they heard someone else’s story it kind of encouraged them to share their

thoughts, it kind of built confidence and self-esteem in that aspect. So that was

something that was shared after a group experience.

P6, a female, partially licensed psychologist with 18 years’ experience in the

field, also found that patients benefited from sharing comment experiences during the

group. This belief was reinforced when P6 met with patients individually and heard them

describe their experiences. P6 indicated,

 71

So, after groups, I would meet with some of the clients, some of the patients

individually, and they would tell me, some of them felt the group was good for

them. It allowed them to be able to express themselves and talk about things but

also it gave them a sense that they were not the only ones who were experiencing

the things that they may have experienced. When I would meet one-on-one with

the clients, they would talk about how it was good for them to see that they

weren’t alone in what they were experiencing.

P7, a female, partially licensed psychologist with 12 years’ experience in the

field, also found that patients experienced therapeutic benefits by connecting positively

with their peers. P7 reported,

They were able to connect with each other, find very common traits that they had

and then as a result it would kind of like, my impression was that it provided them

a very safe environment for them to allow differences to lower and then be able to

participate and partake more in the group activities. So, I found that that was very

helpful. More often than not, they did describe that they were, you know, feelings

of loneliness, of helplessness and things like that and just being able to identify

those feelings within, in themselves and then also connect how they were feeling

with the feelings of others. I feel like that gave them a more human approach.

A subtheme of the patients benefited from sharing common experiences theme

was instilling hope. This subtheme contained comments from participants about how

patients felt a renewed sense of hope when they shared common experiences with other

patients. Three of the nine participants indicated that patients found new hope in listening
 72

to other people who had overcome the same challenges they were currently experiencing.

Participants indicated that they witnessed patients learn from each other and found

inspiration that they could overcome challenges they had previously thought were

impossible to solve. P8, a female, partially licensed psychologist with 12 years’

experience in the field, described how hope was instilled in patients by saying,

[Patients’] ability to help the other group members like who were just coming in

[was a benefit of the groups]. So, if they’d been there all week or two weeks, the

newer people, I think they were kind of very helpful for installation of hope. [The

more experienced patients would say], ‘Hey, I felt the same way when I got here,

but now I see this, and I learned this.’ And you know, offering up things to help

people who were in the beginning of their struggles. So, I do think that it was

helpful as time went on.

P9 also felt like the key benefit of patients sharing common experiences with each

other was the installation of hope. P9 described this benefit by saying,

[The social aspect] helped like, make the group more therapeutic for everyone

else because they were able to share with one another. They were able to share

their experiences with other patients. So, the other patients benefited from that.

There was this one particular time where these two people knew each other

outside and they were able to share similar experiences. And so, when the other

patients were able to hear that in the group. It gave them a little bit more hope and

say, ‘Hey I can go out and I can do this.’

 73

Participating Increased Social Skills

Five of the nine participants indicated that patients who participated in the focus

groups had improved social skills. According to these participants, patients who were

able to improve their social skills benefited from feeling less isolated and showed a

reduction in symptoms. Participants indicated that many patients did not have ideal social

skills because their symptoms kept them somewhat isolated from other people. The focus

groups provided a safe space to learn healthy interaction techniques. In relation to this

finding, P2 said,

I would say that with the patients that were on the unit, they experienced positive

interactions as a result of the group, especially for those patients that were

switching units and starting to demonstrate social skills and working on

communication skills. I saw the benefit to them because when they came on to the

unit, they were very quiet, they were very internally preoccupied. From the

beginning of them participating in the groups and throughout the weeks, you saw

the definite changes, you saw them getting stabilized on their medication,

improving with their social skills, with their connectedness with their peers on the

unit, with us as facilitators, their communication improved and we could see that

once they went back into the community, that they were going to be successful as

long as they stayed on their medication regimens.

