Mental Health Chapter 9- Intervention in Groups

Group Therapy

-A form of psychosocial treatment in which a number of clients meet together with a therapist for purposes of sharing, gaining personal insight, and improving interpersonal coping strategies. --Leaders of group therapy generally have advanced degrees in psychology, social work, nursing, or medicine. -group psychotherapy based on various theoretical frameworks such as psychoanalytic, psychodynamic, interpersonal, and family dynamics. -encourage improvement in the ability of group members to function on an interpersonal level

Psychodrama

-A specialized type of therapeutic group -Moreno's method employs a dramatic approach in which clients become "actors" in life-situation scenarios. -The group leader is called the director, group members are the audience, and the set, or stage, may be specially designed or may just be any room or part of a room selected for this purpose. -The client plays the role of himself or herself and is called the protagonist. In this role, the client is able to express true feelings toward individuals (represented by group members) with whom he or she has unresolved conflicts. - The client may chose a situation he or she wishes to enact and select the audience members to portray the roles of others in the life situation. The psychodrama setting provides the client with a safer and less threatening atmosphere than the real situation in which to express true feelings. -When the drama has been completed, group members from the audience discuss the situation they have observed, offer feedback, express their feelings, and relate their own similar experiences. -Nurses often serve as actors, or role players, in psychodrama sessions. Leaders of psychodrama have graduate degrees in psychology, social work, nursing, or medicine with additional training in group therapy and specialty preparation to become a psychodramatist.

Self-Help groups

-An additional type of group, in which nurses may or may not be involved, is the self-help group. -They allow clients to talk about their fears and relieve feelings of isolation while receiving comfort and advice from others undergoing similar experiences. These groups may or may not have a professional leader or consultant. They are run by the members, and leadership often rotates from member to member. -valuable source of referral for clients with specific problems

Leadership Styles (Lippitt abd White 1958)

-Autocratic -Democratic -Laissez-faire

Closed group

-Closed-ended groups usually have a predetermined, fixed time frame. All members join at the time the group is organized and terminate at the end of the designated time period. Closed-ended groups are often composed of individuals with common issues or problems they wish to address.

Autocratic

-Focus on leader -Production high, morale low -Autocratic leaders have personal goals for the group. They withhold information from group members, particularly issues that may interfere with achievement of their own objectives. -The focus in this style of leadership is on the leader. Members are dependent on the leader for problem-solving, decision-making, and permission to perform.

Democratic

-Focus on members -Production lower but morale much higher. -The democratic leadership style focuses on the members of the group. - Members are encouraged to participate fully in problem-solving of issues that relate to the group, including taking action to effect change.

Individual/Personal roles

-Fulfilling personal or individual needs -satisfy needs of the individual members, sometimes to the extent of interfering with the effectiveness of the group

Role of the Nurse in Group Interventions

-In health-care settings, nurses serve on or lead task groups that create policy, describe procedures, and plan client care. -serving the consumer -ead various types of therapeutic groups, such as client education, assertiveness training, support, parenting, and transition to discharge groups, among others. -Generalist nurses in psychiatry rarely serve as leaders of psychotherapy groups. -The Psychiatric-Mental Health Nursing Scope and Standards of Practice (American Nurses Association, American Psychiatric Nurses Association, & International Society of Psychiatric Nurses, 2014) specifies that nurses who serve as group psychotherapists should have a minimum of a master's degree in psychiatric nursing.

Currative Factors of Groups (Yalom and Leszcz 2005)

-Instillation of hope -Universality -Imparting of information -Altruism -Corrective recapitulation of the primary family group -Development of socializing techniques -Imitative behavior -Interpersonal behavoir -Group cohesiveness -Catharsis -Existential factors

Maintenance roles

-Maintaining or enhancing group processes -contribute to the success or effectiveness of the group

Laissez-faire

-No focus -Goals undefined -Productivity and morale low -There is no direction from the leader. In fact, the laissez-faire leader's approach is noninvolvement. Goals for the group are undefined. No decisions are made, no problems are solved, and no action is taken. Members become frustrated and confused, and productivity and morale are low.

