Chapter 33 Therapeutic Groups

A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I will be glad when I can help someone else." This statement reflects: a. altruism.

ANS: A Altruism refers to the experience of being helpful or useful to others, a condition that the patient anticipates will happen. The other options are also therapeutic factors identified by Yalom.

A therapy group adds new members as others leave. What type of group is evident? a. Open

ANS: A An open group is a group that adds members throughout the life of the group as other members leave and as more persons who would benefit from the group become available. A closed group does not add new members; the membership is established at the beginning and, except for the occasional losses as some members leave, does not change thereafter. A homogeneous group includes members who are similar, and a heterogeneous group includes dissimilar members; not enough data are provided here to determine which applies in this case.

A leader plans to start a new self-esteem building group. Which intervention would be most helpful for assuring mutual respect within the group? a. Describe the importance of mutual respect in the first session and make it a group norm.

ANS: A It is helpful to motivate members to behave respectfully by describing how mutual respect benefits all members and is necessary for the group to be fully therapeutic. Setting a tone and expectation of mutual respect from the outset is the most helpful intervention listed. Excluding members because of how they might behave could exclude members who would have been appropriate, depriving them of the potential benefits of the group. Conveying expectations by brochure is less effective than doing so orally, because it lacks the connection to each member a skilled leader can create to motivate members and impart the expectation of respect. Confronting inappropriate behavior is therapeutic but only addresses existing behavior rather than preventing all such undesired behavior.

A nurse leads a psychoeducational group for patients in the community diagnosed with schizophrenia. A realistic outcome for group members is that they will: a. discuss ways to manage their illness.

ANS: A Patients with schizophrenia almost universally have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.

A group begins the working phase. One member has a childhood history of neglect and ridicule by parents. Which comment would the group leader expect from this member? a. "My boss is always expecting more of me than the others, but talking to him would only make it worse."

ANS: A People who frequently complain, yet reject help or suggestions when offered, tend to have histories of severe deprivation as children, often accompanied by neglect or abuse. The other comments reflect dynamics other than the help-rejecting complainer, such as the monopolizer who apologizes for talking too much, the person who is insightful and agrees to try a peer's suggestion, and the demoralizing member.

Three members of a therapy group share covert glances as other members of the group describe problems. When one makes a statement that subtly criticizes another speaker, the others nod in agreement. Which group dynamic should the leader suspect? a. Some members are acting as a subgroup instead of as members of the main group.

ANS: A Subgroups, small groups isolated within a larger group and functioning separately from it, sometimes form within therapy groups. When this occurs, subgroup members are cohesive with other subgroup members but not with the members of the larger group. Members of the subgroup may be bored or frustrated or expressing passive aggression, but the primary dynamic is the splitting off from the main group.

A patient has talked constantly throughout the group therapy session, often repeating the same comments. Other members were initially attentive then became bored, inattentive, and finally sullen. Which comment by the nurse leader would be most effective? a. Say to everyone, "Most of you have become quiet. I wonder if it might be related to concerns you may have about how the group is progressing today."

ANS: A The most effective action the nurse leader can take will be the one that encourages the group to solve its own problem. Pointing out changes in the group and asking members to respond to them lays the foundation for a discussion of group dynamics. Asking members to respond to the talkative patient puts that patient in an awkward position, likely increasing her anxiety. As anxiety increases, monopolizing behavior tends to increase as well, so this response would be self-defeating. Asking members what is going on is a broader opening and might lead to responses unrelated to the issue that bears addressing; narrowing the focus to the group process more directly addresses what is occurring in the group. Focusing on the talkative patient would be less effective and involves the leader addressing the issue instead of members first attempting to do so themselves (giving them a chance to practice skills such as assertive communication).

During group therapy, one patient says to another, "When I first started in this group, you were unable to make a decision, but now you can. You've made a lot of progress. I am beginning to think that maybe I can conquer my fears too." Which therapeutic factor is evident by this statement? a. Hope

ANS: A The patient's profession that he may be able to learn to cope more effectively reflects hope. Groups can instill hope in individuals who are demoralized or pessimistic. Altruism refers to doing good for others, which can result in positive feelings about oneself. Catharsis refers to venting of strong emotions. Cohesion refers to coming together and developing a connection with other group members.

A group has two more sessions before it ends. One member was previously vocal and has shown much progress but has now grown silent. What explanation most likely underlies this behavior? The silent member: b. is having trouble dealing with feelings about termination of this group.

