GROUP THERAPY QUIZ 3

the advanced group

šGroup that has matured and become stabled; there’s no longer the initial and forming stage in group

šDeals with once everyone is settled and everyone starts working on their goals , there can be issues that rise up from this as well

Characteristics of the Advanced Group

š Individual reflection: not only talking about issues but reflecting about them as well

š Authenticity

š Self-disclosure: not only talking about issues but reflecting on them as well

š Feedback loops: people will share, trust will be enabled, further sharing continues, the loop begins again

šPeople might also show pathologies, they receive feedback, loop continues again

šThe therapist encourages development of the therapeutic factors

šInstillation of hope, altruism, etc.

key challenges of subgrouping

-Really important as a therapist to discourage subgroups, but realize that it’s natural occurrence: leave channel for communication open if not complications can occur

-The reason subgrouping is natural and difficult to resist is because we seek comfort and from smaller groups

-If therapist conceals subgrouping, it blocks the groups from functioning and it can be disruptive to the group as a whole

-Sometimes two group members will be very guarded in a larger group and close between them two

-Group therapist also has to stop and think what might be causing members to seek help therapy outside of the group as a whole: Could there be someone inside the group members are threatened by, cohesion might not be yet developed

-Essentially when members engage in subgrouping they’re trying to reduce their anxiety: Some might not be comfortable in larger group and comfortable in smaller groups

what is extra-group socializing

šthe first stage of subgrouping

§  Members talk on the phone, have coffee, dinner, etc.

§  Occasionally sexual involvement occurs: important to prohibit and discourage this

subgrouping goals with parents goals

šIf the goals of the subgroup are congruent with the parent group, then subgrouping can enhance the group

šEX. A therapist is leading a group of substance users and you give them a call number in case the members have a strong urgency to use drugs. However, you the therapist aren’t available 24/7 thus you might potentially have numbers of other members to call instead when they feel those cravings

šIn this example, it’s extra group socializing but the goal is similar to the parent group, which is sobriety and not to relapse 

subgroups and drop out rates

šStudies show that there is a greater degree of drop-out rates when subgrouping occurs

šOne of the reasons is because members might feel excluded; might think “well why wasn’t I asked to out for coffee?”

šInstead of processing this feeling of exclusion they drop out instead

conflict in group therapy

šConflict is inevitable and will occur in some shape or form

šIf therapist tries to suppress or deny conflict, it comes out in ugly ways: passive-aggression, micro aggressions, members being rude towards each other, members ignoring other members, excluding them,

šGroups should not be too nice→if they are they’re mirroring the therapist’s avoidance of aggression; Members avoiding stating something that might potentially help another member change due to a fear of aggression from the other member

šKey of being too nice: avoiding making a comment that might potentially help another person in fear of making the other person upset

develops along a predictable sequence in group

hostility

there are various sources of hostility, such as

šAttacking the of Perception: lashing out on someone due to our own projection of discomfort on someone else

šResult of Transference: over-identifying with over-interpreting→EX. might think the leader’s behavior is like that of your parent

šShun Other People that have Similar Characteristics as Us that we do not Like about Ourselves

šHaving a Fragile Sense of Self: EX. if someone is experiencing shame it comes out as anger

šRivalry in Group: can be as simple as competing with another person in group

šPerson has a Character of Begin Hostile: person might struggle with paranoia

šCould be one’s own disappointment in group leader or member

how to deal with hostility

-Both parties believe they are right, they have opposing beliefs: Therapist helps both of them understand whoever is in conflict with each other; Help members agree to disagree; Help understand there is really no absolute truth in that both members can actually be right; it’s not a win-lose situation

-Primary success of overcoming conflict effectively is by cohesion in the group

-Therapist helps individual to develop mutual trust and respect for each other: This keep the channels of communication open for people to verbalize their opposing views in order for mutual trust and respect to develop

-If there’s empathy between group members, it can help with hostility: it humanizes people 