Phases of Group Development

-Phase I: Initial or Orientation phase -Phase II: Middle or working phase -Phase III: Final or termination phase -Ideally, groups progress from the phase of infancy to advanced maturity in an effort to fulfill the objectives set forth by the membership. Unfortunately, as with individuals, some groups become fixed in early developmental levels and never progress, or they experience periods of regression in the developmental process.

Phase II: Middle or working phase

-Productive work -Leader becomes facilitator -Trust established, conflict managed

Phase I: Initial or Orientation phase

-Rules and goals -Promote trust, fulfill goals -Superficially polite

Physical Conditions Affecting Group Dynamics

-Seating -Size -Membership -Open-ended -Closed-ended

Phase III: Final or termination phase

-Sense of loss -Share feelings, reminisce -Abandonment and grief

Task roles

-Serving to complete the task of the group -contribute to the success or effectiveness of the group

Functions of a Group

-Socialization -Support -Task Completion -Camaraderie -Information Sharing -Normative influence -Empowerment -Governance

Types of Groups

-Task -Teaching Group therapy -Supportive /therapeutic -Therapeitic groups -Self-help groups

Member Roles

-Task roles -Maintenance roles -Individual roles

Teaching groups

-Teaching, or educational, groups exist to convey knowledge and information to a number of individuals. -These groups usually have a set time frame or a set number of meetings. -Members learn from each other as well as from the designated instructor. -The objective of teaching groups is verbalization or demonstration by the learner of the material presented by the end of the designated period.

Size

-The larger the group, the less time is available to devote to individual members. In larger groups, aggressive individuals are most likely to be heard, whereas quiet members may be left out of the discussions altogether. Larger groups have the advantage that they provide more opportunities for individuals to learn from other members. -Studies have indicated that a composition of 7 or 8 members provides a favorable climate for optimal group interaction and relationship development.

Supportive-Therapeutic groups

-The primary concern of support groups is to prevent future upsets by teaching participants effective ways to deal with emotional stress arising from situational or developmental crises. -it is important to differentiate between therapeutic groups and group therapy.

Therapeutic groups

-Therapeutic groups, on the other hand, are not designed to conduct psychotherapy, but rather the focus is on group relations, interactions among group members, and the consideration of a selected issue. -like group therapists, individuals who lead therapeutic groups must be knowledgeable in group process; that is, the way in which group members interact with each other. -group leaders are referred to as group facilitators -They must also have thorough knowledge of group content, the topic or issue being discussed among the group, and the ability to present the topic in language that can be understood by all group members. Many nurses who work in psychiatry lead supportive-therapeutic groups.

Membership

-Whether the group is open or closed ended is another condition that influences the dynamics of group process.

Group process

-the way in which group members interact with each other -examples: interruptions, silences, judgments, glares, and scapegoating -will happen whether or not there is a designated group leader, but nurses who are acting as group leaders can guide the way in which members interact with one another to facilitate accomplishing the goals or tasks of the group.

Benne and Sheats (1948) identified three major types of roles that individuals play within the membership of the group. These are roles that serve to:

1) Complete the task of the group. 2) Maintain or enhance group processes. 3) Fulfill personal or individual needs.

Group

A group is a collection of individuals whose association is founded on shared interests, values, norms, or purpose. Membership in a group is generally by chance (born into the group), by choice (voluntary affiliation), or by circumstance (the result of life-cycle events over which an individual may or may not have control).

Family Therapy

A treatment modality that identifies the family, rather than any one individual, as the client. The family is assisted to solve identified problems within the context of the family group.

Governance

An example of the governing function is that of rules being made by committees within a larger organization.

Phase II Member Behaviors

At this point, trust has been established among the members. They turn more often to each other and less often to the leader for guidance. They accept criticism from each other, using it in a constructive manner to create change. Occasionally, subgroups will form in which two or more members conspire with each other to the exclusion of the rest of the group. To maintain group cohesion, these subgroups must be confronted and discussed by the entire membership. Conflict is managed by the group with minimal assistance from the leader.

