Corey Ch 12, 13, Yalom Ch 10

Applying the Cognitive Behavioral Approach With Multicultural Populations

Members who find catharsis distasteful due to cultural conditioning are less likely to be put off by CBT CBT and multicultural therapy share common assumptions that facilitate their integration CBT is culturally sensitive because it uses the client's belief system as part of the method of self-challenge Factors that contribute to CBT's usefulness with diverse client populations include its specificity and focus on objectivity task and action orientation emphasis on collaboration focus on cognition and behavior emphasis on brief interventions and the present problem-solving orientation CBT's emphasis on assertiveness, independence, verbal ability, rationality, cognition, and behavioral change may not work well for some clients More research validating the cultural considerations of diverse racial and ethnic groups is needed Spiegler (2013) contends that cognitive behavior therapy is inherently suited for treating diverse client populations due to its emphasis on individualized treatment and the external environment, its psychoeducational focus, and the active nature of the approach. CBT groups deal more with patterns of thinking and behaving than with experiencing and expressing intense feelings. Cognitive behavioral practitioners typically spend time preparing members to participate in a groupexperience. The group process is demystified and norms are made clear.In CBT, the explicit therapy goals are jointly determined by the therapist and members. Progress toward these goals is continually assessed, which provides opportunities for the members to influence the course and direction of their therapeutic work Cognitive therapists do not impose their beliefs on the group members; rather, they help members assess whether a given belief fosters emotional well-being. CBT group practitioners acknowledge the environmental contributors of problems many clients face, such as stress, inequality, and social injustice Both emphasize the need to tailor interventions to the unique needs and strengths of the individual. Both emphasize empowerment: CBT teaches clients specific skills that they can apply in daily life; multicultural therapy emphasizes cultural influences that contribute to a client's uniqueness. Both emphasize a strength model wherein the inner resources of the client are activated to bring about change. CBT's behavioral roots call attention to the influence of environment, which fits well with the multicultural emphasis on cultural influences. The attention given to transfer of learning and the principles and strategies for maintaining new behavior in daily life are crucial. Because CBT fits into a short-term group format, it is applicable to a variety of practical problems that certain client populations face, and the time frame makes it possible to deal with day-to-day concerns that these clients bring to therapy. CBT's emphasis on assertiveness, independence, verbal ability, rationality, cognition, and behavioral change may limit its use in cultures that value subtle communication over assertiveness, interdependence over personal independence, listening and observing over talking, acceptance over behavior change, and a less linear cognitive style Another limitation of CBT from a multicultural perspective involves its individual orientation, which emphasizes the influence of the physical and social environment. An inexperienced therapist may overemphasize cognitive restructuring to the neglect of environmental interventions.

PREPARATION FOR GROUP THERAPY

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Life Scripts

A life script is a blueprint that tells us where we are going in life and what we will do when we arrive A personal life script is an unconscious plan made in childhood as a result of parental teaching The life script is developed early in life as a result of parental teaching (such as injunctions and counterinjunctions) and the early decisions we make. Among these decisions is selecting the basic psychological position, or dramatic role, that we play in our life script. Indeed, life scripts are comparable to a dramatic stage production, with a cast of characters, a plot, scenes, dialogues, and endless rehearsals. In essence, the life script is a blueprint that tells people where they are going in life and what they will do when they arrive. During our childhood years we also decide whether people are trustworthy. Our basic belief system is thus shaped through this process of deciding about ourselves and others. If we hope to change the life course that we are traveling, it helps to understand the components of this script, which to a large extent determine our patterns of thinking, feeling, and behaving.

The Need for Strokes

A stroke is an act of recognition or source of stimulation People need to receive physical and psychological strokes to develop trust Strokes are exchanges; They can be offered, accepted, refused or rejected, and directly requested Strokes can be classified as: verbal or nonverbal unconditional or conditional positive or negative This need for stimulation and recognition is referred to as a need for strokes (a stroke is a unit of recognition). A stroke is any act of recognition or source of stimulation. An exchange of strokes defines a transaction. A basic premise of the TA approach is that humans need to receive both physical and psychological "strokes" to develop a sense of trust in the world and a basis for loving themselves. There is ample evidence that lack of physical contact can impair infant growth and development and, in extreme cases, can lead to death. Psychological strokes—verbal and nonverbal signs of acceptance and recognition—are also necessary to people as confirmations of their worth. ositive strokes that express warmth, affection, or appreciation verbally or with a look, smile, touch, or gesture are necessary for the development of psychologically healthy people. Negative strokes can be useful in that they set limits: "I don't like it when you use my computer without asking." Negative strokes are a way to give feedback to people about their behavior. They are sometimes essential in protecting children: "Stop right there! Don't go out into the street until I get to the curb and take your hand." Interestingly, negative strokes are considered preferable to no strokes at all—that is, to being ignored. We are all familiar with instances when children's actions elicit negative strokes from their parents. Even these responses are preferable to being ignored, dismissed, or emotionally neglected. TA group members are introduced to how they live the "stroke economy" and can then examine whether they have incorporated any of these five self-sabotaging rules about stroking: Don't give positive strokes when you have them to give. Don't ask for strokes when you need them. Don't accept strokes when you want them (and they are offered). Don't reject (negative) strokes when you don't want them. Don't give yourself strokes.

Feedback

After members practice a new behavior in a group session or report on their homework assignments in daily life, fellow group members or the group leader can provide verbal reactions to these performances. Feedback typically has two aspects: praise and encouragement for the behavior and specific suggestions for correcting or modifying errors. Feedback is a useful part of learning new behaviors, especially if it is constructive, specific, and positive.

Acceptance and Commitment Therapy (ACT)

Another mindfulness-based approach is acceptance and commitment therapy (ACT), which involves fully accepting present experience and mindfully letting go of obstacles (Hayes et al., 2011). In this approach, "acceptance is not merely tolerance—rather it is the active nonjudgmental embracing of experience in the here and now" (Hayes,2004). In the practice of ACT, there is a lack of evaluation and a conscious stance of openness and acceptance toward psychological events. Acceptance is not a specific technique; rather, it is a stance from which to conduct therapy and from which a client can conduct life. ACT is designed to help clients learn that suppressing negative or unwanted thoughts or painful feelings does not work. Commitment refers to making decisions about what clients most value and what they are willing to do to live a meaningful life. Values are a basic part of the therapeutic process, and ACT practitioners might ask clients, "What do you want your life to stand for?" ACT involves teaching clients to become aware of what is important to them and then to begin to shift their behavior toward a way of living that is more consistent with their values (Antony, 2014). The goal of ACT is to increase clients' psychological flexibility. This approach uses concrete homework and behavioral exercises to help clients live by their values. Some acceptance exercises include contemplating the Serenity Prayer, journaling about painful events, saying one's thoughts very slowly, writing difficult thoughts on a card and carrying them around, and doing something different and noting what happens. The focus of ACT is allowing experience to come and go while pursuing a meaningful life.

Mindfulness-Based Stress Reduction (MBSR)

Basically, all the skills taught in the mindfulness-based stress reduction (MBSR) program, such as sitting meditation and mindful yoga, are aimed at cultivating mindfulness. The program includes a body scan meditation that helps clients to observe all the sensations in their body Those who are involved in the program are encouraged to practice formal mindfulness meditation for 45 minutes daily. The MBSR program is mainly designed to teach participants to relate to external and internal sources of stress in constructive ways. The program aims to teach people how to live more fully in the present rather than ruminating about the past or being overly concerned about the future.

PRELIMINARY CONSIDERATIONS

Before convening a group, therapists must secure an appropriate meeting place and make a number of practical decisions about the structure of the therapy: namely, the size and the life span of the group, the admission of new members, the frequency of meetings, and the duration of each session. In addition, the contemporary practitioner often must negotiate a relationship with a third-party payer, HMO, or managed care organization. 1 The tension between therapeutic priorities and the economic priorities of managed care regarding the scope and duration of treatment must also be addressed.2

Behavioral assessment

Behavioral assessment consists of a set of procedures used to obtain information that will guide the development of a specific treatment plan for each client and help measure the effectiveness of treatment. Behavioral assessment (1) is aimed at gathering unique and detailed information about a client's problem, (2) focuses on the client's current functioning and life conditions, (3) is concerned with taking samples of a client's behaviors to provide information about how the client typically functions in various situations, (4) is narrowly focused rather than dealing with a client's total personality, and (5) is integrated with therapy.

BRIEF GROUP THERAPY

Brief group therapy is rapidly becoming an important and widely used therapy format. To a great extent, the search for briefer forms of group therapy is fueled by economic pressures. Managed care plans and HMOs strive relentlessly for briefer, less expensive, and more efficient forms of therapy.x A survey of managed care administrators responsible for the health care of over 73 million participants24 noted that they were interested in the use of more groups but favored brief, problem-homogeneous, and structured groups. Perhaps it is best to offer a functional rather than a temporal definition: a brief group is the shortest group life span that can achieve some specified goal—hence the felicitous term "time-efficient group therapy".28 A group dealing with an acute life crisis, such as a job loss, might last four to eight sessions, whereas a group addressing major relationship loss, such as divorce or bereavement, might last twelve to twenty sessions. A group for dealing with a specific symptom complex, such as eating disorders or the impact of sexual abuse, might last eighteen to twenty-four sessions. A "brief" group with the goal of changing enduring characterological problems might last sixty to seventy sessions.29 Whatever the precise length of therapy, all brief psychotherapy groups (excluding psychoeducational groups) share many common features. They all strive for efficiency; they contract for a discrete set of goals and attempt to stay focused on goal attainment; they tend to stay in the present recent-problem-oriented focus); they attend throughout to the temporal restrictions and the approaching ending of therapy; they emphasize the transfer of skills and learning from the group to the real world; their composition is often homogeneous for some problem, symptomatic syndrome, or life experience; they focus more on interpersonal than on intrapersonal concerns. The brief group is not a truncated long-term group;34 group leaders must have a different mental set: they must clarify goals, focus the group, manage time, and be active and efficient. Since groups tend to deny their limits, leaders of brief groups must act as group timekeeper, periodically reminding the group how much time has passed and how much remains. Leaders must also attend to the transfer of learning, encouraging clients to apply what they have learned in the group to their situations outside the group. They must emphasize that treatment is intended to set change in motion, but not necessarily to complete the process within the confines of the scheduled treatment. The work of therapy will continue to unfold long after the sessions stop. • Leaders should attempt to turn the disadvantages of time limitations into an advantage. Since the time-limited therapy efforts of Carl Rogers, we have known that imposed time limits may increase efficiency and energize the therapy.35 Also, the fixed, imminent ending may be used to heighten awareness of existential dimensions of life: time is not eternal; everything ends; there will be no magic problem solver; the immediate encounter matters; the ultimate responsibility rests within, not without.36 • Keep in mind that the official name of the group does not determine the work of therapy. In other words, just because the group is made up of recently divorced individuals or survivors of sex abuse does not mean that the focus of the group is "divorce" or "sexual abuse." The effective group therapist should be flexible and use all means available to increase efficacy. Time is limited, but leaders must not make the mistake of trying to save time by abbreviating the pregroup individual session. On the contrary, leaders must exercise particularly great care in preparation and selection. The most important single error made by busy clinics and HMOs is to screen new clients by phone and immediately introduce them into a group without an individual screening or preparatory session. Brief groups are less forgiving of errors than long-term groups. When the life of the group is only, say, twelve sessions, and two or three of those sessions are consumed by attending to an unsuitable member who then drops out (or must be asked to leave), the cost is very high: the development of the group is retarded, levels of trust and cohesion are slower to develop, and a significant proportion of the group's precious time and effectiveness is sacrificed. 42 Furthermore, therapy groups add substantially to the effect of pharmacotherapy in the treatment of depression.43 Brief groups for clients with loss and grief have also been proven effective and are significantly more effective than no treatment. 44 Both expressive-interpretive groups and supportive groups have demonstrated significant effects with this clinical population.45 A study of brief interpersonal group therapy for clients with borderline personality disorder reported improvement in clients' mood and behavior at the end of twenty-five sessions.46 Brief group therapy is also effective in the psychological treatment of the medically ill:47 it improves coping and stress management, reduces mood and anxiety symptoms, and improves self-care.

