elements of successful group interventions

Elements of Successful

Group Interventions

Michele Aluoch, LPCCRiver of Life Professional Counseling LLC

Group Therapy• An evolving culture• 1. Treatment of individuals who share their

psychotherapy• 2. Treatment of groups so they mange cooperatively

• Rather than therapist centered is group centered• The group is the common ground• The whole can be worked on by highlighting any part of

it

Types of GroupsHomogeneous Versus

Heterogeneous• Homogeneous- One type of sex,

age, issue, demographic, treatment approach

• Heterogeneous- Varied in background

• What might be some pros and cons?

Types of Groups• Who is likely to benefit from this

therapy?• What will happen if I blend by

sexes, diagnosis, or other variables?

Types of Groups

Open versus Closed Groups• Open Ended- ongoing where new participants

are allowed to join as well as old participants leave with flexiblity

• Closed group=- time limited with a commitment of regular attendees

Types of GroupsGroup Psychotherapy

• Clinical practice• A type of psychotherapy• By a specifically trained licensed counselor or

social worker, psychologist, psychiatrist or nursing staff

• With members characterized by previous clinical assessment results

• Goal= repairing pathology

Types of GroupsTherapeutic Groups

• Led by human services personnel• Not necessarily trained• In a hospital , community mental health center,

or rehabilitation or activities venue• Goal= remediation, achievement of improved

functioning

Types of GroupsSelf Help Groups• Voluntarily face to face groups of people

with similar struggles• Goals: help members control a common

problem, advice on coping strategies, enhancement of self esteem

• E.g, AA, Al-aon, Gamblers Anonymous, weight loss groups, divorce care groups

Task GroupWadsworth, J. (2008). • Accomplishing certain goals

(planning groups, treatment conferences, community organizations, study circles, task forces)

• Courses in: organizational development, management, consultation, theory and practice of task/work facilitation

Psycho-educational GroupWadsworth, J. (2008)

• Imparting and discussing and integrating information (workshops- stress management, support groups

• Courses in: Organizational development, school and community counseling, health promotion, theory and practice of group counseling

Counseling GroupWadsworth, J. (2008). • Addressing relationship issues(Career

counseling, victims of abuse)

• Courses in: human development, health promotion, theory and practice of group counseling

Psychotherapy GroupWadsworth, J. (2008). • Remediating psychological problems

eating disorders, sexual disorders depression, anxiety, etc.)

• Course in: human development, assessment and treatment of mental health disorders

General Group Guidelines

• Few, clear• 8-12 participants• 1- 1 ½ hours each weekly• Homogenous or heterogeneous?• Open ended versus closed group?• Location• Expectations• Confidentiality• Sharing communication

Getting Group Referrals

• Rare to get enough referrals and a specific type of referrals on your own

• Many wrong referrals which can lead to dropouts

• Collateral referral sources• Method for referring is important• Plan for more referrals than needed

because of screening and dropouts

Cost• Cost effective

compared to individual psychotherapy

• $60-$120 for one 45 minute session versus $40 for 90 minutes.

• $40 X 10 = 40

Screening Potential Members

• Hearing what the patient’s goals are- where he/she believes life is at versus where he/she would like to be

• Identification of any disqualifying factors• Discussion of resistance or ambivalence about being

in a group• Exploration of other group experiences role played

scenario• Ability to follow through with time and obligations• Responses to interpersonal problems• Rationale for joining the group- other

mandated/suggested vs. wanting to be there


• Degree of ego when people have strong opinions

• Willingness for consents with other professionals

• Interactions with others in group situations?

• Any significant issues?• Thorough assessment• Comprehensive


Three key Elements:• 1. Expectancy- “Working in a group will really

help me.”• 2. Participation- “I like to share my feelings

with others.”• 3. Domineering- “I argue for arguments sake.”