ANS: B A chief task during the termination phase of a group is to take what has been learned in group and transition to life without the group. The end of a group can be a significant loss for members, who may experience loss and grief and respond with sadness or anger. It is unlikely he would have nothing to say; at the very least, he could be responding to the comments of others even if not focusing on his own issues. He may wish to give quieter members a chance to talk, but again, this would not require or explain his complete silence. Some members, faced with only two remaining sessions, may be becoming more dominant under this pressure of time, but here too this is unlikely to lead a previously active participant to fall completely silent. The member is not attention-seeking.

Which type of group is a staff nurse with 2 months' psychiatric experience best qualified to conduct? b. Medication education group

ANS: B All nurses receive information about patient teaching strategies and basic information about psychotropic medications, making a medication education group a logical group for a beginner to conduct. The other groups would need a leader with more education and experience.

During a support group, a patient diagnosed with schizophrenia says, "Sometimes I feel sad that I will never have a good job like my brother. Then I dwell on it and maybe I should not." Select the nurse leader's best comment to facilitate discussion of this issue. b. "How have others in the group handled painful feelings like these?"

ANS: B Asking others to share their experiences will facilitate discussion of an issue. Giving information may serve to close discussion of the issue because it sounds final. Suggesting a focus on the positives implies a discussion of the issue is not appropriate. Suggesting other possible feelings is inappropriate at this point, considering the patient has identified feelings of sadness and seems to have a desire to explore this feeling. Focusing on other feelings will derail discussion of the patient's grief for his perceived lost potential.

The nurse is planning a new sexuality group for patients. Which location would best enhance the effectiveness of this group? b. A small conference room

ANS: B The conference room would provide a quiet, private area with few distractions, separate from other patient areas and effective for teaching and learning about a private topic. The auditorium is too large, and members' anxiety or lack of trust might lead them to spread out too far from each other, interfering with group process. The day room and the music therapy room are too busy and exposed, reducing privacy and increasing distractions.

During a therapy group that uses existential/Gestalt theory, patients shared feelings that occurred at the time of their admission. After a brief silence, one member says, "Several people have described feeling angry. I would like to hear from members who had other feelings." Which group role is evident by this comment? b. Encourager

ANS: B The member is filling the role of encourager by acknowledging those who have contributed and encouraging input from others. An energizer encourages the group to make decisions or take an action. The compromiser focuses on reducing or resolving conflict to preserve harmony. A self-confessor verbalizes feelings or observations unrelated to the group.

A patient in a detoxification unit asks, "What good it will do to go to Alcoholics Anonymous and talk to other people with the same problem?" The nurse's best response would be to explain that self-help groups such as AA provide opportunities for: b. people with common problems to share their experiences with alcoholism and recovery.

ANS: B The patient needs basic information about the purpose of a self-help group. The basis of self-help groups is sharing by individuals with similar problems. Self-help is based on the belief that an individual with a problem can be truly understood and helped only by others who have the same problem. The other options fail to address this or provide incorrect information.

The next-to-last meeting of an interpersonal therapy group is taking place. The leader should take which actions? Select all that apply. b. Facilitate discussion and resolution of feelings about the end of the group. c. Encourage members to reflect on their progress and that of the group itself. e. Help members identify goals they would like to accomplish after the group ends.

ANS: B, C, E The goals for the termination phase of groups are to prepare the group for separation, resolve related feelings, and prepare each member for the future. Contributions and accomplishments of members are elicited, post-group goals are identified, and feelings about the group's ending are discussed. Group norms are the focus of the orientation phase, and conflict and problem solving are emphasized in the working phase.

A leader begins the discussion at the first meeting of a new group. Which comments should be included? Select all that apply. b. "When someone shares a personal experience, it's important to keep the information confidential." e. "It is important for everyone to arrive on time for our group."

ANS: B, E The leader must set ground rules for the group before members can effectively participate. Confidentiality of personal experiences should be maintained. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. While groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.

A group is in the working phase. One member states, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a waste of my time." Which initial action by the group leader would be most therapeutic? c. Meet privately with the member outside of group to discuss the anger.

ANS: C Meeting privately with the member can convey interest and help defuse the anger so that it is less disruptive to the group. Removing the member would be a last resort and used only when the behavior is intolerably disruptive to the group process and all other interventions have failed. Decreasing the focus on the hostile member and focusing more on positive members can help soften the anger. Angry members often hide considerable vulnerability by using anger to keep others at a distance and intimidated. Changing the subject fails to respond to the behavior.

A patient in a group therapy session listens to others and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This comment is an example of: c. universality.

