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Running head: CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE 1

Concepts, Theories and Practice of Group Work within Mental Health Care Dermot Connolly Stenberg College PSYN 203-3 D. McCreedy August 2013

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE Abstract

This paper explores some of the more influential concepts and practices of the therapeutic group and how they apply to mental illness. The role of the group therapist is first explored including the importance they play in the development of a therapeutic relationship and how that role evolves over time. The relationship between the evolution of the therapist and the development of the group is also critically analyzed and compared against other nursing models. In addition, the role of cohesion is also recognized in the development of group therapy. Using case studies from the field, examples of the relationship between cohesion and a reduction in symptoms is also presented. Finally, the correlation between cohesion, universality and hope are also explored. In particular, the roles each of these factors play in the clients recovery. Keywords: group therapy, therapeutic relationship, stages of development and cohesion.

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE Concepts, Theories and Practice of Group Work within Mental Health Care Unlike individual therapy, group therapy offers the client the opportunity to explore common ground with other members suffering from similar problems. Group therapy offers the client a safe environment in which to engage with others while exploring new methods of treatment under the guidance of a group counselor. (Herkov 2006). For the client, progress towards resolution is achieved through feedback from the group and observing the progress of other members. (Herkov 2006). Since its inception, the implementation of group therapy has

introduced many common themes and practices that have allowed for the practice to be critically analyzed. Such analysis helps to improve the service and empowers the client to determine if group therapy is a suitable form of intervention for them. The purpose of this report is to analyze some of these more influential concepts and practices of group therapy as it applies to the mental health sector. The fundamental role of the group therapist is first explored before reviewing the progression of the group through the different stages of development. Finally, the role cohesion plays in the development of the therapeutic milieu is also considered. Central to the foundation of any effective therapeutic group is the role of the therapist. Of particular importance is the establishment of a positive relationship between the therapist and their clients. For such a relationship to exist, the therapist must hold the client in the highest positive regard in addition to displaying empathy, acceptance and concern towards the client. (Yalom & Leszcz 2005). While the role of the therapist is critical in the formation of a therapeutic relationship, it extends beyond these postures to also include; the activation of the here and now and the creation of the group and its culture. (Yalom & Leszcz 2005). Once group

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE therapy has begun, the role of the therapist changes to that of gatekeeper, where he attempts to manage attrition rates from what Yalom describes as clients of therapeutic failure. (Yalom & Leszcz 2005 p118). While the inability of a client to remain in treatment may be viewed as a failure by some authors, there are others that suggest gender and age can play a significant role in group therapy

attrition rates. In a study carried out in Spain for example, the attrition rates of three hundred and twenty nine alcoholic patients were measured over the course of five years. The study found that women were significantly more compliant to psychotherapy than their male counterparts. (Monras & Gual 2000). The study also found that participants under the age of thirty five were also likely to drop out. Some of the explanations given for early drop out included guilt and lack of family support, but at no point did the authors consider the clients a failure. (Monras & Gual 2000). In the absence of analysis therefore, it could be argued that better discretion could be used before attaching negative connotations to clients who drop out of group therapy. Particularly as many may be quiet vulnerable at the time of their departure. As the group matures and becomes more established, the therapist takes on two additional roles; that of the technical expert and the model setting participant. Both roles are utilized by the therapist to shape the direction of the group in a process called norm construction. (Yalom & Leszcz 2005). Under the role of technical expert, the therapist will follow the role more traditionally associated with that of a therapist where the group is steered in particular directions depending on the goals of the group or the perceived benefits from the therapist. (Yalom & Leszcz 2005).

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE For many clients, group therapy is presents a set of challenges that asks them to depart from their acquired social norms in favor of a set of rules to which they may not be accustomed.

