Work with Groups

Step Seven: Clinical Group Work

Chapter 16

Group MethodTwo 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 GroupsContinued

• 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 MethodValue-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 GroupConstructive-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 GroupsHistorical 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 GroupsHistorical 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.

ProfessionalizationHistorical 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 LossesProfessionalization

• 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 goal-directed activity with small groups aimed at meeting the social and emotional needs of individual members and the group as a whole.

Clinical Group MethodGoals

To promote, enhance, or restore individual:

(1) mental health

(2) social functioning

Not all clinical group work is group psycho-

therapy but all clinical group work serves

therapeutic goals

Groups in Clinical PracticeTypology: 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 PracticeTypology:Psychotherapy GroupsAnalytic Groups

• Psychodrama

• Sociodrama

• Play therapy

• Psycho-education

• Mutual Aid

• Ego Supportive

Groups in Clinical PracticeTypology:Psychotherapy GroupsSocial Microcosm

• Groups focused on social identity

• Groups focused on socialization to societal norms; conformity to law and order

OptimismThe Group’s 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 group’s process

Anti-Group SentimentsContinued

(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 Studies10 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 PropertySize

• 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 PropertyComposition

• 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: Yalom’s 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 PropertyStranger 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 PropertySocio-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 PropertyOpen 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 PropertyCohesion

• 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 PropertyTypology 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.

• Tuckman’s stages are: forming, norming, storming, performing and ending.

• Bion’s stages are: dependency, independence (fight/flight), interdependence (pairing), work, ending

• Generic stages are : beginnings, middles, & ends.

Group PropertyStructure: 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 PropertyStructure: 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 PropertyCommunication 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 PropertyCommunication

• 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 PropertyYalom: 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 PropertyShulman: 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 PropertyNitsun: 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 Yalom’s core curative factor, “interpersonal learning” is “interpersonal threat”.

Group PropertyAnti-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 group’s own destructive process once unleashed.

Group PropertyReparation 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 InformGroup Work Practice.

The major theories that inform analytic group therapy are borrowed from:

(1) Psychology, psychodynamic theory-

personality; Ego identity; Ego strength

(2) Sociology, symbolic-interaction theory

and socialization theory – definition of

self; social identity.

Analytic GroupsPsychodynamic 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 individual’s maladaptive patterns are re-enacted and corrected through the medium of the group. Recapitulations lead to diagnostic hypotheses and corrective interventions.

Analytic GroupsPsychodynamic 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 individual’s family and those in the client’s current interactive environment.

Analytic GroupsPsychodrama: Moreno

• Referred to as the theater of spontaneity; an off shoot of psychodynamic theory.

• Enactment of problem scenes in the client’s 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 client’s life

• Other members recognize self in other and gain insight and healing vicariously.

Analytic GroupsGestalt Therapy: Perls

• Perls rejects analytic orthodoxy. • The hot seat is used to focus on one member• The worker follows the unfolding of the member’s

experience but does not direct it as in sociodrama.• The emphasis in Gestalt therapy is on the client’s

moment to moment awareness and feeling state. • Observers are thought to benefit vicariously.

Analytic GroupsSociological Theories

• The group is a social microcosm of an individual’s environment of socialization.

• Group dynamics reflect experiential learning about social self related to culture, ethnicity, race, religion, sexual orientation, gender, socio-economic 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 GroupsSociological 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 worker’s skill• Analytic group therapist: Need additional training

beyond that offered in most schools of social work.

Group MethodRules 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 MethodContra-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 MethodContra-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 MethodMissteps

It is a misstep to allow a member to leave the group in a vulnerable state because of the group’s 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 member’s negative reaction to group process.

• The practitioner is obligated to intervene in negative group dynamics.

Group MethodSample 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.