• Discuss the potential for each of these for that person in group

Say “No” To• People with poor cognitive abilities• People with little insight• Those who do not want to self reflect• Those unmotivated for change• Defensive• Guarded• Instigators

Say “Yes” To• Those who want change• Those goal minded• Action oriented• Those who ware wiling to learn• Those who respect interpersonal

interactions• Those who would benefit from supportive

role models for imitative behavior• Those who will do the work of therapy• Those who will allow themselves to be

challenged

Exercise: Screening Potential Members

• A dual diagnosed multi-substance using antisocial personality with a history of three assaults and combative style

• A highly dependent woman who needs excessive reassurance for all her decision making and lacks assertiveness skills and a mind of her own

• A young man who has been unable to keep a job and make a living for himself

• A woman grieving a recent diagnosis of terminal cancer• A middle aged female who has been taught to hold

emotions in al her life yet has so much bottled up anger and resentment inside


• A professional career gentleman who is very wealthy and has things in life generally go his way until his recent DUI when his alcohol abuse had been discovered by the public

• A nurse who became shaky on the job and was losing her ability to maintain professionalism because life stresses had mounted up too much

• A court mandated woman who just wants to get the requirements over with in the stupid system

• A man who tends to isolate himself and withdraw and lacks social skills for interpersonal relationships


• A homeless woman who lacks transportation but is highly motivated to get her life back on track as it once was years ago

• A young adult man whose parents are wiling to pay whatever it costs for him to go through a program so he does not waste his life away

• A verbally argumentative woman who becomes manic and talks loud and nonstop

• A woman who is recently widowed who sits most of the day and cries

• A man who hears voices and believes he can hear the thoughts of the people on TV, the animals and nature around him

• A woman who has frequent command hallucinations to rid the world of all tall people, rich people, and people trying to poison her food

Informed Consent• 1. enhances the patient’s autonomy• 2. decreases the risks of regression• 3. shifts responsibility to a collaborative

arrangement• 4. increases practitioner’s accountability

• Open discussion of pros and cons• Automatic part of prep process

Informed Consent• Receptionist given Vs. Therapist given

• Discussed• Preferably:• 1. in person• 2. directly given to the client one on one• 3. with room for discussion• 4. personalized and evolving

Informed Consent• The Nature of the Group• Purposes and goals of the group, individual

versus group goals• Obligations of the member and leader• Agreement to follow group rules• Regular attendance and notice of cancellations• Compliance with homework• Cost and method of payment• Session time, length and number of sessions• How to be reached outside session time

Informed ConsentTherapist Qualities• Credentials, experience, personal

characteristics

Treatment• Risks and Benefits• Giving and receiving feedback• Dealing with emotional reactions

Questions Re. Group Therapy

Group Therapy• How does group therapy work?• How does group therapy compare to other types

of therapies?• What are the risks? • How many clients improve after group therapy?• Do any clients get wore?• How log will it take?• What if therapy isn’t working?


Alternatives• What other types of therapies are out there?• How do they work?• What are the risks and benefits of these

alternatives to group therapy?• What about medication options and

treatments?• Which therapies are most effective for my

issues?


Appointments• What times and dates are the groups?• How often are groups?• How much do they cost?• How is payment made? Insurance ? Our of

pocket?• Who can I talk to between appointments?• What if the weather is bad or I need to

cancel?


Confidentiality• How do you keep group records?• How are records protected?• Who has access to my info.?


Money• What is your fee?• How do I pay?• What about missed sessions?• Do I need to pay for phone calls? Letters? E

mails?• What are your policies about raising fees?• If I lose my source of income do you offer a

sliding scale?


Insurance• What info. Are you required to tell my insurance

company?• What if I get new insurance you do not accept?• What if I lose my insurance?• How would therapy be different if I choose to pay

versus go insurance?

General• What is your training? Licensure?

Five Group Stages

1) Dependency- Also called forming2) Conflict- Also called storming3) Cohesion/We-ness4) Work/Performance5) Adjourning/Termination

Stage One: Dependency

• Forming• Pre-affiliation with the group• Anxiety, caution, dependency• Desire to flee• Leader: primarily an educator

• What do you want?• Why are you here?• Expectations?• Locus of control-blaming others/complaining or learning

to manage what is within

Stage One: Dependency

• Membership- who is in and out• Time starting and ending, vacations• Subject matter sharing• Affective expression guidelines• Sharing when anxiety level is becoming

too much

Stage Two: Conflict• Struggles begin to erupt• Power and control issues• The group as a whole • The subgroups• The outsiders

• Therapist- primarily reaffirming the groups; purpose and setting ground rules and expectations