Introduction

By the mid-1970s the term cognitive behavior therapy (CBT) had largely replaced the term behavior therapy and was applied to a variety of techniques and procedures rooted in various theories of learning. Behavior therapy is best conceptualized as a general orientation to clinical practice that is based on the experimental approach to changing behavior, not just understanding it. As behavior therapy continues to expand, it increasingly overlaps with other theoretical approaches to therapy (Antony, 2014). Third-generation behavior therapies (also called third wave approaches) emphasize mindfulness, acceptance, the therapeutic relationship, spirituality, values, meaning and purpose in one's life, meditation, being in the present moment, and emotional expression Cognitive behavior therapy targets problematic behaviors and maladaptive cognitions and represents the mainstream of contemporary behavior therapy today Cognitive behavioral practitioners use a time-limited, active, directive, transparent, collaborative, present-focused, didactic, evidence-based approach that relies on empirical validation of its concepts and techniques (Antony, 2014). A basic assumption of the cognitive behavioral perspective is that most problematic behaviors, cognitions, and emotions have been learned and can be modified by new learning. This process is often called "therapy," yet a significant component of the process is educational. Members of a group are involved in a teaching and learning process and are taught how to develop a new perspective on ways of learning. They are encouraged to try out more effective behaviors, cognitions, and emotions. Problems may also arise due to a skills deficit—adaptive behaviors or cognitive strategies that have not been learned—and group members can acquire coping skills by participating in this educational experience.

Precise Therapeutic Goals

CBT focuses concretely on specific target areas of change Identifying goals determines direction of therapeutic movement The most unique aspect of CBT with groups is the specific goals of change. A CBT approach to group therapy focuses more concretely on specific target areas of change than any other modality. In most CBT groups, the initial stages of group work are devoted to clients' expanding the final step of their assessment by formulating specific statements of the personal goals they want to achieve. The identification of goals determines the direction of therapeutic movement. The group leader guides the discussion of goals, but the group members are responsible for selecting their personal goals. Group members spell out concrete problematic behaviors they want to change and new skills they want to learn. It is important that goals be specific, measurable, realistic, and achievable At the beginning of each session, an agenda is set to prioritize members' goals and to outline how the time will be spent. This agenda is co-created by members and the group leader. A CBT group at its best is a collaborative endeavor. The task of the group leader is to help group participants break down broad, general goals into specific, concrete, measurable goals that can be pursued in a systematic fashion. For example, if Albert says that he feels inadequate in social situations, and that he would like to change this, the leader may ask questions such as these: What do you mean by "inadequate"? What are you doing or not doing that seems to be related to your feeling of inadequacy? What are the conditions under which you feel inadequate? Can you give me some concrete examples of the situations in which you feel inadequate? In what specific ways would you like to change your behavior?

Stages of a Cognitive Behavioral Group

CBT groups often have a common theme, such as stress management, anger control, acquiring social skills, or pain management. The goal goes beyond demonstrating change within the group setting. The ultimate goal is the transfer of change into the real world. Later group sessions are structured to make this generalization of learning more likely.

CBT Contributions and Strengths of the Approach

CBT is precise in specifying goals, target behaviors, and therapy procedures, which are defined in unambiguous and measurable terms. This specificity allows for links among assessment, treatment, and evaluation strategies. Because of this specificity, explicit criteria for evaluating the success of treatment can be established The cognitive behavioral tradition seeks to tailor specific strategies to each client. CBT is to be credited for conducting research to determine the efficacy of its techniques. There is a commitment to the systematic evaluation of the procedures used in a group. Those interventions that do not work are eliminated, and techniques are continually being improved. CBT practitioners are open to integrating techniques from various theoretical models into their group work. Cognitive behavioral interventions can be incorporated effectively into both heterogeneous and homogeneous groups and can be used with groups that have a wide variety of specific purposes. . A comprehensive review of studies confirming the efficacy of CBT reveals the success of this approach in treating depression, anxiety disorders, panic disorders, social phobia, posttraumatic stress disorders, eating disorders, substance abuse, personality disorders, and childhood depression and anxiety disorders ( The field of cognitive behavior is broadening and there is a context for an integration of CBT with other therapeutic approaches, including the humanistic therapies. A cognitive behavioral group is a concrete example of a humanistic approach in action. Certainly, topics such as values, spirituality, relationship, focusing on the present moment, meditation, and mindfulness were all explored in humanistic psychology, and such topics are now being included in contemporary CBT. Another way that CBT has humanistic dimensions is that group members are collaboratively involved in the selection of both goals and treatment strategies. In many groups, the leader helps members move toward independence by delegating leadership functions to them. The cognitive behavioral approaches to group work fit well with the context of the evidence-based practice movement. More than any theoretical model in this book, CBT relies on using therapeutic strategies that have the support of empirical evidence, and its effects carry across a wide array of clinical disorders.

Applying the Cognitive Behavioral Approach to Group Work in Schools

CBT principles are easy for school-aged children to understand CBT groups tend to be short term and employ brief interventions The teachable concepts can be translated into acquiring life skills CBT can help students learn emotional and behavioral self-control Groups can assist students in coping with what they can change and accepting what they cannot CBT empowers young people to deal with present and future concerns The framework of present-centered, short-term, action-focused, reeducative, cognitive behavioral approaches are a good fit in working with a diverse range of students from the elementary to the high school level. One of the most compelling reasons for employing CBT groups in schools is that they can be used for both remediation and prevention CBT principles are easy to understand, and they can be adapted to children of most ages and from many cultural backgrounds. CBT groups tend to be short term and employ brief interventions, which fits in school settings where time is limited. The teachable concepts can be translated into acquiring life skills. Children and adolescents can learn emotional and behavioral self-control through understanding the connection between thoughts, feelings, and behaviors. CBT groups help participants to cope with what they can change and to accept what they cannot change. The cognitive principles empower young people to deal with both present concerns and future problems.

Cognitive Behavioral Approaches

CBT's clinical procedures are supported by research CBT is based on principles of learning that are systematically applied Treatment goals are specific and measurable Focus is on members' current problems Aim is to change maladaptive behaviors to adaptive ones The therapy is largely educational—teaching group members skills of self-management

Application: Therapeutic Techniques and Procedures

Cognitive behavioral approaches to groups offer great promise for those who want to learn the skills necessary for self-management. Areas in which one can learn to control behavior and bring about self-directed change are controlling excessive eating, drinking, and smoking and learning self-discipline at work or in school. For the purpose of this discussion, the techniques have been grouped under four general approaches that can be applied to the practice of cognitive behavioral groups: (1) social skills training groups, (2) cognitive therapy groups, (3) stress management groups, and (4)mindfulness and acceptance-based cognitive behavior therapy.

Cognitive Restructuring

Cognitive restructuring is the process of identifying and evaluating one's cognitions, understanding the negative behavioral impact of certain thoughts, and learning to replace these cognitions with more realistic, appropriate, and adaptive thoughts. Members are expected to identify self-defeating cognitions and to monitor their self-talk. Cognitive restructuring is based on the theory that our thoughts are causally linked to our behavior and emotions; the route to changing behavior and emotion is to change negative or self-defeating cognitions Clients are given an orientation to the basic concepts of cognitive restructuring, including a rationale for the procedure. Clients learn to identify thoughts pertaining to problem situations. Coping thoughts are introduced and practiced. There is a shift from self-defeating to coping thoughts. Clients learn and practice reinforcing self-statements. Homework is carried out, and there is follow-up. Typically, members provide one another with feedback and various models of a cognitive analysis. After clients decide on a set of realistic cognitive statements, cognitive modeling is used, in which the members imagine themselves in stressful situations and substitute self-enhancing statements for self-defeating remarks. In cognitive rehearsal, members imitate the model and get feedback from others in the group. After several trials in the group, they are given the assignment to practice a new set of statements at home before they try out a new style in the real world. In the final step of cognitive restructuring, homework is assigned at the end of each session and then monitored at the beginning of the following session. As members make progress, assignments can be developed at successive levels of difficulty.