P1 also described how they saw improved social skills in patients after they

participated in the focus groups. P1 indicated,

 74

The development of socializing skills [was a positive factor of the groups]. What

often happens with people with mental health disorders [who] exhibit symptoms,

people often are afraid of them. Especially if they’re violent or aggressive. So, I

believe that speaking. especially developing the socializing techniques, it helps

people to interact with other people whether they’re having an episode or

symptomatic or not, to be able to advocate for themselves. And say like, ‘All right

something I do not feel, something is not right, maybe I’m not taking my

medication.’ Or whatever the piece may be in order to help them and benefit them

in terms of believing some of the symptoms that they may have in the moment.

Like P1 and P2, P7 reported improved social skills in patients who participated in

the focus groups. P7 described this by saying,

[The groups were] very helpful. I liked the fact that it really capitalized on social

skills. So, if there were any deficient social skills just by allowing, if I remember

correctly, I believe we would pass around an object and whoever was holding the

object would be the person who would be speaking at the moment. Establishing

the group rules at the very beginning and communicating that to everyone. I felt

that that was like a very helpful process. Especially since some were not as

socially adept as others. I thought that was very helpful.

Group Structure Was Important

Eight of the nine participants indicated that the structure of the groups was

important to ensuring benefits for participants. Although all participants agreed that the

groups were overall beneficial for participants, most participants also felt that the benefits
 75

could be maximized by following the group structure and ensuring appropriate groupings.

This finding could be supported by several factors. P4, for example, believed that the

groups were more effective when the moderator minimized the amount of jargon they

used during the sessions. P4 said,

I think some of the language [was confusing for patients]. We were using

different terminologies it was hard for them to grasp. It could have been related to

either their mental illness [or] because of their educational level. But we had to

keep reiterating certain points.

Three participants indicated that ensuring small groups was important to making

sure patients felt comfortable and able to speak up. Participants generally felt like under

five patients per group was a good number, though one participant thought a group as

small as three would be ideal. P8 said,

I guess a learning experience was choosing the group members so that you could

have and develop cohesion within the groups. And the size of the groups knowing

how many you should have in a group. I think we found like three to four was like

an ideal number in the space that we had there.

Two participants talked about the need to ensure confidentiality among group

members. These participants indicated that confidentiality should be discussed up front

with patients and the facilitator should set expectations about keeping the information

divulged in the group private. P5 said,

I think that the other factor was confidentiality. Knowing that this information is

very personal and it’s going to be respected, and appreciated, especially if the
 76

group leader asserted that at the beginning. It was very important for the patient to

know. They felt like, ‘Okay, I can trust this group setting. I can grow... Trust the

facilitator,’ because what they say will be respected.

Four participants indicated that the structure of the groups themselves supported

the overall effectiveness. These participants talked about how helpful the manual was in

structuring the groups, and how following the established process down to the icebreaker

games played at the beginning supported the overall effectiveness. P7 said,

I felt like being able to go through the steps of the way that the group therapy was

set up and not missing any was a big factor. It was very helpful because it was

very structured but not scripted. It gave the freedom to change to object to be

something that maybe [the patients] would identify better with. It wasn’t the same

redundant activity. There were many activities with many different focuses, some

on social skills, others on how to maintain effective medication management

strategies, others were identifying feelings, being able to express feelings. So,

there were so many different components that could be provided with the same

model. So, I thought that that was very helpful.

Like P7, P2 felt like the group structure was important to the overall success of

the group. However, P2 indicated that the icebreaker portion of the group was part of the

overall success of the focus groups. P2 said,

I like the icebreakers and just kind of going around the room, giving everybody

the opportunity to introduce themselves and answer whatever the icebreaker

 77

question was. It was a really good experience to see them participating in

whatever the topic was and asking questions or having comments as appropriate.

Although most participants agreed that the group structure could be successful if

conducted in an appropriate manner, seven of the nine participants still believed that there

were some patients that were just not ready for or comfortable in a group environment.