ANS: C Realizing that one is not alone and that others share the same problems and feelings is called universality. Ventilation refers to expressing emotions. Altruism refers to benefitting by being of help to others. Group cohesiveness refers to the degree of bonding among members of the group.

A group is in the working phase. One member says, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a total waste of my time." Which comment by the group leader would be most therapeutic? c. "It must be hard to be so angry." Direct this comment to another group member, "You were also angry at first but not now. What has helped you?"

ANS: C The member's comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. "You seem to know a lot..." conveys hostility from the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This comment suggests countertransference and is non-therapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.

A nurse at the well child clinic realizes that many parents have misconceptions about effective ways of disciplining their children. The nurse decides to form a group to address this problem. What should be the focus of the group? c. Health education

ANS: C The nurse has diagnosed a knowledge deficit. The focus of the group should be education. Support and socialization are beneficial but should not be the primary focus of the group, and symptoms are not identified for intervention here.

During a group therapy session, a newly admitted patient suddenly says to the nurse, "How old are you? You seem too young to be leading a group." Select the nurse's most appropriate response. d. "You are wondering whether I have enough experience to lead this group?"

ANS: D A question such as this is common in the initial phase of group development when members are getting to know one another, dealing with trust issues, and testing the leader. Making explicit the implied serves to role model more effective communication and prompts further discussion of the patient's concern. Asking the patient to tell the leader more about the question focuses on the reason for the member's concern rather than on the issue raised (the experience and ability of the leader) and is a less helpful response. "I am old enough to be a nurse" and "age is not pertinent" are defensive responses and fail to address the patient's valid concern.

Which outcome would be most appropriate for a symptom-management group for persons with schizophrenia? Group members will: d. describe ways to cope with their illness.

ANS: D An appropriate psychoeducational focus for patients with schizophrenia is managing their symptoms; coping with symptoms such as impaired memory or impaired reality testing can improve functioning and enhance their quality of life. Names of medications might be appropriate for a medication education group but would be a low priority for symptom management. Addressing intra-family issues would be more appropriate within a family therapy group or possibly a support group. Rating anxiety lower would be an expected outcome for a stress-management group.

A patient tells members of a therapy group, "I hear voices saying my doctor is poisoning me." Another patient replies, "I used to hear voices too. They sounded real, but I found out later they were not. The voices you hear are not real either." Which therapeutic factor is exemplified in this interchange? d. Interpersonal learning

ANS: D Here a member gains insight into his own experiences from hearing about the experiences of others through interpersonal learning. Catharsis refers to a therapeutic discharge of emotions. Universality refers to members realizing their feelings are common to most people and not abnormal. Imitative behavior involves copying or borrowing the adaptive behavior of others.

Which remark by a group participant would the nurse expect during the working stage of group therapy? d. "I don't think I agree with your action. It might help you, but it seems like it would upset your family."

ANS: D In the working stage, members actively interact to help each other accomplish goals, and because trust has developed, conflict and disagreement can be expressed. Focusing on trust and confidentiality typically occur in the orientation phase as part of establishing group norms. Commonality and universality are also themes typically expressed in the orientation phase, whereas reflecting on progress is a task addressed in the termination phase.

Guidelines followed by the leader of a therapeutic group include focusing on recognizing dysfunctional behavior and thinking patterns, followed by identifying and practicing more adaptive alternate behaviors and thinking. Which theory is evident by this approach? d. Cognitive-behavioral

ANS: D The characteristics described are those of cognitive-behavioral therapy, in which patients learn to reframe dysfunctional thoughts and extinguish maladaptive behaviors. Behavioral therapy focuses solely on changing behavior rather than thoughts, feelings, and behaviors together. Interpersonal theory focuses on interactions and relationships. Psychodynamic groups focus on developing insight to resolve unconscious conflicts.

A young female member in a therapy group says to an older female member, "You are just like my mother, always trying to control me with your observations and suggestions." Which therapeutic factor of a group is evident by this behavior? d. Corrective recapitulation of the primary family group

ANS: D The younger patient is demonstrating an emotional attachment to the older patient that mirrors patterns within her own family of origin, a phenomenon called corrective recapitulation of the primary family group. Feedback from the group then helps the member gain insight about this behavior and leads to more effective ways of relating to her family members. Instillation of hope involves conveying optimism and sharing progress. Existential resolution refers to the realization that certain existential experiences such as death are part of life, aiding the adjustment to such realities. Development of socializing techniques involves gaining social skills through the group's feedback and practice within the group.