Cognitive Therapy Groups

Cognitive therapy (CT) is an insight-focused therapy CT can be applied to a wide range of groups CT emphasizes changing negative thoughts and maladaptive beliefs Attention is paid to automatic thoughts and logical errors Members are encouraged to form hypotheses and test their assumptions (collaborative empiricism) CT groups emphasize the present and are time limited Two of the best-known CT models were developed by Albert Ellis and Aaron Beck Automatic thought records Disputing beliefs Monitoring moods Developing an arousal hierarchy Monitoring activities Problem solving Socratic questioning Relaxation methods Risk assessment Relapse prevention Cognitive behavioral therapy utilizes a group dynamics format, in conjunction with standard cognitive behavioral techniques, to change maladaptive and dysfunctional beliefs, interpretations, behaviors, and attitudes (Petrocelli, 2002). Some of the most common interventions include automatic thought records, disputing beliefs, monitoring moods, developing an arousal hierarchy, monitoring activities, problem solving, Socratic questioning, relaxation methods, risk assessment, and relapse prevention Aaron Beck (1976, 1997), a practicing psychoanalytic therapist for many years, grew interested in his clients' automatic thoughts—the personalized notions that are triggered by particular stimuli that lead to emotional responses. Beck asked his clients to observe negative automatic thoughts (or faulty beliefs) that persisted even though they were contrary to objective evidence, and from this he developed a comprehensive theory on depression. Beck (1976) and J. Beck (1995, 2011) contend that people with emotional difficulties tend to commit characteristic "logical errors" that tilt objective reality in the direction of self-deprecation. Cognitive therapy perceives psychological problems as stemming from commonplace processes such as faulty thinking, making incorrect inferences on the basis of inadequate or incorrect information, and failing to distinguish between fantasy and reality. The cognitive model of group therapy is based on a theory that emphasizes the interaction of thoughts, feelings, and behaviors; these components are interrelated and multidirectional (White, 2000b). The most direct way to change dysfunctional emotions and behaviors is to modify inaccurate and dysfunctional thinking. The cognitive model of group therapy is based on a theory that emphasizes the interaction of thoughts, feelings, and behaviors; these components are interrelated and multidirectional (White, 2000b). The most direct way to change dysfunctional emotions and behaviors is to modify inaccurate and dysfunctional thinking. Group leaders can assist members in detecting those times when they get stuck imagining the worst possible outcome of a situation by asking these questions: "What is the worst thing that could occur?" and "If this happens, what would make this such a negative outcome?" Guiding group members to look for evidence to support or refute some of their core beliefs and faulty thinking can also be useful. As individuals identify a number of self-defeating beliefs, they can begin to monitor the frequency with which these beliefs intrude in situations in everyday life. This simple question can be frequently asked, "Where is the evidence for _____?" If this question is raised often enough, members are likely to make it a practice to ask themselves this question, especially as they become more adept at spotting dysfunctional thoughts and paying attention to their cognitive patterns. After group members have gained insight into how their unrealistically negative thoughts are affecting them, they are trained to test these automatic thoughts against reality by examining and weighing the evidence for and against them. This process involves actively participating in evaluating their beliefs. One such method to promote new learning engages the member in a Socratic dialogue with the therapist. The therapist designs a series of purposeful questions that (1) defines the problem; (2) assists the member in identifying his or her thoughts, images, and assumptions; (3) examines the meaning of events for the client; and (4) assesses the consequences of keeping maladaptive thoughts and behaviors Through a process of guided discovery, they acquire insight about the connection between their thinking and the ways they feel and act. In guided discovery, the group therapist helps to illuminate the meaning of thoughts and problems in logic and also helps members to acquire new information and different ways of thinking, acting, and feeling (Bieling et al., 2006). Group members, not the group leader, then determine the usefulness of their beliefs. In a cognitive therapy group, the emphasis is on the present and the approach is time limited. Group sessions are focused on current problems, regardless of diagnosis. The role of the past is considered throughout treatment, especially in understanding more about a client's core beliefs. However, merely understanding the origin of a problem is not enough; clients must act on this knowledge to change dysfunctional beliefs and behaviors that are maintaining present problems.

Final Stage

Consolidation of learning and transferring lessons to daily life are major goals Data are collected at termination and at follow-up meetings to assess group outcomes During the final stage of a cognitive behavioral group, the leader is primarily concerned with having members transfer the changes they have exhibited in the group to their everyday environment. Practice sessions involving simulations of the real world are used to promote this transfer. Members rehearse what they want to say to significant people in their life and practice new behaviors. Feedback from others in the group, along with coaching, can be most useful at the final stage. Sessions are systematically designed so that new behaviors are gradually carried into daily life. Although preparation for generalization and maintenance of change is given a special focus in the final stage, it is a characteristic of all phases of the group. Giving and receiving feedback Providing many opportunities to practice new and more effective behaviors Carrying learning further by developing a specific plan of action to continue applying changes to situations outside of the group Preparing members for dealing with possible setbacks Assisting members in reviewing the group experience and the meaning it holds for them One of the main goals of successful therapy is to teach clients the skills they will need in becoming their own therapists (Ledley et al., 2010). The leader's role shifts from a direct therapist to a consultant in the final stage. Members are typically encouraged to apply their newly learned skills to new situations with others outside of their group. In addition, they are taught self-help cognitive skills such as self-reinforcement and problem solving as a way of preparing them for situations they have not encountered in the group. As the time of termination approaches, many of the initial assessment instruments are repeated as a way of evaluating the effectiveness of the group program. Termination and follow-up are issues of special concern to CBT group practitioners. Short- and long-term follow-up interviews are scheduled, at which time data are collected to determine the outcomes of a group. Follow-up interviews can serve as "booster sessions" that help members maintain the changed behaviors and continue to engage in self-directed change. Follow-up group sessions provide opportunities for members to review what they have learned, to update the group on how they are doing, and to encourage members to be accountable for their changes or lack of them.

Dialectical Behavior Therapy (DBT)

Dialectical behavior therapy (DBT) integrates cognitive behavioral concepts with the mindfulness training of "Eastern psychological and spiritual practices (primarily Zen practice)" (Linehan, 1993b). Linehan (1993a, 1993b) formulated DBT for clients whose symptoms include behaviors resulting in nonfatal self-harm. These symptoms are most typical of an individual diagnosed as having a borderline personality disorder but may also be encountered with other clients. DBT emphasizes the importance of the psychotherapeutic relationship, validation of the client, and the etiologic importance of the client having experienced an "invalidating environment" as a child. DBT involves teaching clients both mindfulness and acceptance. The practice of acceptance involves being in the present moment, seeing reality as it is without distortions, without judgment, without evaluation, and without trying to hang on to an experience or to get rid of it. It involves entering fully into activities of the present moment without separating oneself from ongoing events and interactions. DBT is not a quick fix approach for it generally involves a minimum of one year of treatment. The group work must be accompanied by individual therapy. In some settings, Linehan (1993b) allows for the "integration of DBT skills training with individual psychodynamic therapy". Clearly, to practice DBT requires intensive training and supervision.

Decisions and Redecisions

Early decisions Based on injunctions and counterinjunctions, we make early decisions Early decisions had a purpose at one time, yet they may not be functional as we become adults TA groups allow members to examine early decisions Making new decisions Whatever has been decided can be redecided Redecision is done emotionally, not just cognitively, and can be very empowering Members can create a new ending to scenes where early decisions were made As indicated earlier, transactional analysis emphasizes the cognitive and behavioral dimensions, especially our ability to become aware of decisions that govern our behavior and of the capacity to make new decisions that will beneficially alter the course of our life. In the TA group Alejandro not only had the opportunity to become aware of his decisions and of the injunctions behind them but was also helped to investigate whether these decisions were still appropriate. At one time the decisions to avoid people might have been necessary for Alejandro's physical and psychological safety—a matter of sheer survival. Even though injunctions and counterinjunctions carry the weight of parental authority, the Gouldings (1978, 1979) point out that the child must accept these messages if they are to have an impact on his or her personality. The Gouldings add that many childhood injunctions are not issued by the parents but derive instead from the children's own fantasies and misinterpretations. It is important to note that a single parental injunction may foster a variety of decisions on the part of the child, ranging from reasonable to pathological. Whatever injunctions people have received, and whatever the resulting life decisions were, transactional analysis maintains that people can change by changing their decisions—by redeciding in the moment. A basic assumption of TA is that anything that has been learned can be relearned. In their groups the Gouldings developed an atmosphere in which members were challenged from the outset to change. Robert Goulding (1975) started each group session by asking members this question: "What do you want to change today?" The group work related to making new decisions frequently requires members to return to the childhood scenes in which they arrived at self-limiting decisions. Mary Goulding (1987) believed that there are many ways of assisting a member to return to some critical point in childhood. Once the client is there, he or she reexperiences the scene, reliving it in the here-and-now, only this time with a different outcome. The redecision is a decision that is truly empowering. After members experience a redecision from being in an old scene, they design experiments so that they can practice new behavior to reinforce their redecision both in and out of group. Members typically leave group sessions with homework assignments aimed at reinforcing the new decision.

Objective evaluation

Emphasis is on evaluating effectiveness of techniques Evaluation is an ongoing process Once target behaviors have been clearly identified, treatment goals specified, and therapeutic procedures delineated, the outcomes of therapy can be objectively assessed. Because CBT groups emphasize the importance of evaluating the effectiveness of the techniques they employ, assessment of clients' progress toward their goals is ongoing. At every subsequent session, an assessment of behavioral changes may be made so members can determine how successfully their objectives are being met. Providing members with feedback is a vital part of cognitive behavioral group therapy. The range of these techniques is quite wide, and many CBT group practitioners are very eclectic in their choices of treatment procedures. They are willing to draw techniques from many of the therapeutic approaches in helping members change their patterns of thinking, feeling, and acting.

The Initial Stage

Establishing good contact and developing a strong therapeutic alliance is the first step The leader inquires about the members' actual contracts for change The first step in the group process consists of establishing good contact. To a large extent, the outcome for group members depends on the quality of the relationship the group leader is able to establish with the members and on the leader's competence. TA group leaders pay attention to the quality of the therapeutic relationship, for they realize that the therapeutic alliance is central to assisting members in achieving their goals t is the leader's responsibility to assist the client in revealing what is not working in their lives. Obviously, the trust factor in the group has a lot to do with the willingness of clients to get to their chief complaint. It is incumbent on the group leader to provide the necessary ingredients for sustainable change: a safe place, nurturance, adequate structure, and support. The next step in the process consists of making an inquiry into the member's actual contract for change. Typical questions are: "What are you going to change about yourself today?" "In your finest vision, in what ways might you be different?" These questions communicate that change is possible immediately. Notice that members are not asked to state what they hope to change or what the leader will do to bring about change; nor are they asked what changes they want in the future. The emphasis is on members taking action in the here-and-now to bring about change.