Stage Three: Cohesion• Becoming coherent around a set of rules

and norms• Building trust and openness• Communication is more free• Feedback becoming more open with

guidelines

Stage Four: Work/Performance

• Open exchange and feedback• May move back and forth at this point• Expect fluctuations• Emotions and catharsis higher• Opportunity for disllusionment and

depression

Stage Five: Termination

• Separation from the group• Chance to generalize skills on own outside

the group• Fears about resurgence of presenting

problems• Gift giving, sharing food, positive

affirmations• Plans for ongoing maintainence of

therapeutic gains

Record Keeping• General goals and observations of group

as whole• Also specific observations and goals for

each participant- separate files for each• Required for accountability standard of

care as well as third part payers, and employers, continuity of care if release of information

Group Therapeutic Factors

• Universality• Altruism• Installation of Hope• Imparting of Information• Corrective recapitulation of the

primary family experience• Development of socializing

techniques

Group Therapeutic Factors

• Imitative behavior• Cohesiveness• Existential factors• Catharsis• Interpersonal Learning• Self understanding

Universality• All group members have shared

experiences• We are in this together• Leads to validation and acceptance

decreases stigma and isolation

Universality• A connection• Healing is possible because it

happened for someone else.

Exercise• Kay states that “it is clear I am not like the rest of you.

You have not at all gone through the level of hard times I have. My mom abandoned me at birth and I had no home. I never had any support system. Everything I’ve had I’ve struggled for. I had to protect myself, take care of myself, look out for number one. Seems none of you would now what it is like walking the street even as a 6 and 8 year old trying to scavage for my own food, having nowhere to do homework because drug dealers are in and out of the house, and daily having everyone stare at you because you are different. You all at least get sleep- I never know when the next gunshot is coming and if I’m safe.”

ExerciseBob states that he struggles being in a group with ‘you people’. He comments that “you don’t know the stress of heading a top company and managing and administrating anything because you can’t’ even manage your own lives. Whatever homelessness, lack of jobs, and life issues he believes are the other group members’ faults because they have not had the determination and resolve to do more and be proactive in their own lives.

Altruism

• By helping each other group members gain a sense of internal satisfaction.

• Providing assistance and insight to others• Improved other’s self esteem- “I’m worth

helping.”

Altruism

• Annette asks if she can offer some help about an idea that has worked for her regarding dealing with relatives. She wants to demonstrate how it is done to Carol.

• Gene states that he can connect some of the group members with referrals and phone numbers to a local employment agency that will give them on the job skills and training if they need a job. “They have helped me so much,” he says.

Installation of Hope

• Believing there are positive outcomes possible

• Belief plus agency• Anticipating an improved state• Possibility thinking, options• Concrete ways of achieving goals• An optimistic attitude• Hearing about others who have overcome

problems• Sense of “f they could do it, I can too”

Installation of Hope

• Related to self efficacy• Related to ability to effectively problem

solve• Related to motivation- willingness to give

and receive honest feedback, to experiment with new outcomes, and set reasonable goals

• A common therapeutic factor• Cultivated by self, therapist, and group• Cultivated through active involvement

Instillation of Hope• An opportunity to witness change

in others • Being celebrated for steps made• Tied to meaning making: 1. life has

a meaning, 2. decreased depression and anxiety

• Tied to creativity (foods , hobbies, leisure, self care)

Instillation of HopeThree task or Goals Related To Hope:• Comprehending the environment• Managing the environment• Pursuing meaningful ends

• Bricklayer metaphor- one goal produces another and more hope

Imparting of Information

• Providing psycho-educational info. regarding disorders, dynamics, techniques

• Therapist is expert with the information• Knowledge to build applications on• About diagnosis, how issues affect relationships,

treatment approaches, • Examples: how life might change after a loss or trauma• How to ask for what’s needed, how to develop new

skills, how to do daily tasks with a disability in a wheelchair, how to have hope filled proactive behaviors when you have a terminal illness, how to be accountable when you are tempted to slip into toxic behaviors

Imparting of Information

• Reflecting on what has been learned in a given group

• Tying together these and learning experiences

• Finding success out of what felt like stuckness or failure

Corrective recapitulation of the primary family experience

• People ted to if in a therapeutic situation long enough act out significant life interpersonal themes and problems

• Another opportunity for working through

• Family is represented symbolically• Family= first group• Power to change is in the interchanges

Corrective recapitulation of the primary family experience

• Processing times in which members relate to other members as if they were a part of their families

• Processing bringing past family dynamics into the present

• Identifying old dysfunctional family of origin messages

• Developing alternatives

Exercise• James screams at another group member stating “Did I

ask you for your opinion? I dolt need a father! Never had one anyway and don’t want one now!”