What can be defined as conflict in group

Not agreeing with someone, issues between members, something that triggers members frustration, irritation, and aggravation

how does therapist manage conflict

šHave members experience the issue

šTherapist helps clients reflect on the self-defeating moves from here and now feelings to process: It decreases the intensity of the emotions and allows for reflection

šMembers might come to contributions of the conflict: members are more willing to acknowledge how they contributed to the conflict

šAn indirect self-defeating mode of fighting can sometimes occur in groups: the statement of “See what you’ve done to me today?”-> it’s like the person if hurting the other person but themselves more

self disclosure in groups

šClients often fear and value it

š  Integral component of group therapy

šInvolves risk and must be done in sensitive supportive group environment

the predictable sequence clients follow when engaging in self disclosure

šthe discloser shares with receiver who is likely to feel obligated to reciprocate with personal disclosure.

šNow they are both vulnerable and the disclosure in group creates an environment that elicits more disclosure

šIn this regards self disclosure is contagious; the more you will self disclosure the more others will too

maladaptive disclosure in groups

1.Members who do not disclose do not gain genuine acceptance by the group: members are very guarded of what they want to engage in

2.Too much disclosure alienates others and monopolizes time interfering with the group process: It interferes with the group process making the session all about that member and others might feel deprived

termination stage of group therapy

šConcluding phase of therapy; should truly begin when you meet the first time as a group

šHowever, the talk about termination should really begin in the pre-group session with your clients

šEX. “we are in our 8^th session today and have 9 more to go; how does everyone feel about that approaching day when we all say our goodbyes?”

šThese discussions need to be had because grief and loss are natural part of one’s life

importance of timed termination in group

šshould be processed in group for a few sessions to allow for closure and lessen the shock of departure

šDon’t wait until the last session to talk about termination because people will not have time to process that goodbye

šPeople like predictability→ having sessions to process

termination and members dropping out

šMembers that suddenly drop out are also part of termination→Processing loss of other group members is important to process

-New members should not be brought in without having a session of one or more meetings where you process this ‘loss’

what is a conjoint therapy

Client in individual therapy with one therapist and a different therapist moderates group; two therapists co-leading group therapy

o   The two therapists are co-leading the therapy

o   KEY: treatment modalities have to be similar to each other

§  Ex. if group is focusing on the here and now, then in individual you also have to be focusing on the here and now, not focus on the past per say

what is a combined therapy

Participating in group and individual therapy with same therapist

o   This increases cohesive groups because the therapist knows their clients more and is able to put their clients in a group that will benefit them more

Group therapy alone can be effective, but there are some clients in which conjoint therapy would be more effective, such as the following

·      Clients who have a history of child SA

·      Clients who are going through a severe life crisis

·      Clients who have suicidal ideation

when combining co-therapists, we want to make sure we don’t have clashing therapeutic theories from one therapist or the other

§  Some approaches mesh very well while others do not

§  EX. here and now approaches mesh well with CBT approaches, but here and now with psychodynamic approach of therapy wouldn’t go well together

o   Main concern is for the client to be getting therapy someplace else, which wouldn’t be helpful for the client, in the case of a different theoretical orientation

12-step group are

NOT group therapy

12 step groups and their leaders

It has no leader, rather it only consists of peers

o   Quite effective and very effective if the group therapist doesn’t discourage it, rather encourage that social support

o   Important for the therapist to not go “Oh, that’s not group therapy, just come to group instead”

o   The 12 step can complement group and the therapist can even implement things from the 12 steps into group

o   If the client is not for the ideal of the 12 steps, then do not pressure them to go

12 step groups and feedback

do not get feedback

o   Each member shares their group experiences

o   This is effective because these kinds of groups usually have members who have ‘senior’ members and new members

§  The ‘senior’ members take the newer ones under their wing, they get a ‘sponsor’ who helps them with the 12 steps

what is a ‘sponsor’

a more experienced person in 12-step meetings

Misconceptions of 12 step groups

§  Myth that 12 step groups don’t believe in psychotherapeutic medications

§  Groups may disown personal responsibilities: Not releasing personal responsibility for your addiction, there are steps further down the 12 step rules that make people do this action→ EX. one group might take on the disease model, stating that ‘the addiction is out of one’s control’