Games

Games are an ongoing series of transactions that end with a negative payoff Games prevent intimacy Game playing involves receiving strokes and defending early decisions Game playing results in rackets (unpleasant feelings afterwards) In TA groups, members identify games they played as children and games they currently play Members must decide if they want to live more honestly and authentically Kartman triangle A transaction, which is considered the basic unit of communication, consists of an exchange of strokes between two or more people. A game is an ongoing series of transactions that ends with a negative payoff called for by the script that concludes the game and advances feelings such as anger, depression, or guilt. The basic nature of the game is to get negative strokes and reinforce the script. By their very nature, games serve the function of preventing intimacy. Games consist of three basic elements: a series of complementary transactions that on the surface seem plausible; an ulterior transaction that is the hidden agenda; and a negative payoff that concludes the game and is the real purpose of the game. Stephen Karpman (1968) assigns three roles to game participants: persecutor, rescuer, and victim. The persecutor plays some form of "Gotcha" or "Blemish" (looking for the flaw), whereas the rescuer plays some form of "I am only trying to help you." Berne (1964) described an anthology of games, including "Yes, but," "Kick me," "Harassed," "If it weren't for you," "Martyr," "Ain't it awful," "I'm only trying to help you," "Uproar," and "Look what you made me do!" Games always have some payoff (or they wouldn't be perpetuated), and one common payoff is support for the decisions described in the preceding section. For example, people who have decided that they are helpless may play the "Yes, but" game. A group situation provides an ideal environment for the participants to become aware of the specific ways in which they choose game-playing strategies to avoid genuine contact and choose patterns of thinking, feeling, and behaving that are ultimately self-defeating. Group members bring to the group and act out the very games that they play outside of the group. Group members can learn about their own games and rackets by observing the behavior of others in the group, as well as by analyzing how their responses in the group are connected to their responses to life situations in early childhood. Later, as members become aware of the more subtle aspects of game playing, they begin to realize that games prevent close human interaction. Consequently, if the members decide that they want to relate more closely to others, they also have to decide not to play games anymore. Anytime any element of the script, including a game, is interrupted, the person is in a position to redecide an early life script decision. Games start off with the optimal goal of supporting the person's basic life position and script injunction. Eventually, members are taught to make connections between the games they played as children and those they play now—for example, how they attempted to get attention in the past and how those past attempts relate to the games they play now to get stroked. The aim of this TA group process is to offer members the chance to drop certain games in favor of responding honestly and authentically—an opportunity that may lead them to discover ways of changing negative strokes and to learn how to give and receive positive strokes.

Advantages of a Group Approach

Group leaders can derive practical benefits from the use of specific behavioral techniques, regardless of their theoretical orientation. As a matter of fact, certain experiential and humanistic models can be enhanced by systematically incorporating some of the cognitive behavioral techniques into their relationship-oriented frameworks. . Behavioral principles are instrumental in fostering group cohesion, which enables members to feel that they are not alone with their problems. The mutual learning and exploration of personal concerns bind the members of a group in a meaningful way. Another strength of the cognitive behavioral approaches is the wide range of techniques that participants can use to specify their goals and to develop the skills needed to achieve these goals. The specificity of the CBT approaches helps group members translate fuzzy goals into concrete plans of action, which helps the members keep these plans clearly in focus. These cognitive behavioral principles and techniques lend themselves to short-term groups, which is certainly a factor contributing to the widespread useof CBT groups.

The Physical Setting

Group meetings may be held in any room that affords privacy and freedom from distractions. In institutional settings, the therapist must negotiate with the administration to establish inviolate time and space for therapy groups. The first step of a meeting is to form a circle so that members can all see one another. For that reason, a seating arrangement around a long, rectangular table or the use of sofas that seat three or four people is unsatisfactory. If members are absent, most therapists prefer to remove the empty chairs and form a tighter circle. If the group session is to be videotaped or observed through a one-way mirror by trainees, the group members' permission must be obtained in advance and ample opportunity provided for discussion of the procedure. Written consent is essential if any audiovisual recording is planned.

Coaching

In addition to modeling and behavior rehearsal, group members sometimes require coaching. This process consists of providing the members with general principles for performing the desired behavior effectively. Coaching seems to work best when the coach sits behind the client who is rehearsing. When a member gets stuck and does not know how to proceed, another group member can whisper suggestions. After one or two coached rehearsals, the coaching is reduced in subsequent role playing.

Injunctions and Counterinjunctions

Injunctions are parental messages that we acquire Some examples of injunctions: "Don't be" "Don't be close" "Don't think" "Don't feel" "Never talk to strangers" "Always chew with your mouth closed" "Look both ways before you cross the street" Shoulds In TA groups members explore the "dos" and "don'ts" by which they were trained to live Members identify messages they have internalized Members then critically examine them to decide if they want to continue living by them The Gouldings' redecision work is grounded in the TA concepts of injunctions and early decisions (M. Goulding, 1987). When parents are excited by a child's behavior, the messages given are often permissions, or reinforcement for the behavior. However, when parents feel threatened by a child's behavior, the messages expressed are often injunctions, which are issued from the parents' own Child ego state. Such messages—expressions of disappointment, frustration, anxiety, and unhappiness—establish the "don'ts" by which children learn to live. hese messages are predominantly given nonverbally and at the psychological level between birth and 7 years of age. According to Mary Goulding (1987), children decide either to accept these parental messages or to fight against them. If they do accept them, they decide precisely how they will accept them. The decisions children make about these injunctions become a basic part of their permanent character structure. When parents observe their sons or daughters not succeeding, or not being comfortable with who they are, they attempt to "counter" the effect of the earlier messages with counterinjunctions. These messages come from the parents' Parent ego state and are given at the social level. They convey the "shoulds," "oughts," and "dos" of parental expectations. Examples of counterinjunctions are "Be perfect." "Try hard." "Hurry up." "Be strong." "Please me." "Be careful." The problem with these counterinjunctions is that no matter how much we try to please we feel as though we still are not doing enough or being enough. This demonstrates the rule that the messages given at the psychological level are far more powerful and enduring than those given at the social level.

Treatment plan

It is based on specified goals Members are expected to take an active role with tasks Once members have specified their goals, a treatment plan to achieve these goals is formulated. Cognitive behavioral techniques are action oriented; members are expected to take an active role with tasks, not simply engage in reflection and talk about their problems. Initially, the group leader generally develops the plans in a collaborative fashion that includes each group member. After an initial assessment, and as the members learn the necessary skills, the group participants together with the group leader brainstorm intervention strategies that might be used or specific actions that might be taken. Ultimately, the person with the problem is the judge of the strategy or actions he or she must take.

Role and Functions of the Group Leader

Leaders use short-term interventions Leaders need to be skilled in brief interventions CBT leaders assume the role of teacher and encourager Some specific educational and therapeutic functions: Conduct intake interviews with prospective members Conduct ongoing assessment of members' problems Utilize many techniques to help members reach goals Model appropriate behaviors and active participation and collaboration Provide reinforcement to members for new learning Help members develop a plan for change Cognitive behavioral groups have a detailed, concrete, problem-oriented structure. They tend to utilize short-term interventions, and leaders need to be skilled in drawing on a wide variety of brief interventions aimed at efficiently and effectively solving problems and assisting members in developing new skills. Cognitive behavioral group leaders assume the role of teacher and encourage members to learn and practice social skills in the group that they can apply to everyday living. Group leaders are expected to assume an active, directive, and supportive role in the group and to apply their knowledge of behavioral principles and skills to the resolution of problems. Through their conduct in a group, leaders model active participation and collaboration by their involvement with members in creating an agenda, generating adaptive responses, designing homework, and teaching skills Members in cognitive behavioral groups identify specific skills that they lack or would like to enhance. They proceed through a series of training sessions that involve interventions such as modeling the skill, behavioral rehearsal and coaching, feedback, practicing skills both in the group sessions and through homework, and self-monitoring. In discussing the social learning that occurs in therapy through modeling and imitation, Bandura (1969, 1977, 1986) suggests that most of the learning that takes place through direct experience can also be acquired by observing the behavior of others. In Bandura's view, one of the fundamental processes by which clients learn new behavior is imitation of the social modeling provided by the therapist. Therefore, group leaders need to be aware of the impact of theirvalues, attitudes, and behaviors on group members, as well as those behaviors that members model to each other. Group leaders conduct intake interviews with prospective members during which the preliminary assessment and orientation to the group takes place, and they also conduct an ongoing assessment of members' problems. Leaders draw on a wide array of techniques designed to achieve the members' stated goals. A major function of leaders is serving as a model of appropriate behaviors. Also, leaders prepare and coach members to model by role playing for one another how an individual might respond in a particular situation. Leaders provide reinforcement to members for their newly developing behavior and skills by making sure that even small achievements are recognized. Leaders teach group members that they are responsible for becoming actively involved both in the group and outside of therapy. To broaden their repertoire of adaptive behaviors, members are strongly encouraged to experiment in the group and to practice homework assignments. Leaders emphasize a plan for change and an active stance on the part of the members and help members understand that verbalizations and insight are not enough to produce change. Leaders help members prepare for termination well ahead of the group's ending date so that members have adequate time to discuss their reactions, to consolidate what they have learned, and to practice new skills to apply at home and work. A basic assumption of CBT is that a good working relationship between the leader and members is a necessary, but not sufficient, condition for change. Cognitive behavioral practitioners stress the value of establishing collaborative partnerships with members. In short, cognitive behavioral group leaders must be skilled technicians who also possess the human qualities that lead to a climate of trust and care, which is necessary for the effective application of therapeutic techniques. Although a quality relationship improves the effectiveness of behavior therapy, the crucial elements for success are the therapeutic techniques used by the leader to help members reach their goals.

Limitations of the approach

May prevent members from meeting personal needs if too highly structured Problematic if overly didactic If rigidly applied, can focus exclusively on problems or symptoms rather than on the meaning of a behavior Cognitive behavioral groups do have their disadvantages. For example, when groups are too highly structured, as cognitive behavioral groups can often become, individual clients may be prevented from meeting their personal needs. CBT groups have a didactic emphasis, which can be both a strength and a limitation. Groups have an educative function, yet this didactic aspect needs to be balanced with the experiential aspects of group work. A cognitive behavioral group therapist needs to be aware of a range of group process issues, a few of which include observing connections between group members, encouraging open dialogue, promoting expression of feelings, and encouraging useful feedback between group members When CBT is too rigidly applied, the group leader may lose sight of the people in the group by focusing exclusively on techniques or on solving specific problems.

Final stage:

Members are challenged to transfer what they have learned in the group to their daily life and receive support Members prepare for situations they may face after the group ends Once a redecision is made from the Child ego state, the changes in one's voice, body, and facial expressions are obvious to everyone in the group. The group process provides support for members who begin to feel and behave in new ways. Group members are encouraged to tell a new story in the group to replace their old story, and they typically receive verbal and nonverbal stroking to support their new decision. Attention is also given to ways that members might devise other support systems outside the group. It is also important for members to plan specific ways in which they will change their thinking, feeling, and behavior. The focus during the final phase of group work is on challenging members to transfer their changes from the therapy situation to their daily life and then supporting them in these changes.

