Loneliness Group Intervention for Geriatric Psychiatry Inpatients
Phase: NA
Conditions: Loneliness
Sponsor: London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's

 
 
 
AWARENESS, COURAGE, AND 
LOVE (ACL) GROUPS: A 
GERIATRIC PSYCHIATRY 
INPATIENT PILOT 
INTERVENTION FOR 
LONELINESS 
Loneliness intervention for geriatric psychiatry 
Serena Wong 
      
NCT05619718 

 
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Research Protocol 
Background and Rationale 
Loneliness is a key predictor of mortality in older adults. It is also a prominent risk factor 
for mental and physical illness in older adulthood (Ong et al., 2016). Concurrently, the population 
of older adults is rising to unprecedented levels. Group-based interventions that target loneliness 
in geriatric psychiatry patients would be an efficient use of limited resources to address this 
common psychosocial need. In their meta-analysis, Masi et al. (2011, p. 23) recommended a “rich 
and forgiving social environment” for lonely individuals to correct their maladaptive social 
cognitions. Several recommendations from meta-analyses on loneliness interventions have also 
stressed that more randomized group comparisons are needed (Cohen-Mansfield & Perach, 2015; 
Poscia et al., 2018). To our knowledge, no interventions for loneliness thus far have been trialed 
upon geriatric psychiatry inpatients.   
Inpatient psychiatry units are ideally suited for piloting a novel intervention for loneliness 
that is based on Awareness, Courage, and Love (ACL) groups. Awareness, Courage, and Love 
(ACL) groups are an outgrowth of functional analytic psychotherapy, which is an empirically-
based behavioural therapy that emphasizes the principle of positive reinforcement within 
relationships (Holman et al., 2017; Kanter et al., 2010; Kohlenberg & Tsai, 1991; Tsai et al., 
2009a). Awareness involves the practice of mindfulness, and in particular, the noticing of emotions 
within oneself and in others (Tsai et al., 2009b). Courage refers to engaging in vulnerable self-
disclosures. Love encompasses healthy caring for oneself and others, and in particular, responding 
affirmingly to another person’s self-disclosures. ACL groups are led by skilled facilitators across 
the globe to address loneliness in the community (https://www.livewithacl.org/). Outcomes of 
these groups have included increased feelings of closeness with others (Tsai et al., 2020), social 
connectedness (Kanter et al., 2018), relational health (Hardebeck, 2022), and mindfulness 
(Kohlenberg et al., 2015). Elsewhere Maitland et al. (2017) have theorized about the processes 
within the ACL model that improve social functioning.  
Bringing ACL groups to geriatric psychiatry inpatients represents a promising avenue 
towards better health outcomes. In Akhter-Khan and Au’s (2020) literature review of Why 
Loneliness Interventions Are Unsuccessful, they underscored the dearth of loneliness interventions 
that are theory-based and called for ideas. Theoretically rooted in functional contextualism, and 
bolstered by empirical support in community samples, ACL groups adapted for geriatric psychiatry 
inpatients may answer that call. These groups would be a novel offering with potential for global 
impact.  
 
Note. Elaboration on the Awareness Exercises: As noted in the protocol, the “self” 
component of awareness refers to paying attention to one’s inner experiences. Awareness is one 
aspect of mindfulness known more formally as present moment awareness. Each awareness 
exercise in the protocol has been outlined: Session 1’s awareness exercise is the Treasure Chest 
Meditation (p. 7), Session’s 2 awareness exercise is the poem by John O’Donohue (p. 9), Session 
3’s awareness exercise is the meditation on loss, and Session 4’s awareness exercise is the Seeing 
Deeply into Another meditation (p. 12).  
 