To this effect P6 said,

There’s always the issue of when clients are resistant to [group sessions] because

of their own insecurities, because of being shy. Or on the opposite end of being

shy, you have some clients that can come into the group session and because of

their inflated ego, they want to take over the group session. That can be frustrating

to other participants.

P3 also reported that although the focus groups benefited most patients, some

patients were reluctant to try therapy in a group setting. P3 recalled,

In my experience a lot of group members walked away even after the first session

with a positive experience. They were able to walk away with benefits that

included shared experiences or a connection with someone. In my experience, if

someone didn’t walk away with something positive it was because maybe they

weren’t appropriate for a group. They weren’t engaged, they weren’t

participating, things of that nature.

P5’s experiences related to the group setting were similar to that of P3 and P6.

Although P5 found that many patients positively benefited from the focus groups, others

did not want to participate and therefore received little therapeutic benefit. P5 reported,
 78

For the most part I want to say that those who were not necessarily completely

regulated, or medication was not doing the effect that we expect, those were some

of the clients that didn’t want to participate or the ones who started participating

and then they ended up leaving the group. So, for the most part once they realize

the value of the group and the setting, it is a way more positive than negative

experience. With the exception of those who were, let’s say dysregulated because

of a remission or things like that (those were not necessarily so much invested in

the process), I think that once they were more stable, thanks to medication, that

participation was a positive experience.

Thematic Summary

I performed data analysis using Braun and Clarke’s (2006) thematic analysis

process to answer the research question in this study. I collected data from the nine

participants via Zoom. I ensured trustworthiness by bolstering credibility, transferability,

dependability, and confirmability.

A total of 21 initial codes were identified from the interview transcripts of the

nine participants. I then grouped these initial codes into four main themes and two main

sub-themes during the final stages of the coding process. The major themes that emerged

from the data included engagement increased therapeutic benefit, patients benefited from

sharing common experiences, participating increased social skills, and group structure

was important. Within the patients benefited from sharing common experiences theme

was a sub-theme related to instilling hope. Within the group structure was important

theme was the subtheme that the group setting was inappropriate for some participants.
 79

Although no participants directly contradicted another participant, some discrepant data

emerged in the sense that some codes arose in certain interviews that remained

unsubstantiated among other participants.

This study found that the focus group were an overall positive experience for the

majority of participants. However, five of the participants also indicated that the benefit

participants experienced from the groups was related to the engagement and willingness

of the patients. Patients who intended to get something out of the focus groups did ;

patients who did not expect or intend to get something from the groups experienced less

benefit. This study also found that patients benefited from the sharing of common

experiences. The data also indicated that patients who participated in the focus groups

had improved social skills. Finally, it was found that the structure of the groups was

important to ensuring benefits for participants. Although all study participants agreed that

the groups were beneficial overall for participants, most participants also felt that the

benefits could be maximized by following the group structure and ensuring appropriate

groupings.

Summary

The purpose of this phenomenological study was to illuminate hospital staff

members’ lived experience of facilitating the Yalom focus group treatment model with

inpatient adults in psychiatric hospital units. A total of nine staff members, one male and

eight females, who participated in this study shared and described their experiences of

facilitating the Yalom focus group on an inpatient psychiatric hospital unit. The research
 80

question and semi-structured interview questions were used to help participants describe

and explore their common experience of facilitating the Yalom focus group.

This study found that the Yalom focus groups were an overall positive experience

for the majority of participants. Although all participants agreed that the groups were

overall beneficial for participants, most participants also felt that the benefits could be

maximized by following the group structure and ensuring appropriate groupings. The

following Chapter 5 will include the introduction, interpretation of the findings of the

study, recommendations, implications and the conclusion of the chapter.

 81

Chapter 5: Discussion, Conclusions, and Recommendations

The lack of current literature regarding hospital staff’s lived experiences of

facilitating the Yalom focus group in a psychiatric inpatient unit prompted the current

study to understand the importance of the Yalom focus group in a psychiatric inpatient

unit. The purpose of this qualitative phenomenological study was to address this gap.