Contracts: The Structure of the Therapeutic Relationship

Members must have the capacity and willingness to understand and design a therapeutic contract Contracts are the key to all TA treatment and are specific and measurable Members learn that therapy is a shared venture A good contract increases options rather than restricting members to a set outcome; It is open to revision This short-term contract fits well with the requirements of brief therapy Transactional analysis is based largely on the capacity and willingness of group participants to understand and design a therapeutic contract that requires them to state their intentions and set personal goals. Contracts are the key to all TA treatment and are the central focus of the initial stage of a group. Widdowson (2010) recommends avoiding premature contracting. If therapists pursue a firm and fully formed contract too early in therapy, clients may terminate prematurely. New group members often do not have a clear sense of their goals, and they need to feel understood if they are to formulate a meaningful contract. The initiation of a contract begins with group participants creating a vision (from the Child) of how they will be different as a result of their time in group. From the creation of the vision, the contract becomes specific and measurable and contains a concrete statement of the objectives group participants intend to attain and how and when these goals are to be met. A therapeutic contract is based on the premise that the group leader and the group members are on an equal footing. Contracts place the responsibility on members for clearly defining what, how, and when they want to change. The leader is responsible for pointing out flaws and sabotages and must ultimately agree to help the members achieve their contracts. It is common practice to write down each contract and hang these charts on the wall, clearly identifying the person to whom each belongs. Because everyone in the group knows the other participants' contracts, there is a measure of accountability. The process of TA treatment focuses primarily on change as defined by the contract, and the therapeutic partnership is aimed at accomplishing this mutual goal. The extent to which members have fulfilled their contracts and benefited from group therapy can be measured. Although contracts are emphasized in TA, they are intended to be practical tools for helping people change themselves; they cannot be rigid and should be open to revision. Contracts are developed in steps and are subject to modification as members penetrate more deeply into the areas in which they are seeking to change. These short-term contracts fit well with the requirements of limited therapy and brief therapy characteristic of many community agencies. Contracts can guide the course of brief therapy and can provide a basis for evaluation of outcomes.

Mindfulness and Acceptance Approaches in Cognitive Behavior Therapy

Mindfulness and acceptance-based CBT Represents the new wave in CBT Clients train themselves to focus on present experience Involves receiving present experience without judgment, but with curiosity and striving for full awareness of the present moment Acceptance is best viewed as a client's ability to notice, accept, and even embrace private events Members are encouraged to practice mindfulness in the group and in their daily life Major therapeutic approaches include: dialectical behavior therapy mindfulness-based stress reduction mindfulness-based cognitive therapy acceptance and commitment therapy Over the past decade or so, third-generation behavior therapies have been developed that center around five interrelated core themes: (1) an expanded view of psychological health, (2) a broad view of acceptable outcomes in therapy, (3) acceptance, (4) mindfulness, and (5) creating a life worth living Mindfulness is a process that involves becoming increasingly observant and aware of external and internal stimuli in the present moment and adopting an open attitude toward accepting what is rather than judging the current situation The essence of mindfulness is becoming aware of one's mind from one moment to the next, with gentle acceptance. When distractions occur, these are noticed and attention is then drawn back to one's present experience. Acceptance is a process involving receiving one's present experience without judgment or preference, but with curiosity and kindness, and striving for full awareness of the present moment (Germer, 2005b). The concept of acceptance does not imply resigning oneself to life's problems. Instead, acceptance is best viewed as a client's ability to notice, accept, and even embrace private events (Antony, 2014). The four major approaches include (1) dialectical behavior therapy (Linehan, 1993a, 1993b), which has become a recognized treatment for borderline personality disorder; (2) mindfulness-based stress reduction (Kabat-Zinn, 1990), which involves an 8- to 10-week group program applying mindfulness techniques to coping with stress and promoting physical and psychological health; (3) mindfulness-based cognitive therapy (Segal et al., 2013), which is aimed primarily at treating depression; and (4) acceptance and commitment therapy (Hayes et al., 2011; Hayes, Strosahl, & Houts, 2005; Roemer& Orsillio, 2009), which is based on encouraging clients to accept, rather than attempt to control or change, unpleasant sensations. Behavior therapists are increasingly recognizing that in many cases optimal treatment may require more than one behavioral approach. Moreover, the growing trend toward psychotherapeutic integration involves incorporating treatment strategies from two or more orientations.

Modeling

Modeling refers to a process in which clients learn through observation and imitation of both the leader and the other members. Modeling procedures can be useful in demonstrating specific skills to be learned and also useful for teaching and practicing life skills. Role modeling is one of the most powerful teaching tools available to the group leader. As we have seen with other approaches, an advantage of group counseling over individual counseling is that it offers members a variety of social and role models to imitate. Modeling is incorporated in a number of cognitive behavioral groups, especially in skills training groups and assertion training groups.

DURATION AND FREQUENCY OF MEETINGS

Most group therapists agree that, even in well-established groups, at least sixty minutes is required for the warm-up interval and for the unfolding and working through of the major themes of the session. There is also some consensus among therapists that after about two hours, the session reaches a point of diminishing returns: Although the frequency of meetings varies from one to five times a week, the overwhelming majority of groups meet once weekly. It is often logistically difficult to schedule multiple weekly ambulatory group meetings, and most therapists have never led an outpatient group that meets more than once a week. But if I had my choice, I would meet with groups twice weekly: such groups have a greater intensity, the members continue to work through issues raised in the previous session, and the entire process takes on the character of a continuous meeting. Some therapists meet twice weekly for two or three weeks at the start of a time-limited group to turbocharge the intensity and launch the group more effectively.5 Avoid meeting too infrequently. Groups that meet less than once weekly generally have considerable difficulty maintaining an interactional focus. If a great deal has occurred between meetings in the lives of the members, such groups have a tendency to focus on life events and on crisis resolution. We found that the marathon session did not favorably influence the communication patterns in subsequent meetings.21 In fact, there was a trend in the opposite direction: after the six-hour meetings, the groups appeared to engage in less here-and-now interaction. The influence of the six-hour meeting on cohesiveness was quite interesting. In the three groups that held a six-hour initial meeting, there was a trend toward decreased cohesiveness in subsequent meetings. In the three groups that held a six-hour eleventh meeting, however, there was a significant increase in cohesiveness in subsequent meetings. Of course therapists wish to accelerate the process of change, but the evidence suggests that the duration of treatment is more influential than the number of treatments. The transfer of learning is laborious and demands a certain irreducible amount of time.23

Size of the Group

My own experience and a consensus of the clinical literature suggest that the ideal size of an interactional therapy group is seven or eight members, with an acceptable range of five to ten members. The lower limit of the group is determined by the fact that a critical mass is required for an aggregation of individuals to become an interacting group. Many of the advantages of a group, especially the opportunity to interact and analyze one's interaction with a large variety of individuals, are compromised as the group's size diminishes. Furthermore, smaller groups become passive, suffer from stunted development, and frequently develop a negative group image.52 Obviously the group therapist must replace members quickly, but appropriately. If new members are unavailable, therapists do better to meld two small groups rather than to continue limping along with insufficient membership in both. The upper limit of therapy groups is determined by sheer economic principles. As the group increases in size, less and less time is available for the working through of any individual's problems. Since it is likely that one or possibly two clients will drop out of the group in the course of the initial meetings, it is advisable to start with a group slightly larger than the preferred size; thus, to obtain a group of seven or eight members, many therapists start a new group with eight or nine.

Working stage:

Once contracts are created, members' rackets are explored and games are identified and analyzed Members are encouraged to take responsibility for their thinking, feeling, and behaving Early decisions and injunctions are also explored, hopefully leading to new decisions After contracts have been formulated, the Gouldings' approach to group therapy explores rackets the members use to justify their life scripts and, ultimately, their decisions (M. Goulding & Goulding, 1979). The aim is to expose the rackets of group members and have them take responsibility for them. As in Gestalt therapy, members are asked to be in these situations—to recall them not as observers but as participants in the here-and-now. Members are asked to act out both their own responses and the responses of other significant people in the scene. During this stage of group work, games are analyzed, mainly to see how they support and maintain rackets and how they fit with one's life script. In this connection much work is devoted to looking for evidence of the participants' early decisions, discovering the original injunction that lies at the base of these early decisions, and determining the kinds of strokes the person received to support the original injunction. Once the person becomes aware of the original injunction, he or she is in a salient position to make a new decision about the injunction. A major function of the TA group leader is to have the members take responsibility for their thinking, feeling, and behaving. Members are challenged when they use "cop-out language," such as "can't," "perhaps," "if it weren't for," "try," and other words that keep members from claiming their own power. The leader also creates a group climate in which the members rapidly become aware of how they maintain their chronic bad feelings by their behavior and fantasy. It is the therapist's task to challenge them to discover alternate choices. The Gouldings take the position that clients can change rapidly, without years of psychotherapy. It is clear that TA groups can be short term, solution focused, and structured in such a way that members acquire skills in addressing current and future problems. Through the use of fantasy, in which group members reexperience how their parents sounded, acted, and looked, the therapist creates a psychological climate that enables members to feel the same emotional intensity they felt when, as children, they made their original decisions. If participants are to be successful in going beyond an impasse, the Gouldings stress that they must be in the Child ego state and allow themselves to psychologically relive earlier scenes. If participants remain in their Adult ego state and merely thinking about new insights, the injunction will maintain its original power.

Social Effectiveness Training

One model of social skills training is social effectiveness training (SET), which is a multifaceted treatment program designed to reduce social anxiety, improve interpersonal skills, and increase the range of enjoyable social activities (Turner, Beidel, & Cooley, 1994). The primary components of this program are exposure to reduce social anxiety and social skills training to improve general social skills and social deficits. This treatment is based on over a decade of both clinical experience and empirical literature. The social skills training component is conducted in weekly small group sessions over a 12-week period. This group experience focuses on training in three areas: (1) social environment awareness, (2) interpersonal skill enhancement, and (3)presentation skill enhancement. In these three areas, participants are taught the nuances of interpersonal interactions and conversations, including the verbal and nonverbal dos and don'ts of successful social encounters as well as the presentation of communication skills in public speaking. Didactic instruction, modeling, behavior rehearsal, corrective feedback, and positive reinforcement are utilized in the group process to achieve these outcomes.

