Use of Groups in Clinical Practice - Oxford University Press

Use of Groups in Clinical Practice - Oxford University Press

Work with Groups Step Seven: Clinical Group Work Chapter 16 Group Method Two Goals Like the history of social work itself, the history of group work entails commitment to two goals: (1) Individual change (clinical group work) (chapter 16) (2) Social change (non-clinical group work)

(chapter 17) Types of Groups Aggregation: a gathering of people in time and place who have no intent of forming or maintaining an affiliation. (waiting at a bus stop; movie audience) Natural Groups: Members come together spontaneously on the basis of naturally occurring events, interpersonal attraction or the mutually perceived needs of the members. (the family is a primary natural group followed by friendship

groups and neighborhood groups) Types of Groups Continued Formed Groups: Members (1) come together through some outside influence or intervention, (2) usually have some sponsorship (boy/girl scouts, agency auspice), (3) are convened for a particular purpose and (4) usually have a professionally trained leader. Practitioners work with both natural and formed groups.

Group Method Value-Added Skills Practitioners, whether in clinical social work or in policy, advocacy, management or community practice must acquire additional skills in group method. In addition, competent group work requires learning two distinct group skill sets; one for clinical group work (this chapter) and another for policy, advocacy, management and community practice (Chapter 18).

Paradox of Group Constructive-Destructive Forces There is universal ambivalence toward groups whether they are used in clinical or non-clinical settings. It is impossible to have any kind of group without the occurrence of contradictory process such as individuality/belonging; attachment/alienation; progression/regression. Constructive and destructive forces co-exist in any form of group life.

Inevitable Group Tensions The following inevitable group tensions occur whether in clinical or non-clinical groups: (1) Competition, (2) Rivalry, (3) Envy (4) Dominance, (5) Submission, (6) Criticism (7) Group pressure, (8) Scapegoating (9) Hostility, and (10) Rejection Types of Clinical Groups Historical Perspective Settlement House Movement: group program

activities and skill training. Members socialize and improve their lives. Recreation Movement: pursuit of leisure activities to encourage constructive use of time and to create a sense of community. Progressive Education: small groups are used to solve shared problems and to foster mutual aid Types of Clinical Groups Historical Perspective Therapy-Mental Health and Child Guidance Movement: group healing for

those in emotional pain. Foulkes is credited with fathering the group analytic method Residential living and treatment facilities: recognition of the dynamics of group living; effort to create a therapeutic social milieu; manage negative group dynamics. Professionalization Historical Perspective Grace Coyle (1948) established group work as a method within social work National Association for the Study of Group Work

(NASGW, 1936) transformed into American Association of Group Workers (AAGW): began group journal. NASW (1955) Merger of AAGW with National Association of Social Workers AASWG (1979) Association for the Advancement of Social Work Practice with Groups; effort to revitalize group work Merger: Gains and Losses Professionalization Group work gained professional status following its merger with NASW, however, its significance as a

method was overrun by the sheer number of caseworkers in the profession. Group Works tilt toward professionalization led to a tilt toward clinical group work Its standing as a significant model of non-clinical practice in policy, advocacy, management and community practice was lost. Group method was further eroded with the move toward generalist practice. Definition Group method is one clinical method choice

among several clinical method options (individual and family methods). Clinical group work is defined as goaldirected activity with small groups aimed at meeting the social and emotional needs of individual members and the group as a whole. Clinical Group Method Goals To promote, enhance, or restore individual: (1) mental health (2) social functioning

Not all clinical group work is group psychotherapy but all clinical group work serves therapeutic goals Groups in Clinical Practice Typology: Therapeutic Groups Recreational groups: Activities, fun, sport Skill acquisition: budgeting, cooking, car repair, sewing, life skills Play groups: developmental skills; interpersonal skills, taking turns, listening, sharing Self enhancement: dance, drama, poetry, music, art, book discussion

Social Milieu: Residential living Groups in Clinical Practice Typology:Psychotherapy Groups Analytic Groups Psychodrama Sociodrama Play therapy Psycho-education Mutual Aid Ego Supportive

Groups in Clinical Practice Typology:Psychotherapy Groups Social Microcosm Groups focused on social identity Groups focused on socialization to societal norms; conformity to law and order Optimism The Groups Potential Foulkes, Yalom, and Schulman are optimistic about the groups potential to bring about healing through its curative

properties. These scholar-practitioners admonish group therapists to trust the group Therapists are taught to rely on the creative properties of groups. Caution:The Anti-Group: Destructive Properties of Groups In contrast to Foulkes optimism, Nitsun cautions practitioners about the anti-group. Nitsun identifies 10 aspects of group life that cause anti-group sentiments among group

members: (1) the group is a collection of strangers (2) the group is unstructured (3) members create the group; worker is not always in control of the groups process Anti-Group Sentiments Continued (4) it is a public arena (5) it is a plural entity (6) it is a complex experience (7) it creates interpersonal tension

(8) it is unpredictable (9) it fluctuates in its progress (10) it is an incomplete experience Anti-Group Dynamics in the Analytic Group According to Nitsun (1996) the paradox of group life deepens when groups are used as a method of therapy. The therapy group is exaggerated by the paradox of group life generally and specifically by the conditions members bring to the group.