Recent literature contained a scarcity of research on group therapies for psychiatric

patients in the acute setting, despite the shift in expectations of clinical group sessions

provided within inpatient psychiatric units (Deering, 2014; Emond & Rasmussen, 2012).

The current study’s aim was to examine a hospital staff’s lived experiences of facilitating

the Yalom focus group treatment model with psychiatric hospital inpatient adults. I

explored the staff’s perceived experience of the group being beneficial to group

attendants.

A phenomenological qualitative design was used for the study. This approach was

appropriate to answer the research questions because it allowed for exploring and

interpreting the lived experiences of group facilitators of the Yalom focus group in an

inpatient psychiatric unit, including their perceptions, beliefs, and attitudes (see Finlay,

2014). Purposeful sampling was used because it was compatible with the qualitative

research design to obtain information from a population (Ayres, 2007; Gentles et al.,

2015). Experiences of staff participants with the focus group were explored by capturing,

describing, and interpreting their facilitation of the group. The aim of conducting this

study was to provide more in-depth and meaningful information about Yalom focus

group facilitators’ perceptions of facilitating the group. Chapter 5 provides a review of

 82

the previous chapters. The chapter discusses the interpretation of the findings, the

limitations of the findings, recommendations for future research, and the implications for

positive social change. The chapter concludes with a summary of the study.

Interpretations of Findings

Nine participants who were identified as facilitators for the Yalom focus group on

an inpatient unit at an urban psychiatric hospital unit volunteered for the study. All

participants’ direct perceptions and descriptions of their lived experiences were analyzed

to gain insight into the phenomenon being studied. Via the lens of a phenomenological

qualitative method, the aim of conducting this study was to capture the participants’

perception of the effectiveness of group participation to evoke positive behavioral and

psychological changes in group attendees.

Engagement Increased Therapeutic Benefit

Participants indicated that the benefit they experienced or witnessed from the

group participants was related to the engagement and willingness of the group

participants to engage in the group activities. The results suggest that the willingness to

engage in Yalom focus group sessions mindfully can help patients benefit from the

group’s experience. The findings imply that group participants’ benefits may be

contingent on the individuals’ intent and willingness to engage in group activities. The

research question for this study was based on the premises of existential theory, which

states that humans can alter maladaptive behaviors and emotional processing based on

their willingness to be cognizant and accepting of existential challenges (Frokedal et al.,

2017; Greenburg & Rice, 1992; Krug, 2009; Watson & Schneider, 2016). The findings
 83

are consistent with this theory by indicating that participants’ willingness to engage in

Yalom focus group sessions can benefit them in their psychiatric therapy.

The results of the current study have been reported in other studies. For instance,

previous research indicated that acceptance of group therapy has been based on

recognizing its unique benefits and therapeutic factors for patients (Burlingame &

Baldwin, 2011). The unique therapeutic factors that contribute to group therapy’s

recognition are the installation of hope, universality, imparting of information, the

corrective recapitulation of the primary family group, socialization skills, and altruism

among group participants (Burlingame & Baldwin, 2011; Kemp, 2010). Although current

findings revealed that the Yalom focus groups led to increased engagement and

therapeutic benefits, previous studies revealed that one of the most influential factors that

strengthened group therapy in mental health practice was the need to meet the demand to

provide mental health services among patients (Kemp, 2010). The current findings

contribute to the literature by establishing that group therapy being facilitated with

inpatient psychiatric patients is beneficial (see Visagie et al., 2020).

Patients Benefited From Sharing Common Experiences

Most participants indicated that group participants benefited from the group

experience by sharing common experiences. Group attendees benefited from the

solidarity of speaking and sharing their personal and mental health experiences with

others, which led to diminishing feelings of hopelessness.

Results demonstrated that patients benefited from sharing common experiences

because of the idea that this sharing of common experiences instilled hope in patients.
 84

Some participants indicated that group participants found new hope in listening to other

people who had overcome the same challenges they were currently experiencing, thereby

providing hope for overcoming the same challenges as their focus group members.