Such rules include active participation and sharing with a group of strangers while being asked to alter their behaviors. (Yalom & Leszcz 2005). For many, such a transition can be a difficult one and clients will often look for encouragement to participate and take risks without fear of ridicule of retribution. (Yalom & Leszcz 2005). To this end, the therapist looks to reassure the client by engaging in the therapeutic process themselves where the clients observe the therapeutic effects of risk taking without any adverse effects on the therapist. Yalom refers to such a process as model setting. (Yalom & Leszcz 2005). The importance of the role of the group therapist is effectively demonstrated during the evolution of the group. Effective group work takes time and as the team moves towards their collective goals, they follow a series of stages. This hypothesis of group development was first proposed in 1965 by Bruce Tuckman who developed a five stage theory in order to better understand the dynamics of group formations. (Mind tools 2013). Tuckman hypothesized that all groups will go through the initial stage of forming where the group is largely dependent on the therapist for guidance and structure as subgroups are formed between members. (Tuckman 1965). The second stage is characterized by confrontation and conflict as group members mould themselves to the organization of the group. (Tuckman 1965). While such conflicts may not come to the surface, they still require the skills of the group leader to recognize and mange them effectively. While the importance of group cohesion will be analyzed later in this discussion, its importance in group development cannot be overstated. Tuckman describes the role of cohesion in the Norming process of group development. (Tuckman 1965). Norming is characterized by

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE the alignment of behaviors as group members come to accept the different opinions of each participant. (Tuckman 1965). During norming, members begin to discuss their problems allowing for the dissolution of sub groups and proactive growth through group cohesion.

Tuckman classifies the next stage as performing and acknowledges that this stage is not met by every group. Performing is marked by the independence of each group where members are working either solely or in sub groups towards a common goal. (Tuckman 1965). In the final stage of group development, Tuckman describes the termination of the group as the adjourning phase. (Tuckman 1965). During this phase, the achievements of the group are recognized as the groups objectives are either met or have timed out. The adjourning phase can be a source of anxiety for some group members as they attempt to maintain their normal activities in the absence of their group support structure. (Tuckman 1965). In many ways the adjourning phase draws many parallels with the some of the theories surrounding psychiatric nursing such as the resolution phase of Hildegard Peplaus interpersonal relationships theory. (Nursing theory 2011). Like the adjourning phase, the resolution phase proposed by Peplau can be a source of great distress for the client and the nurse / therapist. The goals of the relationship are evaluated by the client with either their nurse or therapist. If all goals have being satisfactorily met, then the professional relationship must be dissolved, with all ties being cut to facilitate the clients need for independence and growth. (Nursing theory 2011). While Tuckmans model is very applicable in a group therapy setting, it is important to remember that the model is applicable in all settings where teamwork is preformed. (Mind tools 2013). Some of the limitations of the model center on the fact that not all groups follow each stage. Depending of the time limitations imposed on the group for example, some stages may be omitted or skipped. Tuckman himself acknowledged for example, that the performing stage is

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE not always attainable due to the groups members inability to operate independently. (Tuckman 1965). Critics of the Tuckman model could therefore argue against it validity, if it is not applicable to all group settings. It has being well established that we all have an inherent need to belong to something or to be accepted. Such an attachment makes us feel loved and our transgressions understood. (Yalom & Leszcz 2005). By their very nature, therapeutic groups generate positive

reinforcement that nurtures such attachments through the establishment of an environment where open expression of feelings and emotions is encouraged. (Yalom & Leszcz 2005). Within such an environment, group cohesion is fostered through the encouragement of each member to try new ideas and conceive new forms of expression. Reference was made earlier on the importance of the established therapeutic relationship between the therapist and the client. In fact studies have shown that the success of therapy and in particular group therapy can be attributed to an effective therapeutic relationship founded on empathy, warmth and acceptance. (Yalom & Leszcz 2005). One such study focused on the development of cohesion with a group of individuals undergoing group therapy for social phobia. The study concentrated on measuring the cohesion ratings of participants at the midpoint and endpoint of their group therapy and found significant increases in cohesion rates throughout the course of their therapy. (TaubeSchiff, Suvak, Antony, Bieling & McCabe 2007). The study also found a close correlation between increased cohesion rates and a reduction in social anxiety symptoms. (Taube-Schiff, Suvak, Antony, Bieling & McCabe 2007). Yet cohesion alone does not bring about recovery in the client of group therapy. Other factors in addition to cohesion play a role equally as important such as universality and hope. (Tomasulo 2011). For the client, hope is derived from the commonality of purpose which allows