§  Psychotherapy neglects spirituality: False, because one is thought to accept clients regardless of their spirituality, helping them to grow

§  Myth of not needing the 12-step model: Not true especially if person doesn’t have any social support from family or friends

Advantages of Having a Co-Therapist in Group

§  Can be helpful o both therapist as well as to the client

§  Parent dynamic between client and therapists that can sometimes mimic the client’s relationship with their parents: Helpful for the parental transference that can occur

§  Opportunity for each therapist to have a different perspective: One therapist might have a gift with certain clients that the other one might not have, or one therapist might be able to get the message across with clients better than the other one

§  The two co-therapists can serve as the peer consultation: After and before sessions, communicating and working effectively with each other

Disadvantages of having a Co-therapist in Group

§  If there happened to be a conflict between the two it can manifest itself among the group itself: The two need to work on the conflicts or communicate better

§  Competition can arise between the two therapists: Comparing themselves to each other based on level of competence, seniority level, peer relationship

§  When one co-therapist is assigned to a therapist: No rapport or relationship between the two; if you are thinking of getting a co-therapist interviewing them to see if there’s a match is an excellent way of seeing if the two will work effectively, have common theoretical orientations

BIG reason why communication is important in co-therapy

§  There will be clients that will attempt to split the two therapists

o   Splitting: siding with one therapist over the other in attempts to split the team

o   Similar to the child splitting the parents: “if I can’t get my mom to side with me then I can try to get dad on my side”-> what this does is that ‘dad’ says yes and ‘mom’ says no causing conflict between the two

o   Communicating will allow the two therapists to see the splitting that is going on and keep it from occurring

The Leaderless Meeting

(Not really common anymore)

·      Occurred in 1950s but diminished in popularity today

Audiovisual Technology

Immediate or delayed play back during sessions

·      Important to obtain the informed consent of the client that you’re recording

·      Often done for teaching and research purposes: teaching for graduate students or because of research being done on the groups

Written summaries

·      Can be very helpful for clients when therapist writes down a detailed summary near the end of group

·      Could even have assignments for your clients in which they have to write a summary of how group went

o   Could ask the client in individual to talk about it to integrate group into individual

Structured Exercises

·      CBT uses a lot of structured exercises, mindfulness groups

·      An activity that Mindfulness groups do is go for a walk

o   Called mindfulness walk, in which therapist helps them focus on the here and now as they’re going for a walk; feeling the sun, leaves, etc.

·      Other examples that mindfulness group do include:

o   deep breathing exercises

o   3 things that someone might see, hear, taste, smell at the present moment

o   progressive muscle relaxation

·      With children there tends to be more structured exercises for their developmental level interpretations

Modifications for Certain Specialized Groups

šWhen one is doing substance use groups, you tend to have a variety of interpersonal difficulties: Tend to have members at different levels of their abuse

šIf conducting therapy with, it’s important to know if you are familiar and agree with the 12-Steps: Will have clients who are either court ordered or go freely by choice; Compliment the therapy we do with substance

šThe principles and therapeutic factors one learns in long term outpatient can be applied to other specialized groups

Rule of Thumbs to remember for specialized groups

šAssess the client’s situation: look at what types of groups one is dealing with: If one is working with certain types of groups, some things that one typically wouldn’t allow in regular you would allow in these groups→ EX. in regular groups, frequent absences are frowned upon, but if one is working with a chronically illness group absences might be more frequent-> in this case we should expect frequent absences

šImportant to realize that some groups are under the pressure of manage care and mandatory attendance: Will have clients who are court ordered

šSome groups require longer check-ins than one would typically do in outpatient: Having the opportunity to check in with majority of the members at some point in the group; Don’t wait until the end of the session to check in with the members

šFormulate goals that are clear and appropriate for your specialized group and link these goals back to the group task