Objectives and Hypotheses: 

 
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The objective of this clinical trial is to adapt, implement, and evaluate an ACL group for 
older adults in a psychiatric unit. This trial will not target psychiatric disorders, but rather, 
addressing a common psychosocial need in a psychiatric sample: the need for social closeness and 
belonging. The following research questions will be answered: (a) Are ACL groups with geriatric 
psychiatry inpatients feasible and acceptable? (b) Do such ACL groups demonstrate preliminary 
efficacy?   
Accordingly, it is hypothesized that such groups will be well-received by geriatric 
psychiatry inpatients, as indicated on post-treatment program satisfaction questionnaires. 
Feasibility will be determined by the difference or lack thereof in attrition rate of the ACL group 
compared to TAU. Additionally, it is hoped the loneliness group will alleviate loneliness and boost 
social connectedness compared to treatment-as-usual.   
 
Methodology: 
Participants will complete simple, abbreviated surveys either orally or independently using 
pencil-and-paper. The primary outcomes will be loneliness and social functioning. Measures will 
be selected based on their psychometric properties and use with older adult samples. Before the 
first session (baseline) and after the last session, measures for loneliness, social closeness, 
relational health, subjective wellbeing, and sacred moments will be completed. All measures, 
except those related to program satisfaction, will be administered a final time at follow-up.   
To assess the efficacy of the ACL groups, the Inclusion of Other in the Self Scale, UCLA 
Loneliness Scale-6 (ULS-6), De Jong Gierveld Loneliness Scale (DGLS), and Relational Health 
Indices will be administered. The Inclusion of Other in the Self Scale (Aron et al., 1992) is a one-
item, pictorial indicator of social closeness. The ULS-6 has been validated with older adults (Neto, 
2014) and the DGLS (1985) captures social loneliness. Moreover, relational health will be 
measured with the peer version of the Relational Health Indices (Liang et al., 2002). In terms of 
secondary outcomes, subjective wellbeing will be assessed using a one-item pictorial life 
satisfaction indicator (Cantril, 1965). Sacred moments will be captured by the Sacred Moments 
Scale (Pargament et al., 2014).   
To assess the acceptability of the ACL groups, program satisfaction surveys will be 
administered after the final session. Acceptability will be assessed qualitatively with the 
Satisfaction Questionnaire, which includes open-ended items about group experiences, including 
what was most helpful, least helpful, and perceived changes as a result of the group (Owen et al., 
2014). A quantitative measure of program satisfaction will also be completed, with acceptability 
and satisfaction items adapted from Simmons et al. (2013). To assess the feasibility of the ACL 
groups, attrition rates between the ACL group and with the Mutual Help group will be 
compared. Session feedback forms will also be completed after every session in both groups. 
Tables 1 and 2 below depict the administration of measures for each condition at every time point.  
 
Design: 
The design will use an experimental treatment-outcome design with a treatment-as-usual 
(TAU) control group. Participants will be randomly assigned into the ACL or Mutual Help group 
for four weeks (i.e., four sessions, respectively). Mutual Help groups represent the standard of 
care. They have been offered weekly in the geriatric psychiatry unit, serving as a voluntary, semi-
structured forum to discuss news related to the ward, practice gratitude, offer suggestions to 

 
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improve the inpatient experience. These groups are facilitated by social workers, occupational 
therapists, and therapeutic recreation specialists.   
ACL groups were selected for the purpose of this study. They will be facilitated by the 
social workers and psychologist. To prevent participant crossover during the active research phase, 
the Mutual Help and ACL groups will be scheduled to occur at the same time. There will be a 
comparison between the preliminary efficacy of four weekly ACL groups versus four Mutual Help 
Meetings in the geriatric psychiatry unit. The duration of ACL treatment was set at four weeks to 
allow for a full course of therapy. Each ACL session will last approximately 60 minutes. Outcomes 
will be measured pre- and post- treatment, in addition to between-groups comparisons with the 
ACL and Mutual Help groups.  Session-by-session measures will also be completed after each 
ACL and Mutual Help meeting. Additionally, patients will be contacted two weeks after their final 
session of ACL and Mutual Help to complete follow-up measures. Efficacy will be established by 
improvements in outcome measures at post-treatment and/or follow-up relative to baseline.   
Note. Patients are not invited back to inpatients group if discharged.  
Note. According to Yalom (1975), the convention for group psychotherapy census is 5-8 
and we adhere to that range. 
 