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE clients to bond as they strive together towards a common goal. (Tomasulo 2011). In fact the more the homogenous the group, the more powerful the effects of cohesion, universality and hope. Yet the very factors that contribute to the strength of group therapy can also limit its potential. (Tomasulo 2011). The moment may arise where the client wishes to expand their experiences or explore alternative emotions that are limited within a homogenous group. In instances such as these, continued growth can only be achieved through participation in a more

heterogeneous group model. (Tomasulo 2011). Yet despite this challenge, cohesion still plays an important role in the success of any group therapy. It helps facilitate a supportive environment where clients form meaningful relationships under conditions of acceptance and understanding. (Yalom & Leszcz 2005). In addition, studies into attrition rates of group therapy suggest that early dropout rates impede the progress not only of the client but also of the group. (Yalom & Leszcz 2005). Further analysis into cohesion suggests that it can facilitate a more stable group environment resulting in lower attrition rates and better attendance. (Yalom & Leszcz 2005). Research would suggest therefore that cohesion not only has direct positive implications on the group through the development of relationships, but it also has an indirect positive impact in the attrition rates of the group. For the client of the mental health sector, the range of therapeutic services available to them is extensive. In addition, choice exists into the format that service is provided. The use of group therapy as a form of psychiatric treatment has evolved over the years to allow for the development of several common themes. The development of such themes has empowered both the client and the therapist to make informed decisions about which type of treatment is suitable for their needs. To this end, some influential concepts to group therapy have developed over the years and include; the role of the group therapist, the stages of group development and the

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE importance of group cohesion. The analysis of each of these concepts has revealed a clear interrelationship between each of them. The role of the therapist for example is fundamental in the establishment of a therapeutic relationship. It is that therapeutic relationship that holds the group together as the role of the therapist evolves over time. Such evolution can be tracked through different development stages of group development which modifies the role of the

therapist to include gate keeper, technical expert and model setting participant. This evolution of responsibilities plays an important role in the development of group cohesion where client will look towards their therapist for reassurance as their explore new forms of treatment and engage more with their group members.

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE References Herkov, M. (2006). About Group Therapy. Psych Central. Retrieved from: http://psychcentral.com/lib/about-group-therapy/000677 Mind tools (2013). Forming, storming, norming and performing. Retrieved from: http://www.mindtools.com/pages/article/newLDR_86.htm Monras, M. & Gual, A. (2000). Attrition in group therapy with alcoholics: A survival analysis. Drug and alcohol review.19. 55-63. Retrieved from:

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http://onlinelibrary.wiley.com/doi/10.1080/09595230096156/abstract?deniedAccessCust omisedMessage=&userIsAuthenticated=false Nursing theory (2011). Hildegard Peplau theory. Retrieved from: http://nursingtheory.org/theories-and-models/peplau-theory-of-interpersonal-relations.php Taube-Schiff, M., Suvak, M., Antony, M., Bieling, P. & McCabe, R. (2007). Group cohesion in cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy. 45. 687-698.

Tomasulo, D., (2011). Therapeutic factors: The power of universality, cohesion and hope. Psychology Today. Retrieved from: http://www.psychologytoday.com/blog/the-healingcrowd/201107/therapeutic-factors-the-power-universality-cohesion-hope

Tuckman, B. (1965). 5 Stages of Group Development. Adapted from Development sequence in small groups. Psychological Bulletin, 63. 384-399 and Tuckman, B. & Jensen, M. (1977).

CONCEPTS, THEORIES AND PRACTICE OF GROUP WORK WITHIN THE MENTAL HEALTH CARE Stages of small group development. Group and Organizational Studies, 2. 419-427. Retrieved from

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http://stenbergcollege.mrooms3.net/pluginfile.php/40904/mod_resource/content/0/PSYN _203_groups_session_6_rf1.pdf Yalom, I. D., & Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy (5th ed.). USA: Basic Books.

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