šModify your techniques and determine which therapeutic factors play the greatest role in achieving one’s goals: EX. there might be a ’buddy system’ similar to having a sponsor in a 12 step group

Acute Inpatient Therapy Group

šImportant because they require radical modification of all the things we’ve learned of thus far

šConsider the clinical setting more so than ever because the group has a relationship with a much larger setting: You have the main group in addition to the nurses, psychologist, secretaries, psychiatrist; Environment is much more complex and effectiveness requires not only the therapist but the administration too

šExtrinsic factor could be turnover rates, this is out of our control: 95% of the time you will not have the same group twice

šThere’s a heterogeneity of pathology, this is also out of control: Will have patients who will actively be experiencing  psychosis, under medication, suicidal( low vs high functioning)

-Consider Time: know that you only have limited time with the group, thus may not have time for pre-group sessions

šLeader has a different role in inpatient: If there’s a co-therapist, the leader doesn’t have control over who that co-therapist will be

Examples of Manageable Goals in Inpatient

šHelping them stay in group the entire time

šDecrease isolation and become more engaged in group

šBe more helpful towards others

šHelp relieve their anxiety with structured exercises 

šCall on people in group

šInstead of depending on others in group to provide active support, the therapist will be the one who will be the active supporter

šEmphasize the positives in group in an inpatient setting

šGoals need to be short term and more manageable

inpatient vs outpatient groups

šHelp individuals obtain support from the group: therapist needs to provide more directive support

šLateness: If one of the members show up late, praise them for showing up in inpatient; in outpatient one would discourage it

šGiving advice: In inpatient praise them for their attentiveness for wanting to help; in outpatient ‘giving advice’ is discouraged

šStill focused on here and now in inpatient, probably even more than in outpatient

šFilling the agenda: members in both inpatient and outpatient want to change maladaptive behaviors→ In inpatient, though, not everything is going to be done  and will not meet everyone’s agenda→ As therapist one would ask “If time permits, what would you like to get done”

šStill need to have an ‘end of meeting’ in both inpatient and outpatient groups

Groups with people with medical illnesses

šDoesn’t mean the illnesses is due to the psychological distress, but it creates psychological distress in people 

šFamily distress comes with medical illnesses: In attempts to console the family, a sense of isolation from the person arises

šMight be important to obtain consent from patient’s doctor to know what’s going on: Different questions may come up, such as questions about death, death anxiety, life’s purpose→ lots of existential questions

šExpect frequent absences in the group: some might be permanent while others are temporary 

psychological distress in those in illness groups

when people go through medical illnesses they experience a decrease in activities one used to engage in

this decrease can potentially contribute to certain symptoms such as feelings of worthlessness

General characteristics of medical group

šHomogenous regarding medical illness: Might have members in different stages of the illness; some might be more terminally ill than others

šTime limited

š4-16 sessions

Cognitive Behavior Therapy

šMost common form of therapy, existing in both individual and group therapy

šTend to be more structured in processed groups

šLook at the same idea of attempting to access thoughts through probing, asking Socratic questions, and encourage self examination of thoughts and self monitor: As members are doing all of this, therapist is working on identifying patients’ core beliefs; Therapists job is to restructure the core beliefs into more adaptive firming affirmation beliefs

šCBT groups are also time limited, involving 8-12 session lasting from 2-3 hours: Tend to be more structured, focused, and goal is to acquire cognitive and behavioral skills; Not uncommon to have HW in these kinds of groups(EX. have clients go home and log their automatic thoughts relating them to their mood and behavior)

two main categories of core beliefs in CBT groups

beliefs within relationships( Am I worth loving)

beliefs about competence( can I achieve what I need to conform my worth)

what is the group focus of CBT groups

šGroup focus is for clients to go home and function effectively

šEX. Might begin with teaching a skill for challenging their automatic thoughts, middle of the session you address target goals, end the session by consolidating gains and identifying future situations that might cause relapse into the maladaptive thinking

šTopics of discussion might include reinforcement, rewards

Doing exercises and making them process afterwards and worksheets are common techniques used