Research findings indicated that sharing common experiences among patients instilled

hope and inspiration in overcoming challenges they thought impossible. These findings

relate to existential theory, which states that the release of painful emotions in an

environment where the group facilitator encourages and acknowledges the patient’s

bravery in sharing and also invites group members to give emotional meaning and

support to the member’s emotional release can help the patient obtain relief from constant

feelings of shame and guilt, which can instill hope among patients (Behenck et al., 2017;

Tillich, 2014; Yalom, 1983).

The current findings indicated that engaging in the Yalom focus groups provides

hope among patients for overcoming the same challenges as their Yalom focus group

members. The findings concur with Grandison et al. (2009) and Yalom (1983) who

indicated that engaging in Yalom focus group sessions improves concentration, active

listening, and basic conversation skills, and increases awareness of interpersonal

strengths and weaknesses. The group is also designed to provide introductions to group

therapy and psychoeducation that will promote engagement in group treatment in post

discharge settings (Grandison et al., 2009; Yalom, 1983).

Consistent with current study findings, previous research demonstrated that the

unique therapeutic factors contributing to group therapy’s benefits included the

installation of hope, universality, and social skills (Bledin et al., 2016; Hastings-Vertino
 85

et al., 1996). Similar to the current research findings, previous literature revealed that

therapeutic factors, including universality and witnessing other patients with similar

issues, led participants to experience a decrease in negative mental health symptoms,

generating a feeling of hope and motivation to remain engaged in the therapeutic process

(Behenck et al., 2017; Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al.,

2014). Patients sharing various treatment information or resources useful or essential to

the healing process led to enhanced hope and inspiration.

Similar to the current findings, prior research demonstrated that the benefit for the

member assisting the group is the ability to fulfil the inherent human need to assist others,

thereby improving self-esteem, hope, interpersonal coping, and adaptivity to symptoms

among patients (Bledin et al., 2016; Caruso et al., 2013; Restek-Petrovic et al., 2014).

Previous research revealed that feeling hopeless is a common experience for individuals

with chronic mental health challenges (Caruso et al., 2013; Restek-Petrovic et al., 2014).

Installation of hope is a curative factor that recognizes the power of a group member to

observe improvements in other group participants as well as minor improvements in

themselves and, as a result, restore hope for the individual (Behenck et al., 2017; Bledin

et al., 2016; Restek-Petrovic et al., 2014). Current findings add to the literature by

indicating that sharing common experiences among patients instilled hope and inspiration

to Yalom focus group participants to overcome challenges that they thought impossible.

Participating Increased Social Skills

In addition to instilling hope and inspiration among group participants who

learned from their group members, sharing common experiences also increased social
 86

skills among these group participants. Most participants indicated that the focus groups

helped patients improve their social skills through engagement and communication. This

finding was illustrated when participants indicated that patients’ willingness and intent

changed positively after attending focus groups. Existential theory was the basis for

Yalom’s focus group because it is rooted in the assumption that individuals experience

emotional or behavioral suffering when they are unwilling to engage in a focus group

session and are unwilling to accept the existential challenges (Krug, 2009; Rice &

Greenberg, 1992; Shannon, 2019). This theory assumes that a patient’s awareness and

acceptance of one or more of these existential challenges is a significant and necessary

aspect of the recovery process for identified acute psychiatric symptoms, which aligns

with current findings indicating that a patient’s acceptance of focus groups instilled hope,

inspiration, and confidentiality and helped them overcome challenges and develop social

skills (see Fernando, 2007; Krug, 2009).