Groups can become pathological, mobilizing aggressive and destructive forces (Nitsun 1996; Bion, 1961). Anti-Group Dynamics in the Analytic Group According to Bion, neurotic and psychotic conditions are in essence group disruptive. According to Knopka, groups possess destructive power even when they are composed of healthy, rational, well-meaning individuals Otherwise good people harm other good people

when the destructive forces of group life are not properly managed. Empirical Studies 10 Properties Common to All Groups Empirical studies about how groups work have identified 10 properties common to all groups. All group workers must take into account the following properties of group: (1) size (2) purpose, (3) composition, (4) open or closed membership, (5) degree of desired cohesion, (6) group stages, (7) group structure,

(8) interaction and communication patterns, (9) curative factors and (10) anti-group sentiments and forces. Group Property Size Size refers to the optimum number of members needed to form a group to accomplish purpose-driven goals. The optimal size for achieving clinical goals is 5-10 members. Size must allow for absences and attrition.

Group Property Composition Group composition affects group dynamics and ultimately the effectiveness and efficacy of outcome. The group worker must weigh the value of homogeneity and heterogeneity on numerous composition variables e.g. gender, age, diagnoses, severity of condition, tension needed for change, compatibility or incompatibility of members,. etc. Example: Yaloms in-patient groups are heterogeneous on diagnoses; homogeneous on level of functioning,

capacity for insight, attention span (1 hr.) not disruptive, able to talk. Group Property Stranger Composition Stranger composition is the sine qua non of the therapy group. Nitsun notes that the psychological challenges of belonging to a group may be greater than commonly recognized. Group life often re-evokes and recreates feared interpersonal situations.

Groups can lack containment and protection; members fear breach of confidentiality and exposure to a wider community. Group Property Socio-Demographic Composition Workers must take into account socio-demographic variables such as race, gender, class, ethnicity, religious affiliation, sexual orientation. How syntonic or dystonic members should be on these socio-demographic variables depends on the purpose of group.

If the difference is too great, subgroups may form, creating greater intolerance and blocking change. If there is not enough difference the tension needed for change will be absent. Group Property Open or Closed Membership Open: anyone welcome, at any time Closed: no new members once formed. Whether membership should be open or closed depends on the purpose of the group and the degree of cohesion sought.

Analytic groups: closed membership- trust is needed for self-disclosure. Recreation or skill training groups: open Group Property Cohesion The degree of cohesion depends on the goal of the group. The goal may be: To break down cohesion when groups act cohesively to achieve destructive ends e.g. gangs To foster cohesion where no camaraderie

exists and when worker wants group to foster group identity and sense of belonging Group Property Typology of Group Stages Every group and every session passes through identifiable stages. See exhibit 16.3 Failure to recognize and work with group stages can lead to therapeutic errors and missteps. Tuckmans stages are: forming, norming, storming, performing and ending. Bions stages are: dependency, independence (fight/

flight), interdependence (pairing), work, ending Generic stages are : beginnings, middles, & ends. Group Property Structure: Subgroups Like other systems, groups have a structure. Groups have the following structural forms: the individual member, sub groups, and the group as a whole. Subgroups (cliques) may come in pairs, triads for foursomes; leaders and followers. In-group/outgroup: Sub groups have boundaries

that include and exclude other group members. Ingroup/outgroup dynamics are destructive to individual members and to the group as a whole. Group Property Structure: Roles A role structures interaction The role a member plays may interfere with individual change and may block the work of the group as a whole. See exhibit 16.4 Schulman identifies the following roles that occur in groups: (1) gatekeeper, (2) deviant, (3)

scapegoat, (4) internal leader, (5) quiet member, (6) defensive member-denial.(7) monopolizer. Cliques and roles are structural formations. Group Property: Norms Patterns of Interaction Communication and interaction patterns establish group norms. Norms may be explicit or implicit. Explicit norms: day and time of meeting; length of meeting (1.5 hr.); duration of group (brief-12 weeks); use of talk or activity.

Implicit norms: Is it safe to trust? To take a risk? To be angry? To miss a session? To cry? Norms: sabotage or support the work of the group Group Property Communication Patterns Often groups begin by using a maypole or round robin pattern of communication where each member, in turn, directs some communication to the leader. Eventually the communication patterns become dynamic and implicit.

A sociogram captures implicit group communication & interaction patterns; who initiates an exchange, how frequently and to whom it is directed. Group Property Communication What is communicated may be expressed verbally or nonverbally. Members communicate through words, feelings (tears, laughter,) and behavior (who sits where, who comes in first, leaves last).

