Compassion Focused Therapy (CFT) is an integrative evolutionary informed psychotherapy that aims to understand our evolved minds and motivational systems [11]. These motivations organise and serve us in three distinct and different ways; to defend, to resource seek and to rest. The primary focus of CFT is making use of the evolved psychophysiological systems that allow us to care. CFT understands the function and motivation to care and be cared for is an evolved capacity or simply put, humans have evolved to be regulated by relationships [12]. This makes CFT ideal as a group therapy.

It is routine for services in the NHS to offer psychoeducational and skills training groups, such as Compassionate Mind Training Groups (CMT) [13]. These are typically 12 sessions or modules which are structured and manualised [14,15,16].

A further development to CMT groups, is the CFGP (Compassion Focused Group Psychotherapy; Lucre et al., [9]). This is a five-phase model encompassing assessment and formulation, waiting list group, preparation and engagement group, compassion focused trauma group and moving on group. This model builds on elements of compassionate mind training with what they describe as “a process-driven group psychotherapy format with more structured components to foster a sense of social safety and safeness, a secure base and safe haven between group members” [12]. This group psychotherapy model was specifically developed to address the needs of those who have experienced attachment and relational trauma. Lucre and colleagues use the group process as the container from which to explore fears, blocks and resistances to the flow of compassion (see Lucre [17], for further details of 5 phase model group structure). An analysis of CFGP found to provide significant improvement on subscales including shame, which was sustained at 12 month follow up [17].

During a period of service redesign the interest in therapeutically driven groups increased in response to growing referrals and clinical demand. To meet the requirements of the service and with an opportunity to implement a novel approach into local psychological therapy services a proposal was made to implement Compassion Focused Group Psychotherapy. A small-scale test of change [18] was approved where a quality improvement approach to implementation and evaluation was authorised. In principle, this would encompass phases one, three and five (with adaptation) of Lucre’s five-phase model. This paper aims to present the evaluation of this work and its role in further service development. The paper uses qualitative feedback from patients who have attended the group.

A working group was devised to develop a CFT Group within an adult psychological therapies service within the NHS. This was first envisioned as a ‘Compassionate Mind Training’ (CMT) group, that ideally would combine elements of both a psycho-education informed skills-based approach and a formulation driven group psychotherapy. Working within the literature and service remit this was devised as an initial conjoint session to assess suitability and where appropriate this would be followed by three individual and thirteen group session closed group programme that was separated into three parts – orientation, group therapy, moving on (Figure 1).

Groups were always facilitated by two senior therapists (Band 7 and above), who had been trained via the Compassionate Mind Foundation both in Compassion Focused Therapy (>3 days) and Compassion Focused Group Psychotherapy (>3 days) and attend monthly group CFT supervision.

Referrals for the group were sought from within the department where group was initially populated by existing patients who had either completed a piece of therapy but had continued difficulties within self-organisation or were making limited progress within individual therapy. The group programme was, therefore, initially used by the department as a means of supporting people through endings or where self-criticism and shame acted as blocks to individual therapy. Due to service demands and structural changes by the third group most patients entering the programme were new to service, however most reported a history of previous psychological therapy or mental health treatment.

Orientation comprised of two sessions, one of which was focused on an initial meeting with the therapists facilitating the group and one focused on the beginnings of an individual threat-focused formulation. The orientation sessions were thought of as a ‘dry run’ offering patients an opportunity to meet and ask the therapists questions, travel to and be within the group room and for therapists to begin collecting psychometric data and early assessment information on compassionate motivation and capacity. The patients would also be allocated a key worker, who was a member of the clinical team that they could approach with questions between sessions, with the aim to offer a safe base if it was difficult to raise issues in the larger group. This design was in keeping with the principles of trauma informed practice [19,20].

If patients were felt to be appropriate for the group, each patient received an individual session with one of the therapists, their “key worker”, to develop their formulation. This would start the psycho-educational element but also establish individualised understanding of their difficulties within the compassionate framework. This would allow the therapists insights into how they can adapt the group sessions to individual patient needs and promote a sense of direction and goals for the group members to hold in mind whilst in group. This also helped the group facilitators identify common themes and shared experiences amongst group members, but also potential conflicts.

The group would consist of between 6-9 members and was closed (i.e. the same people in each session). The format was 12 sessions, punctuated by an individual review session after session 6. Appendix 1 provides a brief outline of each session. Sessions were delivered dynamically and responsive to what group members reported on each week. It was not uncommon that while being sensitive and attentive to themes emerging from the group, that session content would be moved around, therefore adding to the active and need focused aspect of the therapy programme. When themes emerged in group, the facilitators would follow the lead of the group, whilst at the same time relating it and interweaving key messages and underpinning theory of CFT. Session 6 would formally mark the end of the more content and psychoeducational sessions. Each group member received an individual session to re-check psychometric data and further develop their formulation. This, ideally, identified further fears, blocks and resistances that would be elaborated on and reviewed within group sessions.

The final 6 sessions offered the opportunity for, within the limitations of the 12-group sessions format, with boundaries to safely engage with exploratory work into self-criticism, shame and the compassionate kitbag [21]. Chair-work was lightly explored during this part of the programme, for example as a useful object to collect the qualities of the group compassionate other, for role-taking items from group members compassionate kitbags or for therapist delivered role playing of the group’s inner critic or multiple self (sad, angry, anxious and compassionate parts). This decision was informed by the progress, capacity and need of each group, therefore each group required and/or could tolerate different work. However transitional work always remained the same and from session 7 the awareness of endings was never far from the group room, with dedicated time given to this in the latter sessions.