Open and Closed Groups

Open groups tolerate changes in membership better if there is some consistency in leadership. One way to achieve this in the training setting is for the group to have two co-therapists; when the senior co-therapist leaves, the other one continues as senior group leader, and a new co-therapist joins.3 Most closed groups are brief therapy groups that meet weekly for six months or less. A longer closed group may have difficulty maintaining stability of membership. Invariably, members drop out, move away, or face some unexpected scheduling incompatibility. Groups do not function well if they become too small, and new members must be added lest the group perish from attrition. A long-term closed-group format is feasible in a setting that assures considerable stability, such as a prison, a military base, a long-term psychiatric hospital, and occasionally an ambulatory group in which all members are concurrently in individual psychotherapy with the group leader. Some therapists lead a closed group for six months, at which time members evaluate their progress and decide whether to commit themselves to another six months.

Key Concepts of TA

People have a basic trio of Parent, Adult, and Child (P-A-C) ego states The need for strokes Injunctions and counterinjunctions Decisions and redecisions Games Basic psychological life positions Life scripts and script analysis

Behavior Rehearsal

Practicing in a group session a new behavior that will be used in everyday situations is called behavioral rehearsal. The aim of behavior rehearsal is to prepare members to perform the desired behaviors outside the group, when modeling cues will not be available. Behavioral rehearsal is an integral part of modeling as members are typically asked to participate by performing the behavior immediately after it has been modeled for them. Behavior rehearsal, which can be thought of as a gradual shaping process, is useful in teaching social skills. Feedback is a useful mechanism of change during behavior rehearsals. Once members achieve successful performance in the group situation, they need to be made aware that application in real life is a basic part of behavior rehearsal.

Initial Stage

Pregroup interviews and the first group session are spent exploring members' expectations A treatment contract is negotiated Informed consent is emphasized Prospective group members generally know very little about cognitive behavioral programs, so it is important that they be given all the pertinent information about the group process before they join. Pregroup individual interviews and the first group session are devoted to exploring the prospective members' expectations and to helping them decide whether they will join the group. Those who decide to join negotiate a treatment contract, spelling out what the group leader expects from the member over the course of the group, as well as what the client can expect from the leader. roup members should be informed about what CBT is, how it works, and what is unique about this therapeutic approach. Ledley and colleagues specify four key points that can be a part of the informed consent process in a group. First, group members need to know the meaning of collaborative empiricism, which involves a partnership between the group therapist and the members in addressing the problems they bring to a group. Second, group members should be informed that CBT is generally a time-limited form of treatment. Third, it is useful to let members know that generally their goals can be accomplished relatively quickly because CBT is an active, structured, directive, problem-focused, and present-focused approach to helping people deal with psychological problems. Finally, group members can be informed that cognitive behavioral practitioners rely upon techniques that have proven to be effective. During the initial phase of a group, the CBT group leader assumes an active role in teaching members how to get the most from the group experience. In the early stage, members learn how the group functions and how each of the sessions is structured. Key tasks at this stage deal with helping members get acquainted, orienting members, increasing the motivation of group members, providing a sense of hope that change is possible, identifying problem areas for exploration, creating a sense of safety, and establishing the beginnings of cohesion. Behavioral techniques can be especially effective during the beginning stages of therapy, not only to modify maladaptive behavior patterns but as a way to instill hope and provide for success in the therapy experience A useful practice is to conclude each group meeting with a review or summary of the session. This process, which is best done by the group members, offers participants an opportunity to clarify their goals and identify insights and skills that have been explored. In addition to a summary, members also can be asked for their reactions to the session. Homework, which ideally grows out of the group session, can then be collaboratively developed

Problem Solving

Problem-solving therapy is a cognitive behavioral strategy that teaches individuals or groups to systematically work through steps in analyzing a problem: identifying and evaluating new approaches to the problem and developing strategies for implementing these approaches (Cormier et al., 2013). The main goal is to identify the most effective solution to a problem and to provide systematic training in cognitive and behavioral skills so the client can generate more adaptive ways of coping with stressful problems in living and also cope effectively with future problems. Adopt a problem-solving orientation. Clients are helped in assessing, defining, and understanding the problem. They need to understand that it is essential to identify problems when they occur so that action can be taken. Clients must also be convinced that skills can be acquired to cope with daily problems. Finally, it is important to carefully assess alternative courses of action when problem solving. Define the problem. Clients are helped to understand why certain problem situations are likely to occur and are given the expectation that they can learn ways to cope. Set goals. Client goals can focus on the problem situation, reactions to the problem situation, or both. The question clients explore is: "What must happen so that I no longer have the problem?" Brainstorm alternative solutions. The objective is to think of as many solutions as possible to maximize the chances of finding an adequate solution to a problem. Clients are discouraged from evaluating any of the possible solutions until all the suggestions have been presented. Make a decision. Based on the alternatives generated in the fourth stage, clients examine the potential consequences of each course of action and make their choice and develop solution plans. Implement the solution. This may be the most important stage because the best solutions will be effective in dealing with a problem situation only if these solutions are implemented appropriately. Evaluate the effectiveness of the action. This verification phase consists of having clients engage in self-monitoring and evaluating the consequences of their actions in everyday life situations. Throughout the therapy process, clients are taught self-control techniques, and they are encouraged to reinforce their own successful performance. Further, once clients have had an opportunity to observe the therapist (or other models) demonstrate effective problem-solving procedures, they are expected to assume a more active role. Members are encouraged to practice the skills they are learning as they encounter problem situations during the week.

Social Skills Training Groups

SST is a highly structured educational approach The goal of SST is to enhance an individual's capacity to function in social situations SST involves assessment, direct instruction, modeling, role playing, homework assignments, and follow-up . Social skills training (SST) is a broad category that deals with one's ability to interact effectively with others in a variety of social situations. SST is a highly structured educational approach in which group leaders serve as teachers (Strong Kinnaman & Bellack, 2012). Social skills training in groups involves the application of many of the behavioral techniques discussed earlier in this chapter, a few of which include psychoeducation, modeling, reinforcement, shaping, feedback, role playing, behavioral rehearsal, and generalization of learning to assist individuals in improving their abilities to communicate effectively and to develop better ways of interacting socially. Individuals who experience psychosocial problems that are partly caused by interpersonal difficulties are good candidates for social skills training. The goal of SST is to enhance an individual's capacity to function in social situations. SST involves these phases: assessment, direct instruction, modeling, role playing, homework assignments, and follow-up (Twohig & Dehlin, 2012). Group members identify particular social skills deficits or communication-related problems that they would like to change, then target these social skills in the group sessions.

Script Analysis

Script analysis helps members see the ways in which they feel compelled to play out their life script Script analysis offers members alternative life choices Members can learn how to free themselves of self-defeating patterns Through a process known as script analysis, the TA group helps members become aware of how they acquired their life script and to see more clearly their life role (basic psychological life position). Script analysis helps members see the ways in which they feel compelled to play out their life script and offers them alternative life choices. Script analysis demonstrates the process by which group members acquired a script and the strategies they employ to justify their actions based on it. The aim is to help members open up possibilities for making changes in their early programming. The analysis of the life script of a group member is based on the drama of his or her original family. Through the process of acting out portions of their life script in the group sessions, members learn about the injunctions they uncritically accepted as children, the decisions they made in response to these messages, and the games and rackets they now employ to keep these early decisions alive. These and other cognitive and emotive techniques often help group participants recall early events and the feelings associated with them. The group setting provides a supportive place to explore the ways in which these past situations are influencing the participants. They start a process of becoming autonomous and regaining their personal power. As the group members analyze their own life from a TA perspective, they can check the accuracy of their self-interpretations by asking for feedback from the leader and the other members.

Child ego

The Child ego state is the original part of us and is most naturally who we are. It is the part of ourselves we use to form long-lasting relationships. The Child ego state consists of feelings, impulses, and spontaneous actions and includes "recordings" of early experiences. The Child ego state is divided into Natural Child (NC) and Adapted Child (AC), both of which have positive and negative aspects. The positive aspects of the Natural Child are the spontaneous, ever so endearing, loving and charming parts of all of us. The negative aspect of the Natural Child is to be impulsive to the degree that our safety is compromised. The positive aspect of the Adapted Child is that we respond appropriately in social situations. The negative aspect of the Adapted Child involves overadapting and giving up our power and discounting our value, worth, and dignity.

Meichenbaum's Stress Inoculation Training

Stress inoculation training (SIT) consists of a combination of elements of information giving, Socratic discussion, cognitive restructuring, problem solving, relaxation training, behavioral and imagined rehearsals, self-monitoring, self-instruction, self-reinforcement, and environmental change. Meichenbaum (2008) contends that SIT can be used for both preventive and treatment purposes with a broad range of people who experience stress responses. This approach is designed to teach coping skills that can be applied to both present problems and future stressors when they are encountered. During the initial stage of SIT (conceptual-educational), the primary focus is on creating a working relationship with clients by educating them to gain a better understanding of the nature of stress and to reconceptualize it in social interaction terms. During this phase, clients are educated about the transactional nature of stress and coping. They learn about the role that cognitions and emotions play in creating and maintaining stress. They also learn how their reactions to stress emanate from their perception of events rather than from the events themselves. In a collaborative fashion, clients identify the determinants of their presenting problems. After an assessment process in which they take an active role, they determine specific goals that will guide treatment. Self-monitoring, which begins at this time, continues throughout the training. Clients typically keep an open-ended diary in which they systematically record their specific thoughts, feelings, and behaviors. Training includes teaching clients to become aware of their own role in creating their stress and to identify their coping strengths and resources. During the second phase of SIT (skills acquisition, consolidation, and rehearsal), clients learn and rehearse coping strategies. Some of these specific techniques include cognitive restructuring; problem solving; social skills training; time management; self-instructional training; guided self-dialogue; relaxation training; and lifestyle changes such as reevaluating priorities, developing support systems, and taking direct action to alter stressful situations. As a part of this phase of SIT, clients are introduced to a variety of methods of relaxation and are taught to use these skills to decrease arousal due to stress. Through teaching, demonstration, and guided practice, they learn the skills of progressive relaxation. Clients rehearse skills by means of imagery and behavioral practice, which they are expected to practice regularly. In cognitive restructuring, clients become aware of the role that their cognitions and emotions play in creating and maintaining stress. Group members are also given self-instructional training, which teaches them to instruct themselves, often silently, in coping with problematic situations. Clients learn and practice a new set of cognitive coping strategies that they can apply when they encounter stressors. In the third phase of SIT (application and follow-through), the focus is on carefully arranging for transfer and maintenance of change from the therapeutic situation to daily life. The assumption is that coping skills that are practiced in the clinic will not automatically generalize to everyday life situations. To consolidate the lessons learned in the training sessions, group members participate in a variety of activities, including imagery and behavior rehearsal, role playing, modeling, and graduated in vivo practice. Group participants are provided with training in relapse prevention, which consists of procedures for dealing with the inevitable setbacks they are likely to experience as they apply their learning to daily life.

