Groups - Treatment Modalities

Groups

A group is a number of persons who gather in a face-to-face setting to accomplish tasks that require cooperation, collaboration, or working together. Each person in a group is in a position to influence and to be influenced by other group members. Group content refers to what is said in the context of the group, including educational material, feelings and emotions, or discussions of the project to be completed. Group process refers to the behavior of the group and its individual members, including seating arrangements, tone of voice, who speaks to whom, who is quiet, and so forth. Content and process occur continu-ously throughout the life of the group.

Stages of Group Development

A group may be established to serve a particular purpose in a specified period such as a work group to complete an assigned project or a therapy group that meets with the same members to explore ways to deal with depression. These groups develop in observable stages. In the pregroup stages, members are selected, the purpose or work of the group is identified, and group structure is addressed. Group structure includes where and how often the group will meet, identification of a group leader, and the rules of the group—for example, whether individuals can join the group after it begins, how to handle absences, and expec-tations for group members.

The beginning stage of group development, or the ini-tial stage, commences as soon as the group begins to meet. Members introduce themselves, a leader can be selected (if not done previously), the group purpose is discussed, and rules and expectations for group participation are reviewed. Group members begin to “check out” one another and the leader as they determine their levels of comfort in the group setting.

The working stage of group development begins as members begin to focus their attention on the purpose or task the group is trying to accomplish. This may happen relatively quickly in a work group with a specific assigned project but may take two or three sessions in a therapy group because members must develop some level of trust before sharing personal feelings or difficult situations. During this phase, several group characteristics may be seen. Group cohesiveness is the degree to which members work together cooperatively to accomplish the purpose. Cohesiveness is a desirable group characteristic and is associated with positive group outcomes. It is evidencedwhen members value one another’s contributions to the group; members think of themselves as “we” and share responsibility for the work of the group. When a group is cohesive, members feel free to express all opinions, posi-tive and negative, with little fear of rejection or retribu-tion. If a group is “overly cohesive,” in that uniformity and agreement become the group’s implicit goals, there may be a negative effect on the group outcome. In a therapy group, members do not give one another needed feedback if the group is overly cohesive. In a work group, critical thinking and creative problem-solving are unlikely, which may make the work of the group less meaningful.

Some groups exhibit competition, or rivalry, among group members. This may positively affect the outcome of the group if the competition leads to compromise, improved group performance, and growth for individual members. Many times, however, competition can be destructive for the group; when conflicts are not resolved, members become hostile, or the group’s energy is diverted from accomplishing its purpose to bickering and power struggles.

The final stage, or termination, of the group occurs before the group disbands. The work of the group is reviewed, with the focus on group accomplishments or growth of group members or both, depending on the pur-pose of the group.

Observing the stages of group development in groups that are ongoing is difficult with members joining and leaving the group at various times. Rather, the group involvement of new members as they join the group evolves as they feel accepted by the group, take a more active role, and join in the work of the group. An example of this type of group would be Alcoholics Anonymous, a self-help group with stated purposes. Members may attend Alcoholics Anonymous meetings as often or infrequently as they choose; group cohesiveness or competition can still be observed in ongoing groups.

Group Leadership

Groups often have an identified or formal leader—someone designated to lead the group. In therapy groups and edu-cation groups, a formal leader is usually identified based on his or her education, qualifications, and experience. Some work groups have formal leaders appointed in advance, whereas other work groups select a leader at the initial meeting. Support groups and self-help groups usu-ally do not have identified formal leaders; all members are seen as equals. An informal leader may emerge from a “leaderless” group or from a group that has an identified formal leader. Informal leaders are generally members rec-ognized by others as having the knowledge, experience, or characteristics that members admire and value.

Effective group leaders focus on group process as well as on group content. Tasks of the group leader include giv-ing feedback and suggestions; encouraging participation from all members (eliciting responses from quiet membersand placing limits on members who may monopolize the group’s time); clarifying thoughts, feelings, and ideas; summarizing progress and accomplishments; and facilitat-ing progress through the stages of group development.

Group Roles

Roles are the parts that members play within the group. Not all members are aware of their “role behavior,” and changes in members’ behavior may be a topic that the group will need to address. Some roles facilitate the work of the group, whereas others can negatively affect the pro-cess or outcome of the group. Growth-producing roles include the information seeker, opinion seeker, informa-tion giver, energizer, coordinator, harmonizer, encourager, and elaborator. Growth-inhibiting roles include the monopolizer, aggressor, dominator, critic, recognition seeker, and passive follower.

Group Therapy

In group therapy, clients participate in sessions with a group of people. The members share a common purpose and are expected to contribute to the group to benefit oth-ers and receive benefit from others in return. Group rules are established, which all members must observe. These rules vary according to the type of group. Being a member of a group allows the client to learn new ways of looking at a problem or ways of coping with or solving problems and also helps him or her to learn important interpersonal skills. For example, by interacting with other members, clients often receive feedback on how others perceive and react to them and their behavior. This is extremely impor-tant information for many clients with mental disorders, who often have difficulty with interpersonal skills.

The therapeutic results of group therapy (Yalom, 1995) include the following:

·    Gaining new information, or learning

·    Gaining inspiration or hope

·    Interacting with others

·    Feeling acceptance and belonging

·    Becoming aware that one is not alone and that others share the same problems

·    Gaining insight into one’s problems and behaviors and how they affect others

·    Giving of oneself for the benefit of others (altruism).