Current findings confirm previous research, which indicated that group therapy

provides a safe and supportive social environment for group participants to use and

sharpen their social skills (Caruso et al., 2013; Restek-Petrovic et al., 2014). Current

results also confirm previous studies by revealing that exposure to group members is

another means of developing meaningful social relationships that can be maintained

beyond the hospital unit walls (see Behenck et al., 2017; Bledin et al., 2016). The main

objectives of focus groups are to provide a safe and trusting environment for group

participants to begin to work on improving concentration, active listening, awareness of

interpersonal strengths and challenges patients, and appropriate social skills (Yalom,
 87

1983). Current results imply that participating in focus groups led to increased social

skills through interaction and sharing of ideas and common experiences. The study

results align with previous findings demonstrating that learning in focus groups also

occurs when group members imitate other members who address complex relational

issues. It is helpful for a new group member to witness an ongoing group member

confront challenges appropriately, transcending dysfunctional patterns and establishing

new relationships that support change (Bledin et al., 2016). Current findings add to the

previous research by establishing that participating in focus groups led group participants

to increase social skills through interaction and sharing of ideas and common

experiences.

Group Structure Was Important

Participants indicated that the structure of the groups was important to ensuring

group participants’ benefits. Although all participants agreed that the groups were

beneficial for group participants, most participants also felt that the benefits could be

maximized by following the group structure and ensuring appropriate groupings. The

results indicated that the focus groups were more effective when the moderator

minimized the jargon they used during the sessions. The implication is that a well-

structured group becomes beneficial to group participants. Existential theory was used in

this study to investigate the perceived benefits of group participants’ participation in the

Yalom focus group. The implication is that research findings contribute to the theory by

identifying the benefits of willingly engaging in focus groups for the patient’s health

outcomes because group structure provides patients with needed hope and inspiration to
 88

overcome existential challenges. This participation results in improved social skills

through interaction and sharing of ideas and common experiences.

Earlier research findings indicated that focus groups may be helpful in training

and enhancing psychiatric hospital staff’s knowledge of group treatment for inpatient

psychiatric clients, as well as motivating them to consider using the group structure

provided (Sanchez Morales et al., 2018; Wood et al., 2019). Similar to current findings,

which indicated that group structure is important for participants, the Yalom focus group

is a specialized and highly structured approach to group psychotherapy to help

psychiatric inpatients admitted to the psychiatric hospital unit to recover from psychotic

and severely regressed ego states, which may benefit them in the long term (Grandison et

al., 2009; Yalom, 1983). The main objective of the Yalom focus group model is to create

an environment for patients that allows for interpersonal communication between patients

and hospital staff and group facilitators through the sharing of common experiences.

Although few participants discussed the need to ensure confidentiality among

group members, they indicated that confidentiality should be discussed up front among

the patients. In addition, the focus group facilitator should set expectations about keeping

the information divulged in the group private. Similarly, Marsh (2007, as cited in

Burlingame & Baldwin, 2011; Kemp, 2010) noted the therapeutic benefits of the group

sessions, including universality and hope as a result of support from peers, and found a

reduction of some psychiatric symptoms among the group members who participated in a

well-structured group. These findings were also reported in previous research by Kemp

(2010), who revealed that the positive therapeutic effects of group therapy with patients,
 89

including having a forum for them to share experiences and gain a sense of solidarity and

hope, leads to improved patients’ health. However, Lazell (1945, as cited in Burlingame

& Baldwin, 2011; Kemp, 2010) indicated that staff reported reduced requests for sleeping

aid from patients who participated in group sessions. Current findings add to the body of

knowledge by revealing the need to ensure confidentiality among group members;

findings indicated that confidentiality should be discussed up front among the patients.

Group Setting Was Inappropriate for Some Participants

Although most participants agreed that the group structure could be successful if

conducted appropriately, seven participants reported that some group participants were

not ready or comfortable in a group environment. For these group participants, the focus

groups were not helpful or appropriate. The findings imply that although some group

participants may benefit from following a group structure, others not benefit them. This

finding does not support existential theory, which indicates that the existential therapeutic

factor occurs when members learn through group interactions to take responsibility for

their decisions and the consequence of a decision they make, whether good or bad (Bloch

et al., 1979). The shortness of the group sessions and treatment experience also

contributes to realization limits, which are beneficial to participants of the focus group.