Members communicate near problems-and introduce problems as the session ends; doorknob. Non-problems: Themes are discussed rather than the specific problem of a specific individual. Group Property Yalom: Curative Factors Groups possess curative factors: (1) hope, (2) universality, (3) imparting information, (4) altruism, (5) corrective recapitulation of the primary family group, (6) imitative learning, (7) interpersonal learning,

(8) group cohesion, (9) catharsis, and (10 ) existential factors. Group Property Shulman: Mutual Aid Mutual Aid consists of: (1) sharing data, (2) the dialectic process, (3) discussing taboo areas, (4) all-in-the-same-boat, (5) mutual support, (6) mutual demand, (7) developing a universal perspective, (8) individual problem solving, (9) rehearsal, and (10) strength-in numbers

Group Property Nitsun: The Anti-Group Analytic therapy groups contain destructive forces which the group therapist must manage. The anti-group challenges the optimistic perception of the therapy group as a healing medium. When therapy groups fail to develop as therapeutic entities, such groups may act pathologically. The flip side of Yaloms core curative factor, interpersonal learning is interpersonal threat.

Group Property Anti-Group Phenomenon Rise of anger and hostility in the group A high drop out rate

Excessive member absences A state of tense, negative impasse Abrupt ending of the group Nitsun remains skeptical about the ability of the group, or its leader, to control the groups own destructive process once unleashed. Group Property Reparation and Transformation Foulkes believes that reparation & transformation lie in confrontation of anxiety about destructiveness.

Confrontation awakens the urge to repair. Containment, if not resolution, of group destructive forces relieves some anxiety. Brief and short term models of group therapy appear to minimize the likelihood that destructive forces will be unleashed. Theories that Inform Group Work Practice. The major theories that inform analytic group therapy are borrowed from: (1) Psychology, psychodynamic theorypersonality; Ego identity; Ego strength

(2) Sociology, symbolic-interaction theory and socialization theory definition of self; social identity. Analytic Groups Psychodynamic Theory The purpose of analytic groups is to change individual maladaptive patterns of communication and interpersonal interactions thought to originate in childhood. There and then plays out in the the here and now of current relationships. An individuals maladaptive patterns are reenacted and corrected through the medium of the

group. Recapitulations lead to diagnostic hypotheses and corrective interventions. Analytic Groups Psychodynamic Theory Individuals in analytic group therapy benefit from insight (interpretation) and from experiencing self-others correctively in the interactive group moment Group members and the therapist substitute for the individuals family and those in the clients current interactive environment.

Analytic Groups Psychodrama: Moreno Referred to as the theater of spontaneity; an off shoot of psychodynamic theory. Enactment of problem scenes in the clients life are followed by corrective scenes. The client plays both the protagonist and antagonist to view the problem from different perspectives. Other group members may stand in for significant others in the clients life Other members recognize self in other and gain

insight and healing vicariously. Analytic Groups Gestalt Therapy: Perls Perls rejects analytic orthodoxy. The hot seat is used to focus on one member The worker follows the unfolding of the members experience but does not direct it as in sociodrama. The emphasis in Gestalt therapy is on the clients moment to moment awareness and feeling state. Observers are thought to benefit vicariously.

Analytic Groups Sociological Theories The group is a social microcosm of an individuals environment of socialization. Group dynamics reflect experiential learning about social self related to culture, ethnicity, race, religion, sexual orientation, gender, socioeconomic class and handicapping condition. Issues of poor self-esteem, identity, social status, and stigma arise through group dynamics and are the focus of attention. Analytical Groups

Sociological Theories When sociological theories are used, it is hypothesized that how an individual feels, thinks, and behaves is the result of socialization to status (structure-function theory) and reference group membership (symbolic interaction theory). When psychological theories are used, causality is attributed to childhood and current interpersonal maladaptive patterns of interpersonal relationship. Managing Destructive Group Behavior

Managing the Anti-Group: Caution is warranted when the destructive forces of group life are unleashed. It is difficult to transform such forces once they have developed. Transference- Counter-Transference: Groups trigger multiple transferences and counter-transferences. This is potentially helpful and harmful depending on the workers skill Analytic group therapist: Need additional training beyond that offered in most schools of social work. Group Method

Rules of Thumb Group method is not appropriate for all clients. The clinician must be able to predict and balance the needs, strengths, and vulnerabilities of members, when composing a group, in a manner that will benefit each member and the group as a whole. A worker should not knowingly compose a group that will lead to dynamics that she/he is unable to manage. Group Method

Contra-Indications No one should be forced to participate in a group against their will; this includes non-clinical school and work groups. Analytic group method is contra-indicated for those individuals who are non-verbal, unable to take into account the viewpoint of another, or who may be secondarily traumatized by their participation . Group is not an appropriate method for those who have a cultural norm against self-disclosure.

Group Method Contra-Indications Group is not an appropriate method for those who are highly vulnerable to the aggressiveness of others or those, who are themselves, highly aggressive. Group Method Missteps It is a misstep to allow a member to leave the group in a vulnerable state because of the groups process.

The worker should not leave unchecked, the attack of one member or the group on another, negative ingroup/outgroup dynamics, individual acting out, or a members negative reaction to group process. The practitioner is obligated to intervene in negative group dynamics. Group Method Sample Process Recording See exhibit 16.6 Process Recording of a boys recreational group- constructive use of time

See exhibit 16.7 on the decision schema for choosing group method as a clinical intervention. See chapter 17 for the use of group method in policy, advocacy, management and community practice.

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