• Lucy cries stating “you’ll leave me too just like they all did. Mom chose her life over me when she put me up for adoption. Wait until you find something else to do too.”

• Nikki exclaims, “why try and solve problems anyway. The same things happen. It was just like when I grew up. Dad hit the bottle and hid at the bar. Mom kept quiet and dove into household chores. But no one talked. No one dare say how messed up the home was.”

Development of socializing techniques• Meeting new people• Dealing with different people• Entering into the group• Dealing with feeling as if you are an

outsider• Giving/receiving feedback• Socialization cues• Communication means (verbal and

nonverbal)

Development of socializing techniques• Breaking through isolation to connect

with others in meaningful ways

Exercise• John admits, “we always stuck to our own kind of

people from our neighborhood. Have seen more types of people in this group then I ever saw I all my years growing up. “

• Bonnie says even those she is 55 years she “is not sure how to begin communicating her feelings to other because he is so fearful of rejection.

• Dave, the tough 40 year old man, finally breaks down. “I never learned how to love someone. I just screamed louder or hit someone. Now I want to show my wife I love her but where do I begin? I hear you guys talking and I don’t know what love is.”

Imitative Behavior• Observing and trying new things• Safe, vulnerable setting• Skill acquisition is often more successful

when done by observing and imitating peers than therapist

• Building desire to succeed and master issues• Therapist and members role played and

offered real life alternatives to member destructive behaviors

Cohesiveness• Somewhere I belong• Even when I am gone a bit I fit back in• Apace to identify with• Finding commonalities in the midst of

perceived differences• A sense of bounding• Working together toward perceived goals• Engagement• Mutual acceptance

Cohesiveness• Support• Affiliation with the group• Attraction within the group• Belief that there is meaning in relating to the

group• Feeling accepted as I am• Belonging• Sense of team spirit

Cohesiveness• A subjective experience of the relationship

between self and others

• Identification-methods:• 1. Agreeing among themselves on something• 2. Rallying against a leader or member or issue• 3. Ignoring a leader, member, or issue

• Cannot occur without a therapeutic alliance in place

Example: Cohesiveness

• Mary had a tendency to wear her feelings on her sleeve. It was apparent to all the others that she felt injustice as all the private practice patients seem to have a closeness with each other and the group leader that she felt she and the other “outsiders” could never have . She began frequently asking about the differences between the interactions of the “favored clients” of the therapist and the outsiders.

Existential Factors

• Building a sense of self responsibility• Shifting from an external to internal

locus of control• Issues like meaning, life, death• Who am I?• Where do I exist in the world?• How do I matter?

Catharsis

• A place to feel• Dealing with emotional distress• A place to deal with defenses. Hopes, fears• What to communicate or not communicate

and when• Helping each other mobilize inner

resources attendees may not realize they have

Catharsis

• Insights may be accompanied by resurfacing of old psychological wounds

• The group provides context for feelings expressions

• Being able to show how I really feel

• Getting things off my chest

Exercise• “No one has ever let me be myself. For

the first time I feel like I can share what is going on inside me. No judgment. This group is not like the cold hearted world out there, “ states Jen.

• “Feelings are worthless,” retorts Jeff. “They don’t do anything good. Like dad said you juts need to buck up and act tough. Be a real man.”

Interpersonal Learning

• Observations of others• Direct feedback• Indirect responses• Suggestions• Role modeling• Teaching by leader• Groups within groups

Interpersonal Learning

• Taking advantage of naturally occurring incidents

• Creating teachable moments

Self understanding• Past cycles• What works and what doesn’t work• New alternative options• Why I did what I did• Why others might have done what

they did• Humility

New Factors in the

Literature

Multicultural Diversity, Divergence

Hornsey, M.J., Dwyer, L., Oei, T.P.S., &Dingle, G.A. (April

2005).

• Argument: cohesiveness is too general a concept

• Cohesiveness is not well operationally defined

• Need for personal expression, dissent, challenge are more important in the working phases of groups


Fambrogh, M.J., & Comerford, S.A. (Sept. 2006)

• Allows for more heterogeneity• American society being pluralistic does not do well with

the traditional group tx model• Should not be greatest good but each finding goodness

of fit• One size does not fit all• The majority may not really represent the whole as

used to be thought• The traditional model works when norms are clear,

reinforced and rewarded by the power bearing majority


Fambrogh, M.J., & Comerford, S.A. (Sept. 2006);

Rubenfeld, S. (October 2001).