On completion of session twelve each member had a individual session where psychometrics were repeated reflecting on the progress that was had. This provided a space to digest the previous weeks but also consider next steps, whether this was discharge from the service or onto further psychological work. A final group session was provided three months after this session where psychometrics were taken for a final time and the group were supported in final queries, questions and transitions. The three-month break was envisioned to give group members time away from the service, to apply and consolidate learning, while knowing that should they require contact with therapists/key workers this was possible, or that they could raise issues at the final group session. This provides a continued line to the safe base group had developed across time.

A qualitative evaluation was devised as part of the projects broader evaluation and felt essential in understanding the individual experiences of group an 11-item, open questioned survey was developed and provided to the NHS board’s local research and development department and information governance department. As this was deemed service evaluation and not research, ethical approval was not indicated by the research and development department [22]. As our objective was to qualitatively evaluate a service there were no requirements for ethics approval. Advice was provided from Information Governance. Due to clinical restrictions, of central importance the evaluation being conducted primarily by two NHS therapists co-ordinating the programme, in time and resource an electronic survey was chosen as the method of information gathering which was thought to be ecologically valid [23]. Appendix 2 provides the 11-item questionnaire that was used.

A total of 27 members, who had completed the group programme, across five group intakes were contacted via email by one of the group co-ordinators with 3 patients being excluded due to outdated or unavailable email addresses. Attrition rate across the five groups have been consistently low as detailed in the Table 1. Reasons for drop out were linked to group members opting out due to living circumstances or struggled with the group format. On at least two occasions therapists supported group member to leave the group due to challenges within compassionate capacity for self and others.

These group members had a range of historical and current psychiatric diagnoses, for example PTSD, Borderline Personality Disorder, Complex PTSD, Depression, Autism Spectrum Disorder. However, each member had experienced at least one rupture during childhood within a care-giving relationship that was central the individuals form of self-criticism and self-attack. The survey was live for 31 days with a further prompt email sent at the halfway point. A total of 9 responses were received where a thematic analysis was conducted [24,25] by one of the group co-ordinators and a nurse psychotherapist employed by the same department but external to all compassion focused group therapy work. Both independently familiarised themselves with the survey responses prior to identifying codes for theme development. Themes were then constructed together through discussion and exploration of individual codes, with quotes being used to support theme development and areas of further improvement.

The dominant theme emerging from the qualitative data that was described across all participants was the role therapists played within the group setting, which was distinguished into two subordinate themes.

Structure was the second overarching theme across all respondents’ surveys, with particular focus on how group members entered and exited the programme but also how group sessions were organised.

What became evident for most people was the opportunities created within the group programme for individuals to experience compassionate flow – to others, from others and to themselves – which provided each member an opportunity for connection:

“I loved the support and care towards each other, there was a gentleness, and it felt so safe.”

“The group element was integral to this as I gained such a raw insight into different people’s perspectives.”

“There was no judgement… ever. Purely support from everyone. There was no expectation to share pieces of yourself should you want to hold back.”

For some there was descriptions that moved beyond opportunities for connection but the actual experiences of connectedness:

“A sense of camaraderie. Of belonging. Being able to ask group members for their thoughts on what I was experiencing.”

“It was the most in-depth thing I’ve ever done, but from a safe place. Safety was my main concern, it was something I was really not doing well within in life, and this solid 12 weeks of having that net was just what I needed.”

Finally, what was reflected was the therapeutic methods applied to fears, blocks and resistances to compassion during the programme demonstrated through descriptions of the practical and play-based work completed.

“The meditation has been a tool I’ve used more than anything. Initially I thought I can’t do it or it won’t work for me…for various reasons but I’ve stuck with it and it has been a saviour even after group has ended.”

“I had tried to get through much of this for a long time in my life, so when I had the time in any chair regarding therapy or work on myself, I took it and ran with it.”

“We were given things away (things I’ve kept) as a reminder that even if I don’t use them everyday or need them.”

“Loved the sessions where we were all connected (with the) ball of wool etc.”

But also descriptions shared of personal experiences of the group therapeutic work that mobilised change for them.

“The facts of my life haven’t suddenly changed, and painful memories haven’t been erased, but this therapy has helped me see things differently. It has allowed me to make peace with the past and have confidence in myself going forward. I can calmy stand up for myself now, without doubting myself or feeling guilty.”

Despite the valuable insights generated through this thematic analysis, several limitations must be acknowledged. Firstly, the small number of participants limits the findings, as the sample may not fully represent the diversity of experiences within similar therapeutic groups. We can only speculate as to why 9 out of 27 invited attendees completed the survey but may be representative of the impact group had on them. Secondly, the data was collected via an open-ended survey response rather than in-depth interviews, which may have restricted the depth and nuance of group member reflections. The absence of any follow-up querying also limits the ability to clarify or expand on ambiguous or complex statements. Additionally, the analysis was conducted without the use of inter-rater reliability procedures, which introduces potential bias and limits the credibility and consistency of theme development. One therapist was heavily involved in both the group development and delivery and the thematic analysis, which may introduce further bias. The study also lacked inclusion of demographic information requests within the survey therefore limiting specificity on experiences relating to gender, age, diagnosis or previous experiences of therapy. Furthermore, there was no long-term follow-up data to assess the sustainability of perceived benefits over time, nor was there information available regarding whether participants re-engaged with services or pursued further therapeutic input following discharge. However, it is notable that six participants transitioned into a 25-week Compassion Focused Group (phase 4 of Lucre approach), reflecting both the complexity of their difficulties and the assessed need for continued integrative therapeutic work. This acted as a continuation of care where members from various 12-week groups were brought together to form a new group focusing on ‘putting the compassionate mind to work’. It should also be recognised that, while this programme may offer meaningful therapeutic benefit, it may not fully resolve the enduring and multifaceted difficulties associated with attachment trauma, which often require longer-term interventions.