However, current findings indicated that some group participants were not ready or

comfortable in a group environment and did not benefit from the focus group sessions.

Previous research indicated that psychotherapy groups have been recognized as an

economical and efficient vehicle to deliver treatment typically ascribed to individual

therapy sessions but for multiple patients simultaneously with unique benefits to patients
 90

(Burlingame & Baldwin, 2011; Gambino, 2013; Kemp, 2010). Current findings

disconfirm the previous research, which revealed that developing psychoanalytic groups

with appropriate settings adds a layer to the therapeutic process instead of individual

functioning as a new treatment engagement (Emond & Rasmussen, 2012). Although

current findings disconfirm previous studies, they add to the literature by demonstrating

that although some patients may benefit from following a group structure, others may not

benefit from them.

Limitations of the Study

I acknowledge there are many limitations to this study. The study was limited to a

small number of hospital staff with experience conducting the Yalom focus group on a

hospital unit. As a result, research outcomes may not be generalizable to most inpatient

hospital units globally or nationally. Qualitative studies have limitations as results cannot

be generalized; however, patterns among participant responses can be used for further

research (Creswell, 2009). It is important to note that a larger pool of participants was not

included in this small qualitative study because it was mainly meant to facilitate the

researcher’s in-depth enquiry about the effectiveness of the Yalom focus group in a

natural setting of a particular urban hospital.

Another limitation was the purposive sampling technique adopted by the

researcher. Purposive sampling depends on the researcher’s judgment based on specified

traits and criteria, thus leading to increased risk of selection bias and subjectivity, which

may lead to diverse interpretations. The risk of selection bias and subjectivity may lead to

the unreliability of research findings; thus, the findings may not be transferred or
 91

generalized to other populations. Although the researcher may not be biased, the

subjectivity of purposive sampling based on judgment may risk unintended selection bias.

To that end, purposive sampling may make it challenging to replicate the research by

other researchers because it lacks defined selection criteria. I admit to association bias in

that I have experience conducting Yalom focus groups in the past. To decrease potential

bias, I transcribed the interviews and sent a copy to each participant for review and

confirmation.

Another limitation was that the scope of this study was limited to only hospital

staff, clinicians, interns, or psychiatric inpatient staff who have conducted the Yalom

focus group on an inpatient unit. Individuals with experience conducting the group

outside a hospital setting were not investigated. In this regard, the findings may not be

applied to other groups who have experience conducting the group outside of a hospital

setting.

Recommendations

In this section I offer recommendations for future research based on the strengths

and weaknesses of this study and the literature review in Chapter 2. This qualitative

research study investigated the benefits of using the Yalom focus group with acute in-

patient psychiatric patients. While conducting this study, I discovered positive and

negative views of conducting the group with acute in-patient psychiatric patients. In

general, I discovered that group participants who were intentionally looking to benefit

from the group experienced benefits. I also found that group participants who were

unwilling to benefit from the group experience or inappropriate for the group did not
 92

benefit much from the group experience. Thus, it may be beneficial to study factors

contributing to the willingness to participate in the Yalom focus group among these

demographics to help enhance mindful participation. Another recommendation is a

methodological recommendation to incorporate more qualitative and mixed methods to

learn about patients’ lived experiences of the Yalom focus groups. Longitudinal designs

could be valuable in clarifying relationships among imminent experiences, such as

instilling hope and inspiration and influencing patients to engage in the Yalom focus

group.

Finally, given the limitations addressed previously, I recommend that more

studies be conducted using a quantitative research design and a significant research

participant pool. The potential research should be with more diverse samples of hospital

nurses, interns, doctors, and patients to avoid demographic homogeneity and to identify

any differences based on sharing of experiences among the patients. This approach would

ensure the generalizability and transferability of findings to diverse populations within

the psychiatric section of healthcare as well as the validity of study outcomes.