• Allows for norms to evolve and be altered• There is no status quo• Goals are relative to individual circumstances• Multiple meaning making possibilities• Inequalities and social injustices can be

acknowledged rather than ignored• Multiple perspectives are good


Fambrogh, M.J., & Comerford, S.A. (Sept. 2006) Traditional Contextual

Seeks Cohesion, agreement, sameness, identification

Respect for differences, diversity

Truth Whatever the group majority says it perceives

Evolving respective to the individual and interpersonal dynamics

Approach Don’t rock the boat, share within boundaries

Respect all realities

Timing Process is more important than timing

Interpersonal context, time frames are critical

Philosophy Idealism Pragmatism

Contextualism• Actions and events interact in a

context• Everything is constantly changing• It is not possible to get perfect

agreement and cohesion from all• Group change is also cummulative

Which model do you prefer?

Traditional model?

OR

New Divergent Contextual model?

Authenticity Versus Sincerity

Authenticity-• Approaching truth with wisdom• What I do with when I become self aware• Generally censored• Expresses Love

Sincerity• Desires growth of the person and group• Willingness to deal with the breakdown of safe

ideas to share what’s in one’s heart• Expresses passion•

Facilitative • Encourage group sharing of information

(as opposed to didactic)• Finding out hat the group specifically

needs and tailoring to that• Accepting• Nonjudgmental• Empathic (not necessarily agreeing)

Courage• Affirming the members decision to face possible

issues without any guarantees of outcomes• Willingness to participate in potentially

uncomfortable therapy• Willingness to do something difficult even

without constant recognition• Speaking about certain issues• Broaching new solutions• Being around different diverse people• Trying new techniques• Taking a risk

Individuality• Maintaining self • Multiculturalism• Diversity factors

R religious/spiritual E economic classS sexual identityP psychological developmentE ethnic/racial identityC chronological issuesT trauma and threats to well beingF family issuesU unique physical issuesL language and location or residence issues

Challenging/Confronting

• Can serve to correct imbalances• Ca be therapeutic• Helps to encourage and influence

different ways of building and maintaining change

Building Attachments• Insecure or anxious attachments- fears of

rejection or abandonment• Going between desire to be close and desire to

reject or push away• Believe others are inconsistent and unreliable• Avoidant attachment- act like they don’t need

others, are independent, and others are untrustworthy, irrelevant, or too needy

• Building cohesiveness can assist in building healthy attachments

• Especially important for the therapist to assess herself or himself

Group Therapy Skills• Active listening• Linking• Blocking• Summarizing

Group Problem Resolution

• People who talk too much• People who don’t talk• Members who arrive late or leave

early• Change of therapist• Scapegoating

Talk too Much• Slowing things down• Acknowledge their input• Redirect• Return to group standards and

boundaries

Talk Too Little• Invite input and exploration• Direct inquiries• Roundtable method• Return to value of group as a whole

Silence in Group• Could be resistance or defense mechanism• Not always bad• May be a learned behavior• Silence is communication• May be a cover for hostility• May be an uncertainty of how to react or what is okay to

say or not• Can be a reaction to group changes- breaks, changes in

leaders, newcomers, changes in group stage, etc.• Can occur when fears o risks are present- “What if I

reveal myself?”

Silence in Group• Can be a reaction to

seeing group members reprimanded for sharing too much

• Can be an attempt at punishing the leader

Example • Anna often spoke up throughout group of

her feelings of being unloved, unwanted, and unappreciated in life by others. When the therapist tried to include everyone in discussions she began voicing how her urgent and valuable comments were passed by. ‘I am just a victim as usual. No one wants to hear me. Everyone matters more than me.”

Arrive Late/Leave Early

• Emphasize group norms, rules, and boundaries

• Is this representing something?• What is the message behind this?• Can be used as a n example for a

general issue

Scapegoating• A means for the group to blame rather

than heading issues head on• A defense mechanism, projection• Frequently someone who may be

influential to the group• Should be used therapeutically

Psychodynamic Group Processing

• Who am I?• Who would I like to be?• Who should the others be like?• How should the others perceive me?