Limitations of the Approach

TA has been criticized for being too simplistic One can become lost in the structure and vocabulary of this system to avoid genuine contact with others TA's theory and procedures have not been adequately validated empirically Members may use TA concepts in an intellectual manner and deceive themselves into believing they are becoming self-actualized Like most of the other approaches that have been discussed so far, TA can be criticized on the ground that its theory and procedures have not been adequately subjected to empirical validation. A limitation of TA is that transactional analysis group leaders could work primarily in a cognitive way and not allow enough room for exploration of feelings. A further concern relates to the way in which some practitioners use the structure and vocabulary of this system to avoid person-to-person interactions.

Basic Life Positions

TA identifies four basic psychological life positions: I'm OK—You're OK I'm OK—You're not OK I'm not OK—You're OK I'm not OK—You're not OK Decisions about oneself, one's world, and one's relationships to others are crystallized during the first 5 years of life. Such decisions are basic for the formulation of a life position, which develops into the roles of the life script. Generally, once a person has decided on a life position, there is a tendency for it to remain fixed unless there is some intervention, such as therapy, to change the underlying decisions. Games are often used to support and maintain life positions and to play out life scripts. People seek security by maintaining that which is familiar, even though what is familiar may be highly unpleasant and self-sabotaging. The I'm OK—You're OK position is game free. It is the belief that people have basic value, worth, and dignity as human beings. That people are OK is a statement of their essence, not necessarily their behavior. This position is characterized by an attitude of trust and openness, a willingness to give and take, and an acceptance of others as they are. People are close to themselves and to others. There are no losers, only winners. I'm OK—You're not OK is the position of people who project their problems onto others and blame them, put them down, and criticize them. The games that reinforce this position involve a self-styled superior (the "I'm OK") who projects anger, disgust, and scorn onto a designated inferior, or scapegoat (the "You're not OK"). This position is that of the person who needs an underdog to maintain his or her sense of "OKness." I'm not OK—You're OK is known as the depressive position and is characterized by feeling powerless in comparison with others. Typically such people serve others' needs instead of their own and generally feel victimized. Games supporting this position include "Kick me" and "Martyr"—games that support the power of others and deny one's own. The I'm not OK—You're not OK quadrant is known as the position of futility and despair. Operating from this place, people have lost interest in life and may see the world as a lousy place and life as totally without promise. This self-destructive stance is characteristic of people who are unable to cope in the real world, and it may lead to extreme withdrawal, a return to infantile behavior, various forms of psychotic behavior, or violent behavior resulting in injury or death of themselves or others.

Applying Transactional Analysis to Group Work in Schools

TA is a structured approach TA helps students make connections between what they learned in their family and their attitudes toward others Exploring injunctions is a good starting point in school-based groups children know rules Many of the basic ideas found in TA groups can easily be understood even by very young children. For example, children are able to understand the concept of the need for human strokes. Even children in the early grades are able to understand that acting-out children are striving to get attention (strokes). Children soon learn that negative strokes are better than receiving no strokes. TA concepts and techniques can be usefully applied in guidance classes in schools or in group counseling sessions with students 5 to 17 years of age (Henderson & Thompson, 2011). For example, exploring parental injunctions can be a useful exercise with both children and adolescent groups. Young people can learn a great deal about the messages they have incorporated from their family of origin. A competent TA group leader creates a climate in which the members can begin to question the degree to which they have accepted messages from their family and culture. Members also are encouraged to explore how some of these injunctions influence their present behavior. A main goal of a TA group with students is to facilitate insight so that they are able to reclaim control of their thoughts, feelings, and actions. As children and adolescents develop this self-understanding, they also acquire the ability to make changes both within themselves and in their transactions with others.

Introduction to Transactional Analysis

TA is a theory of personality, a language of behavior, and an organized system of interactional therapy TA is grounded on the assumption that people make present decisions based on their early experiences The goal of TA is autonomy (awareness, spontaneity, and the capacity for intimacy) Redecision therapy, a form of TA, assists members in taking charge of their lives and deciding how to change TA is an interactional and contractual approach to groups Transactional analysis (TA) is a theory of personality, a language of behavior, and an organized system of interactional therapy. It is grounded on the assumption that we make current decisions based on our early experiences. Early in life we may have felt powerless or even experienced ourselves as struggling for survival. The TA therapist focuses on helping clients rethink and redecide these early decisions in light of present circumstances. TA emphasizes the cognitive and behavioral aspects of the therapeutic process. The goal of transactional analysis is autonomy, which is defined as awareness, spontaneity, and the capacity for intimacy (Tudor & Hobbes, 2002). In achieving autonomy people have the capacity to make new decisions (redecide), thereby empowering themselves and altering the course of their lives. Specific client goals are mutually arrived at and agreed upon. In therapy groups, TA participants learn how to recognize the three ego states—Parent, Adult, and Child—in which they function. Group members also learn how their current behavior is being affected by the rules and regulations they received and incorporated as children and how they can identify the life script they decided upon, which is determining their actions. Ultimately, they come to realize that they can now redecide and initiate a new direction in life, changing what is not working while retaining what serves them well. To turn their desires into reality, clients are required to actively change their behavior. TA provides an interactional and contractual approach to groups. It is interactional in that it emphasizes the dynamics of transactions between people, and it is contractual in that group members develop clear statements of what they will change and how they will be different as a result of being in a group. Members establish their goals and direction and describe how they will be different when they complete their contract. Contracting allows for a more equal footing between client and therapist and demonstrates that the responsibility for change is shared between group member and therapist. Contracting for change also minimizes potential power struggles between therapist and client. This chapter highlights the expansion of Berne's approach by the late Mary Goulding and Robert Goulding (1979), leaders of the redecisional school of TA. The Gouldings differ from the classical Bernian approach in a number of ways. They have combined TA with the principles and techniques of Gestalt therapy, family therapy, psychodrama, and behavior therapy. The redecisional approach helps group members experience their impasse, or the point at which they feel stuck. They relive the context in which they made earlier decisions, some of which were not functional, and they make new decisions that are functional. Redecision therapy is aimed at helping people challenge themselves to discover ways in which they perceive themselves in victimlike roles and to take charge of their life by deciding for themselves how they will change.

Contributions and Strengths of the Approach

TA provides a cognitive basis for group process that is often missing in experientially-oriented groups Redecision therapy offers tools to help members free themselves from archaic life scripts Contracts equalize power between the leader and members As a structured, psychoeducational approach, the TA group format lends itself well to agencies within a managed care system TA groups can be used for preventive and remedial purposes The insistence of this approach on having members get out of their persecutor, rescuer, and victim positions and realize that they don't have to continue to live by their early decisions is, I believe, crucial to effective therapy. Conceptually, redecision therapy offers tools members can use to free themselves from an archaic life script and achieve a successful and meaningful life. From my vantage point, one of the strengths of the TA approach to group counseling is the emphasis on contracts as a way to guide each member's work. Contracts equalize the power base between the leader and the members; they also remove much of the mystery that surrounds what a group is all about. Because TA is a structured, psychoeducational approach, the group format lends itself well to agencies within a managed care system. Members identify specific areas they are interested in changing, they formulate a specific contract that guides their work in a group, and they design action plans to reach their goals in the shortest amount of time. This gives TA clear advantages for brief treatment and a focus on specific problems and goals. The emphasis of TA on developing contracts for behavior change enhances the opportunity for bringing about effective changes in brief therapy. Personally, I favor integrating TA concepts and practices with Gestalt and psychodrama techniques. Doing so can integrate the cognitive and emotive dimensions quite naturally. Many of the specific techniques in psychodrama— such as role reversal, self-presentation, doubling, soliloquy, and future projection—are ideal methods of exploring the affective dimensions of injunctions and early decisions.

Adult ego

The Adult ego state is the objective and computer-like part of our personality that functions as a data processor; it computes possibilities and, like the other two ego states, makes decisions, and represents what we have learned and thought out for ourselves. The state is not related to chronological age. The Adult is a thinking state oriented toward current reality; the Adult is objective in gathering information, is nonemotional, and works with the facts of the external reality as perceived by that individual. The Adult often negotiates between the Child's wants and the Parent's shoulds.

Parent ego

The Parent ego state contains the values, morals, core beliefs, and behaviors incorporated from significant authority figures, primarily one's parents. Outwardly, this ego state is expressed toward others in critical or nurturing behavior. Inwardly, it is experienced as old parental messages that continue to influence the inner Child. When we are in the Parent ego state, we react to situations as we imagine our parents might have reacted, or we may act toward others the way our parents acted toward us. The Parent ego state is divided into Nurturing Parent (NP) and Controlling Parent (CP), both of which have positive and negative aspects. The positive aspect of Nurturing Parent is to affirm individuals for both being and doing. The negative aspect of the Nuturing Parent involves discounting others with phrases such as, "Oh, you poor thing." The positive aspect of Controlling Parent is to provide structure intended for the benefit or success of the individual, such as "Finish your homework before you watch television." The negative aspect of Controlling Parent is to be critical and often to discount the Child ego state in others.

The Ego States

The Parent ego state superego judge nurturing parent & controlling The Adult ego state ego refere natural and adaptive The Child ego state id TA is based on the premise that the human personality is structured into three separate ego states: Parent, Adult, and Child (P-A-C). An ego state is a set of related thoughts, feelings, and behaviors in which part of an individual's personality is manifested at a given time (Stewart & Joines, 1987). According to TA, people are constantly shifting from one of these ego states to another, and their behavior at any one time is related to the ego state they are in at the moment. People operate from the ego state that has the most energy and make decisions from that ego state. One definition of autonomy is the capacity to move with agility and intention through ego states and to operate in the one most appropriate to the reality of the given situation. In a TA group, members are first taught how to recognize in which of the five ego states they are functioning at any given time: Nurturing Parent, Controlling Parent, Adult, Nurturing Child, or Adapted Child. The aim is to enable them to decide consciously whether that state or another state is most appropriate or useful.