Therapy groups vary with different purposes, degrees of formality, and structures. Our discussion includes psycho-therapy groups, family therapy, family education, educa-tion groups, support groups, and self-help groups.

Psychotherapy Groups. The goal of a psychotherapy group is for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group. Groups may be organized around a specific medical diag-nosis, such as depression, or a particular issue, such as improving interpersonal skills or managing anxiety. Group techniques and processes are used to help group members learn about their behavior with other people and how it relates to core personality traits. Members also learn they have responsibilities to others and can help other mem-bers achieve their goals.

Psychotherapy groups are often formal in structure, with one or two therapists as the group leaders. One task of the group leader or the entire group is to establish the rules for the group. These rules deal with confidentiality, punctuality, attendance, and social contact between mem-bers outside of group time.

There are two types of groups: open groups and closed groups. Open groups are ongoing and run indefinitely, allowing members to join or leave the group as they need to. Closed groups are structured to keep the same mem-bers in the group for a specified number of sessions. If the group is closed, the members decide how to handle mem-bers who wish to leave the group and the possible addition of new group members (Yalom, 1995).

Family Therapy. Family therapy is a form of group therapy in which the client and his or her family members participate. The goals include understanding how family dynamics con-tribute to the client’s psychopathology, mobilizing the fami-ly’s inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family problem-solving behaviors (Sadock & Sadock, 2008).

Family therapy can be used both to assess and to treat vari-ous psychiatric disorders. Although one family member usu-ally is identified initially as the one who has problems and needs help, it often becomes evident through the therapeutic process that other family members also have emotional problems and difficulties.

Family Education. The National Alliance for the Mentally Ill (NAMI) developed a unique 12-week Family-to-Family Education Course taught by trained family members. The curriculum focuses on schizophrenia, bipolar disorder, clin-ical depression, panic disorder, and obsessive–compulsive disorder. The course discusses the clinical treatment of these illnesses and teaches the knowledge and skills that family members need to cope more effectively. The specific features of this education program include emphasis on emotional understanding and healing in the personal realm and on power and action in the social realm. NAMI also conducts Provider Education Programs taught by two consumers, two family members, and a mental health professional who is also a family member or consumer. This course is de-signed to help providers realize the hardships that families and consumers endure and to appreciate the courage and persistence it takes to live with and recover from mental ill-ness (NAMI, 2008).

Education Groups. The goal of an education group is to provide information to members on a specific issue—for instance, stress management, medication management, or assertiveness training. The group leader has expertise in the subject area and may be a nurse, therapist, or other health professional. Education groups usually are sched-uled for a specific number of sessions and retain the same members for the duration of the group. Typically, the leader presents the information and then members can ask questions or practice new techniques.

In a medication management group, the leader may dis-cuss medication regimens and possible side effects, screen clients for side effects, and in some instances, actually administer the medication (e.g., depot injections of halo-peridol [Haldol] decanoate or fluphenazine [Prolixin] decanoate).

Support Groups. Support groups are organized to help members who share a common problem to cope with it. The group leader explores members’ thoughts and feelings and creates an atmosphere of acceptance so that members feel comfortable expressing themselves. Support groups often provide a safe place for group members to express their feelings of frustration, boredom, or unhappiness and also to discuss common problems and potential solutions. Rules for support groups differ from those in psychother-apy in that members are allowed—in fact, encouraged—to contact one another and socialize outside the sessions. Confidentiality may be a rule for some groups; the mem-bers decide this. Support groups tend to be open groups in which members can join or leave as their needs dictate.

Common support groups include those for cancer or stroke victims, persons with AIDS, and family members of someone who has committed suicide. One national sup-port group, Mothers Against Drunk Driving (MADD), is for family members of someone killed in a car accident caused by a drunk driver.

Self-Help Groups. In a self-help group, members share a common experience, but the group is not a formal or structured therapy group. Although professionals organize some self-help groups, many are run by members and do not have a formally identified leader. Various self-help groups are available. Some are locally organized and announce their meetings in local newspapers. Others are nationally organized, such as Alcoholics Anonymous, Parents Without Partners, Gamblers Anonymous, and Al-Anon (a group for spouses and partners of alcoholics), and have national headquarters and Internet websites (see Internet Resources).

Most self-help groups have a rule of confidentiality: who-ever is seen and whatever is said at the meetings cannot be divulged to others or discussed outside the group. In many 12-step programs, such as Alcoholics Anonymous and Gamblers Anonymous, people use only their first names so their identities are not divulged (although in some settings, group members do know one another’s names).someone who has committed suicide. One national sup-port group, Mothers Against Drunk Driving (MADD), is for family members of someone killed in a car accident caused by a drunk driver.

Self-Help Groups. In a self-help group, members share a common experience, but the group is not a formal or structured therapy group. Although professionals organize some self-help groups, many are run by members and do not have a formally identified leader. Various self-help groups are available. Some are locally organized and announce their meetings in local newspapers. Others are nationally organized, such as Alcoholics Anonymous, Parents Without Partners, Gamblers Anonymous, and Al-Anon (a group for spouses and partners of alcoholics), and have national headquarters and Internet websites (see Internet Resources).

Most self-help groups have a rule of confidentiality: who-ever is seen and whatever is said at the meetings cannot be divulged to others or discussed outside the group. In many 12-step programs, such as Alcoholics Anonymous and Gamblers Anonymous, people use only their first names so their identities are not divulged (although in some settings, group members do know one another’s names).