Newcomers• Stressful because challenges the security, cohesion,

predictability the group has already achieved• May challenge the group expectancies• Can offer new perspective• Can be a good source for new observations and input• Uncertainty who and what and when confrontations and

comments can occur• Old timers see newcomers as upsetting to cohesion

already established in the group• Minority influence can occur with consent and done

properly

Newcomers• Debate and uprising may signal the desire

to work through tension• NOTE: People can be silent in one on one

and outspoken in groups or vice versa

• Doe the therapist confront tensions with newcomers or not?

Example: Newcomers• Two new people joined a group in addition to

those who had already been coming. Ground rules and procedures had long been in effect. With the new attendees there appeared to be regression to former group stages. One of the new group members began arriving late, complained about being hungry and the group time, and frequently had negative comments and “suggestions” about nearly everything in the group. He demanded that the leader reconsider the timing of the group and the way it normally was constructed in terms of time management

Chaos Theory• Groups move back and forth from disequilibrium

to balance• Any change can set a group off balance• Any change can make members reassess• The heart of a group: how do we stay the same

while changing?”• Therapist’s role- containing the group when chaos

is being sorted through

The Seven ResilienciesLaursen, E.K., & Oliver, V. (Spring 2003)

• Reframing problems as strengths

• 1. insight-asking touch questions• 2. independence- being your own person• 3. relationships- connecting with people who

matter• 4. initiative-taking charge• 5. creativity-using imagination• 6. humor- finding what’s funny• 7. morality- doing the right thing

Strengths-based Mental Health Descriptions

Laursen, E.K., & Oliver, V. (Spring 2003)

• Major Depression- sadness regarding a series of events

• Oppositional Defaint Disorder- standing up for yourself when you believe you a re being violated

• Anger- a feeling of anger that is at times justified but you forget to control in a way that is acceptable to others

• Bipolar- Moodswings that keep you from being calm, organized, and collected

• Adjustment disorder- Being comfortable with your current situation that makes it difficult for you to adjust to the new thing

Group Process• Process• Here and now experience• How the group is functioning at a given moment• In relationships and interactions among group

members with each other and with the group leader

• A systems perspective• Process involves doing something about which

participants might have been hesitant or frightened before

Group ProcessBrown, N.W. (April 2003).

• What is the group doing to promote safety?• How is the group establishing norms?• What is the group’s reaction to authority?• What threatens the group?• How does the group mange uncomfortable

emotions?• How are important feelings expressed or ignored?• How is the group managing its work?• What personal feelings or reactions am I having?• How much is from the group versus from my past?• Is the group stuck or forward moving?

Key Aspects For Successful Group

Therapy• Presence in the here and now• Comfort with affect in the room- cerate safety,

invite strong feelings, and place high priority on sharing feelings

• Empathic connection• Facing shame without defenses or withdrawal• Earning different communication styles• Developing alternatives to goal achievement• Improving interpersonal skills

Group CompetenciesLaRocque, S.E

• Comprehensive understanding of stages of groups

• Therapeutic factors which influence change in groups

• Therapeutic techniques for groups• Ways of collaborating between therapist and

group members• Participation/attendance in a group• Hands- on group facilitation• Estimated 4-6 month timeline• Positioning as participant observers in groups

Group CompetenciesLaRocque, S.E

• Identification of and skills for working with therapeutic factors like universality, cohesiveness, the stages of development, and corrective relational experiences

• Assisting group members in affirming, empathizing, confronting, and influencing one another

• Translating theory into techniques

Teaching Group Counseling Skills

(Furr, S.R., & Barrett, B., 2000)

Four essential areas of preparation:• 1. Theory• 2. Opportunity to observe groups and

learn and practice group skills• 3. Participating in an experiential group• 4. Practice leading or co-leading a group



• Students select a group topic weekly• Each week a new step is introduced and

the student assignment for that week is to complete that step

• Teacher lectures and demonstrates that step

• Class size is 20 with 10 in each group

Group Training- Three Phase Model

First phase- 45 minutes, senior co-leader and leader and the outer circle of staff observers• A communication boundary between the inner and

outer circles. Patients work on their issues with the co-leaders.

Second phase- 15 minutes, the inner circle of staff observers, the senior leader, and the co-leader reacting to the discussion in the first phase, and the outer circle of patients who are now observing. There is a communication boundary between the inner and outer circles.