Applying Transactional Analysis With Multicultural Populations

The contractual approach used in TA groups has much to offer in a multicultural context TA is believed to be "user friendly" and has been successfully applied in many cultures TA's concepts are congruent with a gender-sensitive approach to group work Members' life scripts may be rooted in their cultural heritage Members must feel trust and be ready to question their family traditions before they are challenged Group members' contracts act as a safeguard against therapists' imposing their cultural values on members. A contract increases the chances that members will become empowered in a group because they eventually must identify specific problem areas they want to bring into the group. The contractual approach helps clients assume more personal responsibility for the outcomes of their therapy. Individuals who prefer a direct and educational approach to personal development are likely to find TA an appropriate modality because it emphasizes learning practical skills. A number of factors in TA groups make them particularly useful in working with women. Some of these elements are the use of contracts, the egalitarian relationships between the members and the leader, the emphasis on providing members with knowledge of the TA group process, and the value placed on empowering the group members. If leaders hope to avoid reinforcing the cultural status quo, they must learn how traditional gender socialization can hurt both women and men. Both women and men can learn to interact with each other in the group in new ways. Just as they can examine the influence of a host of injunctions and decisions they have made based on certain messages, group members can fruitfully examine how they can free themselves from restrictive gender-role socialization. Before TA group leaders challenge the life scripts of group members, which are frequently rooted in their cultural heritage, it is well for them to make sure that a trusting relationship has been established and that these clients have demonstrated a readiness to question their family traditions. In some cultures it is considered taboo to doubt family traditions, let alone talk about such matters in a nonfamily group or have these traditions challenged by others.

Stages of a Transactional Analysis Group

The core of the work in this approach consists of helping clients make redecisions while they are in their Child ego state. Because the decision was made in the Child ego state in its earliest form, the redecision must be made in the Child ego state in the present. This is done by having members reexperience an early scene as if the situation were occurring in the present. How the leader helps members get into their Child ego state and make a new decision can best be seen by examining the stages of redecisional group therapy.

Key Concepts

The distinguishing characteristic of cognitive behavioral practitioners is their systematic adherence to specification and measurement. Concepts and procedures are stated explicitly, tested empirically, and revised continually. Assessment and treatment occur simultaneously. The specific unique characteristics of behavior therapy include (1) conducting a behavioral assessment, (2) precisely spelling out collaborative treatment goals, (3)formulating a specific treatment procedure appropriate to a particular problem, and (4) objectively evaluating the outcomes of therapy.

Role and Functions of the Group Leader

The leader is a teacher who explains concepts such as structural, script, and game analysis Equality is emphasized and is evident in the contractual agreement The leader helps members discover how their games support chronic bad feelings, which support their life script The leader also challenges members to discover and experiment with more effective ways of being The leader assumes an active role and occupies a central position in the group As a teacher, the TA therapist explains concepts such as structural analysis, script analysis, and game analysis. The TA therapist functions as a consultant. As noted earlier, TA stresses the importance of equality in the client-therapist relationship, an equality that is manifested through contractual agreements between the group leader and the individual members, which make them mutual allies in the therapeutic process. Consequently, the role of the group leader is to facilitate the members in fulfilling their contracts. From the perspective of redecision therapy, the group leader's function is to create a climate in which people can discover for themselves how the games they play are supporting chronic bad feelings and how they hold onto these feelings to support their life script and early decisions. Another function of the TA facilitator is to challenge group members to discover and experiment with more effective ways of being. The role of the leader is to help members acquire the tools necessary to effect change. TA group leaders assume an active role and occupy a central position in the group, but a group leader who does most of the talking may be blocking the member from doing the necessary work toward change. Although the transactional analyst is active in structuring the group sessions, is an active catalyst for the redecision, and confronts impasses, the group member does most of the actual work. It is assumed that group members have the power to change negative childhood decisions by developing their positive ego state forces.

Reinforcement

The term reinforcement refers to a specified event that strengthens the tendency for a response to be repeated. In behavioral groups, social reinforcement is a major intervention provided by the group leader and by other members. In addition to the reinforcement provided by the group leader, other members reinforce one another through praise, approval, support, and attention. It is a good idea to begin each session with members reporting their successes rather than their failures. This sets a positive tone in the group, provides reinforcement to those who did well in everyday life, and reminds the group that change is possible. Reports of success, no matter how modest, are especially important when the members are improving but are still falling short of their expectations and when their changing behavior is being met with disapproval in their everyday environments. In these cases the reinforcement and support of the group are critical if members are to maintain their gains.

rackets

The unpleasant feelings people experience after a game are known as rackets. A racket feeling is a familiar emotion that was learned and encouraged in childhood and experienced in many different stress situations, but it is maladaptive as an adult means of problem solving (Stewart & Joines, 1987). Rackets are often substitute feelings that replaced feelings the child's parents did not allow. For example, Ed was not allowed to show anger as a child. He was told, "You are not angry, you are just tired! Go to your room and rest." So Ed adopted being tired as a racket feeling for anger, and as an adult Ed is often tired for no apparent reason. These rackets are maintained by actually choosing situations that will support them. Therefore, those who typically feel depressed, angry, or bored may be actively collecting these feelings and feeding them into long-standing feeling patterns that often lead to stereotypical ways of behaving. People also choose the games they will play to maintain their rackets. Games and rackets can be thought of as the emotional and relational patterns that people create to foster their life script decisions

Homework

Therapeutic homework is aimed at putting into action what members explore during a group session, which, in essence, is the crux of the matter. Homework affords many opportunities for members to practice new skills in the real world. At its best, homework should integrate what goes on within the group with everyday life. The more time group members are willing to commit to working on their problems outside of the therapeutic context, the more likely it is that they will make positive gains They write that therapists' clarity in describing the homework, providing a rationale, and enlisting client involvement are key factors that determine the effectiveness of homework. If group leaders "assign homework" to members, positive outcomes are unlikely. When group members participate in designing their own homework assignments, they retain a cooperative spirit and keep the motivation needed to carry out the homework. This is particularly important in CBT groups because collaboration is a key element of the group experience. Following up on the homework is essential, for all group members can benefit from the homework experiences of each other. Difficulty in completing homework tasks needs to be addressed appropriately (Dattilio, 2002, 2003). One way of doing this is by asking members what makes it difficult to complete their homework and to explore the degree to which they are committed to make certain changes. Leaders might also inquire about both obstacles to completing homework and ways that members may be engaging in self-sabotage.

Mindfulness-Based Cognitive Therapy (MBCT)

This is a comprehensive integration of the principles and skills of mindfulness applied to the treatment of depression (Segal et al., 2013). Mindfulness-based cognitive therapy (MBCT) is an 8-week group treatment program adapted from Kabat-Zinn's (1990) mindfulness-based stress reduction program and includes components of cognitive behavior therapy. In mindfulness exercises, clients are asked to "just notice" their thoughts and emotions as they arise. Clients learn mindfulness meditation that involves an open and nonjudgmental posture regarding negative thinking, emotions, and bodily states (Wilson et al., 2012). They are encouraged to practice mindfulness not just in the group but to bring this practice into their daily life. Clients come to realize that their thoughts are not facts and that they can allow thoughts to come and go, rather than attempting to dispute them out of existence as might be done in traditional CBT.

Working stage

Treatment planning occurs Assessment and evaluation continue to ensure that treatment goals are being attained Strategies proven to achieve behavioral change are used Treatment planning involves choosing the most appropriate set of procedures from among specific strategies that have been demonstrated to be effective in achieving behavioral change. Assessment and evaluation continue throughout the working stage, and group leaders must continually evaluate the degree of effectiveness of the sessions and how well treatment goals are being attained. To make this evaluation during the working stage, leaders continue to collect data on matters such as participation, member satisfaction, attendance, and completion of agreed-upon assignments between sessions. Throughout the course of a group, individuals monitor their behaviors and the situations in which they occur. In this way they can quickly determine those strategies that are effective or ineffective. By means of this continuing evaluation process, both the members and the leader have a basis for looking at alternative and more effective strategies.

Basic Assumptions and Rationale for a Group Approach

Underlying the practice of TA group work is the premise that awareness is an important first step in the process of changing our ways of thinking, feeling, and behaving. In the early stages of a group, techniques are aimed at increasing participants' awareness of their problems and their options for making substantive changes in their life. Another basic assumption of TA is that all of us are in charge of what we do, of the ways in which we think, and of how we feel. Others do not make us feel a certain way; rather, we respond to situations largely by our choices Redecision therapy, as introduced by the Gouldings, is conducted in a group context in which members can experience elements of their life scripts by relating current issues to early scenes in their life when a decision was initially made. From a redecisional perspective, group therapy is the treatment of choice. Group participants tend to change more rapidly than they can in individual therapy, and groups seem to add a human quality to therapy In the same way that Gestalt groups function in the here-and-now, TA groups bring past issues into the present. Group members facilitate action by representing both family members from the past and contemporaries. Because of the interaction within the TA group, members have easier access to their life script content by seeing it reflected back to them through the words and behavior of other group members. By identifying early decisions and appreciating how valuable they were at the time they were made, members are challenged to see what they would prefer given the reality of today.

Stress Management Training in Groups

Used for a wide variety of problems and client populations Can be used for remediation of stress disorders and for prevention The goal is not to eliminate stress but to educate clients about its nature and effects and to teach them skills to deal with stress constructively Donald Meichenbaum's stress inoculation training (SIT) involves: information giving Socratic discussion cognitive restructuring problem solving relaxation training behavior rehearsal self-monitoring, self-instruction, and self-reinforcement Stress inoculation training (SIT): a three-stage model conceptual/educational 2) skills acquisition, consolidation, and rehearsal 3) application and follow through Stress is a basic part of contemporary life. Although it is not realistic to assume that we can eliminate stress, it is realistic for us to learn how to control how we view and cope with stressful events. Stress management training has potentially useful applications for a wide variety of problems and client populations, both for remediation of stress disorders and for prevention. Stress management training is especially useful in dealing with anger, anxiety, phobias, and medical problems; the training is appropriate for victim populations and for professional groups. A basic assumption of stress management programs is that we are not simply victims of stress; rather, what we do and what we think actively contribute to how we experience stress. In other words, how we appraise events in life determines whether stress will affect us positively or negatively. The training begins with a brief assessment of the client's lifestyle, including identifying aspects that may cause stress. Participants in the program are then presented with a psychoeducational overview of stress from a psychosocial perspective and learn to use behaviors and thoughts for coping with a variety of stressful situations. Clients make a concrete behavioral plan for implementing lifestyle changes that will lead to a better quality of life.