Background

Depression is a common mental disorder affecting approximately five percent of the world’s population, with women more likely to be depressed than men [1]. Depression recurs for at least 50 percent of those who experience an initial episode, and the risk increases with each additional relapse [2]. Depression can create personal, social, and financial challenges for the individual and entail a socio-economic burden in the form of sickness absence and lost tax income, as well as increased social security and treatment costs [1,2]. However, it is estimated that around 75 percent of the population that develops a depressive disorder in low- or middle-income countries receives no treatment [1]. The treatment gap relates primarily to attitudes and cognitive barriers and secondarily to structural factors such as access, waiting lists, and finances [3]. Social networks and role expectations, as well as stigma and prejudice related to depression and mental health in general, can be obstacles to seeking help [3]. Social withdrawal and isolation are common among people with depression [4]. Nevertheless, with regard to living with and recovering from depression, a positive connection has been found between having a social network and having supportive relationships [4,5].

People with mild to moderate depression experience a reduction in depressive symptoms by participating in social group interventions [6]. The course in coping with depression, a cognitive behavioural group intervention based on social learning theory, was originally developed by Lewinsohn and colleagues and called the “Coping with Depression” (CWD) course [7]. The group typically consists of six to ten adults and meet weekly, with two follow-up sessions scheduled after one and six months [8]. The intervention, which was developed to address a need to reach more people through a non-stigmatising method of intervention outside the traditional mental health services [8], has been found effective in reducing depressive symptoms and potentially cost-effective [9]. The intervention is defined as a course in coping with depression, as it is intended to teach participants tools and coping techniques for dealing with depressive complaints and the symptoms expressed [8]. In contrast with traditional group therapy, patients are defined as course participants and the personnel conducting the course are known as course instructors [9]. The original CWD course program includes the teaching of social skills and behavioural activation, the identification of negative thoughts and problem-solving, mood monitoring, and relapse prevention [8]. Over the years, different versions of the CWD course have been developed and adapted to meet the needs of specific populations and intervention goals [9].

Research is lacking on experiences with the CWD course’s group setting. Existing knowledge about the group setting relates predominantly to intervention methods such as group therapy and counseling for people with depression and comorbid mental disorders [10–14]. Research shows that the majority find the group setting valuable in terms of normalisation as it makes it possible to meet others in similar situations [12,13]. When trust has been established, the group is experienced as a safe and supportive place. By sharing experiences and advice, participants can have an opportunity for new insight and growth [10–13]. On the other hand, group dynamics can interfere with achieving a positive therapeutic effect due to personal traits, such as shyness or dissatisfaction, or the presence of dominant participants [12]. More knowledge is needed about the importance of the group setting of CWD courses.

Method

Data analysis

Braun and Clarke’s [18] thematic analysis was used to analyse the data. The first author (ES) performed the first four phases of the analysis in collaboration with the last author (LSB), in which the text was systematised and categorised. In phase five, the interpretation was performed and validated by both authors. In the first phase, the first author familiarised herself with the data by listening to the audio recordings and then transcribing it verbatim, to ensure that the reproduction from speech to text corresponded with what the informants had communicated during the data collection. The text was then read through and keywords relevant to the research question were noted. In the second phase, the data material was transferred to NVivo to generate codes across the data material. In phase three, similarities and differences between the codes in the dataset were identified, which guided the sorting of the codes into relevant groups and their subsequent labelling. For example, the codes as “course participants understand each other,” “course participants support each other,” and “generosity and care in the group” were grouped under a preliminary category labelled “inclusion and emotional support.” In phase four, preliminary themes were developed based on interpretations of the data extracts associated with the codes. The category “inclusion and emotional support” was subsequently organized under the preliminary theme “social fellowship,” which, during the interpretation process, evolved into the theme “fostering a supportive group identity.” The themes were further systematized with sub-themes and were discarded if deemed irrelevant to the research question. The interpretation process moved back and forth between parts and whole in phase five, and the authors developed greater insight into and understanding of the data material, which led to the interpretation of the main theme [18] (Table 1).

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Table 1. Overview of the results.

https://doi.org/10.1371/journal.pone.0323545.t001

Discussion

The aim of this study was to gain a deeper understanding of the use of groups in the CWD course in primary health care. The research question addressed CWD course instructors’ experiences with the group setting. The course instructors’ experience of the group was that it created an arena for the course participants to be in the same boat, and this included the themes of evolving group dynamics and interaction, fostering a supportive group identity, and facilitating mutual learning and support within the group.