(Furr, S.R., & Barrett, B., 2000)Third phase- 15 minutes, Patients, staff observers, and the two coleaders all talk together and process their intrapsychic , interpersonal, and group as a whole reactions to the discussion in phases one and two.

• Staff shared thoughts and feelings while patients observed.



Initial phase:• Group one: Are we safe? Are there

boundaries?• Group two: Who would the leaders favor?• Group three: Everyone processed about

being new and worrying about their roles



Reactive phase- testing how far they can talk about emotions and issues, dealing with issues of control and power, disappointments and hurts, coping with pain

• Group One: Competition between leaders• Group two: There was a discussion about how

uncomfortable staff felt.• Group three: The co-leaders discussed patients

who were unable to continue with the group to the next phase


(Furr, S.R., & Barrett, B., 2000)Work phase: Goal directedness, cooperating on activities

• Group one: moving the group to a neutral position• Group two: Co-leaders demonstrated that it was

possible for people to work together in spite of their differences, which became more apparent as the group matured

• Group three: Patients were particularly interested in how the two co-leaders could feel and express anger with one another and still work together


(Furr, S.R., & Barrett, B., 2000)Termination Phase:• Group One: Patients were sad about terminating

and talked about missing each other.• Group Two: Staff talked about missing each other.• Group Three: All participants integrated what

they had learned.

Leader Skills• Facilitating• Managing conflictFour Categories of Awareness:• 1. Split awareness- Paying attention to what is going on in the

foreground while maintaining an awareness of background process

• 2. Dual awareness- Tracking the external processes while keeping in tune with the internal processes in reaction to what is occurring as well as input for the group

• 3. Role awareness- Noticing roles as they emerge and the effects of these roles

• 4. Self reflective awareness- Notice, evaluate, and comment on inner experiences with members as they occur

Leader Skills• Principles of group dynamics• Group leadership styles and approaches• Group process• Group therapy types of groups• Prepare standards for group leaders• Apply ethical and legal issues for groups• Use multicultural principles• Apply theories of group counseling• Apply group counseling methods

Activity GroupsCowls, J., & Hale, S. (January 2005).

• Trends toward lesser hospital stays and insurance approving lesser stays and treatment days in general

• Move towards more activity groups and psycho-educational groups

• Activity groups-Crafts, cooking, arts, decorating, exercise, wellness

• Psycho-educational groups- social skills, conflict resolution, communication skills

Activity Groups

Cowls, J., & Hale, S. (January 2005)• Why do clients attend groups while they are in the

hospital?• What do they value in these groups?• When in the course of a client’s recovery are they

ready to process and utilize information form these groups?

• Less threatening• Easier to attend• Metaphorical• Produce insight• Easier to get at defense mechanisms

Activity Groups

Cowls, J., & Hale, S. (January 2005)• Can be more effective at developing interpersonal skills

with certain mental health populations• Thinking outside the box• Can develop awareness and insight quicker and

members are more wiling to acknowledge

• Includes: visual arts, music, media, and others symbolic representations

• E.g. Color your World- pick colors that represent feelings or meanings, draw lines and symbols, share story

Draw Your SolutionA problem I am currently facing

Steps to Get to the Solution

What the Solution Would Look Like If It was Solved

Demonstration GroupsGans, J.S., Rutan, J.S., & Lape, E. (2002).

• Used for training group professionals• Mental health professionals (between 6-8) who

volunteer to be members of a group to be held by a senior group therapist in front of an observing group of students, peers, and colleagues

• Once or a few limited times in workshop setting• Opportunity to be led by a senior group

therapist• Improved self confidence in competencies

Demonstration GroupsGans, J.S., Rutan, J.S., & Lape, E. (2002)

The Physical Setting• Should have microphones and ability to

hear various dynamics of each group discussion and training

• The group agreements

Demonstration GroupsGans, J.S., Rutan, J.S., & Lape, E. (2002).

Three Parts of the Didactic Section:• 1. Discussion by the leader of themes and significant

affective moments, salient group dynamics, leader interventions, and theory

• 2. Response to questions or comments from the observer group

• 3. Processing what the observer group is experiencing:• What did they identify with?, Perceptions of the leader’s

work? What would they do differently? Themes they became aware of? Most compelling moments for group members?

CBT Groups• Look at classical and operant conditioning

principles• Focus on the antecedents and consequences in

terms of what they are doing to keep behaviors going.