Implications

Consequences for Clinical Practice

This qualitative study attempted to add to the body of literature regarding the

understanding of clinicians’ lived experience of delivering Yalom focus group in an

inpatient psychiatric hospital unit. Regarding social change, the findings provide

important insight into how clinicians can use the Yalom focus group to manage patients’

emotional challenges on an inpatient medical unit during their admission treatment

 93

period. Given the paucity of group treatment for this population, this insight may enhance

options available for medical professionals tasked with the responsibilities of treating this

population because of its potential improved therapeutic health outcomes for them.

The study findings may help promote awareness of the Yalom focus group as a

potential efficient and effective therapeutic group for psychiatric patients admitted to

inpatient units nationwide and globally, thus helping society in the management of

treatment and caring for psychiatric patients and inspiring quantitative research in the

future. Patients may benefit from this study’s findings by understanding the importance

of the Yalom focus groups in enhancing their social skills, inspiration, and sense of hope

through the sharing of experience. They may then help others engage in such important

groups, which may help them develop hope of recovering from their respective illnesses.

The findings may also contribute to positive social change by helping community

healthcare workers who can use the findings to inspire patients to engage in Yalom focus

groups, thus leading to improved health outcomes. These improved health outcomes

contribute to enhanced healthcare quality and results within the community, resulting in a

positive social change. The study findings could also help ensure positive interactions

between clinicians and patients, leading to improved healthcare outcomes in society. The

positive interaction between patients and clinicians fosters therapeutic conditions that are

supportive with effective collaboration and communication.

Recommendations for Clinical Practice

Healthcare organizations are key beneficiaries of this study’s findings. This

research could serve as a resource for hospital staff when using the Yalom focus group
 94

with patients admitted to acute psychiatric hospital units, provided that the current

recommendation for therapeutic intervention modalities used in various mental health

facilities are evidence-based. Administrators in healthcare facilities can apply this study’s

findings to implement various focus group session programs in hospitals. Such focus

groups would allow patients to share their diverse experiences, including how they

overcame various illnesses and symptoms, and to identify a given disease’s symptoms.

Policymakers in the healthcare sector can also use these findings to support

proposals for funding for future research to evaluate the effectiveness of utilizing the

Yalom focus group as a therapeutic instrument for inpatient psychiatric patients. Future

research could also develop strategies to modify the group delivery to meet current short

hospital stay culture. The overall benefit is the possibility of increasing available group

therapies for this patient population.

Conclusion

This research aimed to evaluate the hospital staff’s lived experience of facilitating

the Yalom focus group treatment model with inpatient adults in psychiatric hospital units.

My findings suggest that the Yalom focus group participants had a positive experience

related to the patients’ engagement, willingness, effort, and intent. Results reveal that

group participants benefited from the camaraderie from speaking with individuals with

similar common experiences and that sharing common experiences instilled hope in

patients.

The study findings provide insight into how group participants learn from each

other to inspire and instill hope in patients that they could overcome challenges they had
 95

previously thought were impossible to solve. Improving social skills among group

participants was a benefit experienced by patients who started feeling less isolated and

showed reduced symptoms. This research provided significant information regarding how

structured focus groups may be important for improving group participants’ welfare

through increased social skills and an increased sense of hope and inspiration.

The study provides important information regarding the use of Yalom focus

groups in enhancing treatment among psychiatric therapies. Facilitating the Yalom focus

group in a psychiatric inpatient unit can encourage patients to share their experiences of

how they dealt with therapeutic treatment, thus leading to informed decision-making by

other patients with similar challenges. Such information on the importance of engaging

with the Yalom focus group in a psychiatric inpatient unit can inspire more patients to get

involved, thus contributing to improved healthcare outcomes. This research can inspire a

quantitative study in the future to evaluate the effects of the structured Yalom focus

groups on in-patient acute psychiatric hospital units, hence contributing to evidence-

based group treatment for patients admitted to psychiatric units.