This study shows that interaction between the participants was a valuable and important supplement to the group setting of the CWD courses. The course instructors wanted the participants to have active dialogue, which they facilitated by asking open questions for the purposes of reflection and sharing. The course instructors had to strike a balance in order to regulate group dialogue such that all participants could participate in their own way according to their individual preferences, and challenges could arise in the meeting between active and silent participants. On the other hand, there is a risk that the presence of the course instructors could obstruct active dialogue in that the individual expertise of the participants is overshadowed by the presence of the professional [20]. In general, the indication is that the more active and influential a participant is within a group, the more likely that person is to benefit from the group [20]. Each group member will influence the social climate through their behaviour [20]. Sharing private experiences can build trust within a group, and active participants who reveal their thoughts and feelings act as contributors to the group dialogue [13]. If the reactions of and feedback from other participants are based on respect and care, then a safe and reliable group atmosphere is created, which helps more people dare to share freely [13,20]. On the other hand, the group setting can become a barrier to equal participation by participants as the result of different personality characteristics [12], which corresponds to findings from this study.

Even though some participants were not verbally involved, it was the informants’ experience that the silent participants participated in the active dialogue through affirming body language and active listening. Nevertheless, silent participants can be just as big a challenge in group dynamics as active participants [20]. Self-disclosure is not only crucial for the development of group cohesion, but it also correlates directly to positive therapeutic effects. Increased verbal participation contributes to increased commitment and appreciation from other participants [20]. There are several possible reasons for a participant’s silence. It is conceivable that symptoms related to depression create a barrier to verbal participation. Fear and anxiety, lack of interest, and hopelessness are described by people with depression as constraints to participation in leisure activities [21].

Passivity and withdrawal from social settings are common symptoms of depression [2]. This study found that the group setting contributed to the development of a social community, regardless of group composition in terms of age and gender. The formal group structure, in which participants worked together towards a common goal, created a sense of belonging. Intervention methods that contribute to increased social contact and by means of which participants identify with the group have been found to reduce depressive symptoms over time [22]. Groups with strong cohesion show a higher degree of satisfaction, attendance, participation, and mutual support [20]. This may have contributed to the fact that participants made new acquaintances and relationships through the informal structure formed during the breaks, as identified by this study. On the other hand, informal group structures can contribute to the formation of subgroups within groups, with participants being included or excluded. Such subgroups can have consequences for group fellowship and complicate unity by creating polarisation or marginalisation [20].

The study finds a synergy effect in groups where participants can take on two roles, as both helper and receiver. Although the group setting is associated with a CWD course, the informants point out that the interaction and learning that take place between the informants are just as important. This is in line with the principle of self-help groups, where the therapeutic effect is expressed through the exchange of experience. Participating in self-help groups can give one hope and the motivation to change one’s life situation [23]. Gathering participants with similar challenges in a group creates an arena that offers the potential for learning and growth and can be related to observational and model learning [20]. By observing, one can learn behaviour. On the other hand, for behaviour to be learned, it is a prerequisite that it be understood, remembered, and applied appropriately in one’s own life [24]. By receiving, one can create distance from one’s challenges and gain new insight from the observation of the alternative coping techniques of others. At the same time, being able to be the one who gives can help mobilise personal effort and provide greater insight into one’s resources, which one can use to help oneself [20,23]. This is in line with the study’s findings and with previous studies which show that participants can act as role models when offered new and more appropriate behaviour and thought patterns [10].

Conclusion

The aim of this study was to gain a deeper understanding of the use of groups in the CWD course in primary health care. The findings show that the group setting develops a supportive fellowship and becomes an arena that allows opportunities for personal and social growth. The group setting creates an interaction effect, whereby participants can learn from each other through the observation and exchange of experiences, as well as an opportunity to form new relationships. The findings indicate challenges in facilitating active dialogue within the groups due to different personalities and commitments. Active course participants are found to be a resource in the group that creates greater commitment and interaction between participants, but which can also obstruct others’ input if allowed to take up too much space. It is a balancing act to include both the active and the silent course participants in the group while respecting the participants’ individual preferences and needs.

The study is believed to have elicited experiences related to the research question, with these findings considered representative of and useful for other CWD course instructors. It remains challenging to determine whether the observed findings are specifically attributable to the type of treatment (group vs. individual), the nature of the treatment (CWD course vs. other interventions), or the characteristics of depressed persons. Further research is needed to disentangle these factors and provide clearer insights into the effectiveness of different treatment modalities and their impact on diverse populations. Greater knowledge about and understanding of the group setting can stimulate greater use of mental health care in groups for people with depression. In this way, the primary health service can reach more users with necessary and knowledge-based mental health care in a cost-effective manner. However, there is also a need for a broader understanding of the group setting from the course participants perspectives. Further research should examine the experiences of course participants who have completed a CWD course in a group and the utility value of the CWD course as compared to individual interventions for people with mild to moderate depression.