• Change by changing toxic thoughts and problematic behavior

• Stop reinforcing the problem and reinforce what’s healthy

• Group may challenge thoughts and behaviors which are unhealthy

CBT Groups• Where is the evidence?• Where is the logic?• What do you have to lose?• What do you have to gain?• What would be the one thing that could happen?• What can you learn from that experience?

• Goal= max beh. Change• Guide group interactions to enhance awareness

of thoughts, beliefs, behaviors and emotions

Writing Groups• Leader with both clinical and writing skills• Not about the quality of the writing style• How to assemble language to share experiences

with others• Writing makes the individualistic world of the

person shareable with others• Facing anxieties, exercising concerns, giving

feedback, hearing advice, sharing differing worldviews

Writing Groups• Gives a chance for the group therapist to process what

the member is looking for

• Empathy?• Agreement?• Support• Listening?• Encouragement? No Criticism or correction?

• Themes can be assigned (controlling person, family/parenting, abuse/trauma, sibling rivalry, something I’m afraid of

Affective Biblotherapy Groups

Schechtman, Z., & Nir-Shfrir, R. (Jan. 2008)• Increase ability to be vulnerable and catharsis in

group• Self administration function• Allows for insight without embarrassment• An indirect method• May include books, films, short stories, poetry• A method of role modeling and identification of

restorative narrative and alternatives

Inpatient Hospital Groups

Burlingame, G.M., Earnshaw, D., Barlow, S.H., Richardson,

E.J., Donnell, A.J., & Villani, J. (October 2002).

• Identify types of groups for populations served (psychotherapy, psycho-educational, skill-based, counseling, activities)

• Should be part of a systems wide approach• Overall hospital staff should enhance group

competencies• Ceo, Administration to highlight the importance of

groups• Key personnel on units selected as “group champions”

to attend annual and specialized trainings

Inpatient Hospital Groups

Burlingame, G.M., Earnshaw, D., Barlow, S.H., Richardson, E.J.,

Donnell, A.J., & Villani, J. (October 2002).

• Establish hospital wide standards of care for group programs

• On units establish structure which allows for an incorporates groups

• Weekly meetings on units with group coordinators• Groups multidimensional- cognitive affective, and

behavioral components• Most hospital staff have little or no group clinical

training so workshops need to be held regularly for building competency

Considerations With Older Adults

Saiger, G. M. (Summer 2001)• Mobility Issues• Health concerns• Accomodations needed• Which subgroup?: medical, managed care,

activities program, group home, retirement village, mental health

• Forgetfulness, dementia issues• Speed• Preoccupations: body functions, health, death,

repetitive stressors

Termination• Should be processed from beginning on

Factors:• Unemployed• Unmarried• Childless• Lower income• Criminal History• Witnessed trauma• More severe psychopathology• Alcohol/substance problems• Social isolation

Scenarios In Group

TherapyFor Discussion

Scenarios In Group TherapyA person likes to talk about his or her problems but does not seem to be mindful and respectful of the needs of the other group members

Some group members have begun dating and developing romantic feelings for each other as they have identified over common issues

Subgroups are developing in the group which are at odds with each other

A group member comments about you (the leader) liking certain people more than others because you set boundaries.

Scenarios In Group Therapy• It is challenging to get any group work done because a

member keeps trying to derail the conversation

• A member has a strong emotional reaction and begins crying uncontrollably

• A member has a strong reaction and begins yelling uncontrollably

• A member admits to the group some trauma previously hidden

• A member tells the group that he will be quitting because the group is not helpful

Scenarios In Group Therapy• A member becomes defensive and insulted over

something that was misperceived

• A member expresses a need to be vulnerable and share a deep issue and realization they have never shared with anyone but they are afraid of the group’s reaction

• The group becomes more social and chatty when they are supposed to be working on a task or issue

• Members of the group perceive that you (the leader) tend to give nonverbal attention and more talk time to your “favorite” group members.

Scenarios In Group Therapy• Your colleague would like to lead a group. She is very

excited about learning some new techniques in grad school but has never tried these techniques out. Eager to try something new she sets up a group using the newly learned techniques. What do you say or do about this? How would you describe here level of competency?

• Your work setting does not want to pay the independently licensed people more to lead the therapy groups so they use some paraprofessionals and lay people with some basic training to do a mixture of therapy, education, and activities groups.

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