Participants  
The sample will consist of geriatric psychiatry inpatients, given their elevated risk for 
loneliness and poorer mental health. Given the flow of admissions and in anticipation of dropout, 
the target recruitment number is 50 inpatients, with a minimum of 5 participants in each of the two 
groups who attend four sessions. Inclusion criteria include admission to the geriatric psychiatry 
inpatient unit and the capacity to consent to group psychotherapy. Exclusion criteria would be 
individuals who are disoriented to person, delirious, unable to tolerate or participate meaningfully 
in the group, or otherwise unable to provide consent research and psychotherapy. To maximize 
inclusivity, no limitations will be based on age, sex, gender, or disease. Of note, the 
aforementioned criteria pertain only to the individuals recruited for the study and who will be 
randomized into ACL or Mutual Help groups.   
Participation in this study will have risks comparable to TAU. These risks are mitigated by 
the facilitators’ backgrounds and training in inpatient geriatric mental health. Adverse impact of 
the ACL group on participants’ health, such as the exacerbation of depressive, manic, or psychotic 
symptoms, as reported by participants and/or nursing staff would be grounds for withdrawal from 
the study. The study will be terminated in the event that the ACL group systematically induces 
paradoxical effects, such as an increase in social isolation or decrease in wellbeing.   
 
Statistical/Analysis Considerations: 
Demographics between treatment and control groups will be compared with the 
expectation of comparable findings in terms of age, gender, income, cognitive functioning, and 
primary mental health diagnoses. After verifying statistical assumptions, mixed ANOVAs will be 
conducted to determine if there is an interaction between time (3 levels: baseline, post-treatment, 
and follow-up) and group (2 levels: control, treatment) on each of the continuous outcome 
variables. If there is a significant interaction, simple main effects analyses will uncover nuances at 
each level between groups.   
 

 
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Table 1. Treatment Group Measure Administration 
Measure 
T1 (Pre) 
W1 
W2 
W3 
W4 
T2 (Post) 
T3 
(2 wk FU) 
Demographics 
X 
 
 
 
 
 
De Jong Gierveld Loneliness 
X 
 
 
 
X 
X 
UCLA Loneliness 
X 
 
 
 
X 
X 
Cantril Life Satisfaction 
X 
 
 
 
X 
X 
Adaptation of Inclusion of 
Other in Self Scale 
 
 
 
 
X 
 
Relational Health Indices 
 
 
 
 
X 
 
Sacred Moment Qualities 
 
 
 
 
X 
 
Session Feedback Process 
Measure 
 
X 
X 
X 
X 
 
Program Satisfaction 
Questionnaire Qualitative 
 
 
 
 
X 
 
Program Satisfaction 
Quantitative 
 
 
 
 
X 
 
 
 
 

 
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Table 2. Control Group Measure Administration 
Measure 
T1 (Pre) 
W1 
W2 
W3 
W4 
T2 (Post) 
Demographics 
X 
 
 
 
 
De Jong Gierveld Loneliness 
X 
 
 
 
X 
UCLA Loneliness 
X 
 
 
 
X 
Cantril Life Satisfaction 
X 
 
 
 
X 
Adaptation of Inclusion of 
Other in Self Scale 
 
 
 
 
X 
Relational Health Indices 
 
 
 
 
X 
Sacred Moment Qualities 
 
 
 
 
X 
Session Feedback Process 
Measure 
 
X 
X 
X 
X 
Program Satisfaction 
Questionnaire Qualitative 
 
 
 
 
X 
Program Satisfaction 
Quantitative 
 
 
 
 
X