Instillation of hope

By observing the progress of others in the group with similar problems, a group member garners hope that his or her problems can also be resolved.

Corrective recapitulation of the primary family group

Group members are able to re-experience early family conflicts that remain unresolved. Attempts at resolution are promoted through feedback and exploration.

Task Completion

Group members provide assistance in endeavors that are beyond the capacity of one individual alone or when results can be achieved more effectively as a team.

Empowerment

Groups help to bring about improvement in existing conditions by providing support to individual members who seek to bring about change. Groups have power that individuals alone do not.

Phase II Group activities

Ideally, during the working phase, cohesiveness has been established within the group. This is when the productive work toward completion of the task is undertaken. Problem-solving and decision-making occur within the group. In the mature group, cooperation prevails, and differences and disagreements are confronted and resolved.

Phase I Member behaviors

In phase I, members have not yet established trust and will respond to this lack of trust by being overly polite. There is a fear of not being accepted by the group. They may try to "get on the good side" of the leader with compliments and conforming behaviors. A power struggle may ensue as members compete for their position in the "pecking order" of the group.

Phase III Leader Expectations

In the termination phase, the leader encourages the group members to reminisce about what has occurred within the group, to review the goals and discuss the actual outcomes, to provide feedback to each other about individual progress within the group, and to discuss feelings of loss associated with termination of the group.

Imitative behavior

In this setting, one who has mastered a particular psychosocial skill or developmental task can be a valuable role model for others. Individuals may imitate selected behaviors that they wish to develop in themselves.

Imparting of information

Knowledge is gained through formal instruction as well as the sharing of advice and suggestions among group members.

Information sharing

Learning takes place within groups. Knowledge is gained when individual members learn how others in the group have resolved situations similar to those with which they are currently struggling.

Group cohesiveness

Members develop a sense of belonging that separates the individual ("I am") from the group ("we are"). Out of this alliance emerges a common feeling that both individual members and the total group are of value to each other.

Phase III Member Behaviors

Members may express surprise over the actual materialization of the end. This represents the grief response of denial, which may then progress to anger. Anger toward other group members or toward the leader may reflect feelings of abandonment (Sampson & Marthas, 1990). These feelings may lead to individual members' discussions of previous losses for which similar emotions were experienced. Successful termination of the group may help me

Camaraderie

Members of a group provide the joy and pleasure that individuals seek from interactions with significant others.

Support

One's fellow group members are available in time of need. Individuals derive a feeling of security from group involvement.

Open group

Open-ended groups are those in which members leave and others join at any time while the group is active. The continuous movement of members in and out of the group creates the type of discomfort described previously that encourages unsettled behaviors in individual members and fosters the exploration of feelings.

Socialization

The cultural group into which we are born begins the process of teaching social norms. This process continues throughout our lives as we interact with members of other groups with which we become affiliated.

Task groups

The function of a task group is to accomplish a specific outcome or task.

Existential factors

The group is able to help individual members take direction of their own lives and to accept responsibility for the quality of their existence.

Interpersonal behavoir

The group offers many and varied opportunities for interacting with other people. Insight is gained regarding how one perceives and is being perceived by others.

Phase I Group activities

The leader and members work together to establish the rules that govern the group (e.g., when and where meetings will occur, the importance of confidentiality, how meetings will be structured). Goals of the group are established. Members are introduced to each other.

Phase I Leader Expectations

The leader is expected to orient members to specific group processes, encourage members to participate without disclosing too much too soon, promote an environment of trust, and ensure that rules established by the group do not interfere with fulfillment of the goals.

Phase III Group Activites

The longer a group has been in existence, the more difficult termination is likely to be for the members. Termination should be mentioned from the outset of group formation. It should be discussed in depth for several meetings prior to the final session. A sense of loss that precipitates the grief process may be in evidence, particularly in groups that have been successful in their stated purpose.

Seating

The physical conditions for the group should be set up so that there is no barrier between the members. For example, a circle of chairs is better than chairs set around a table. Members should be encouraged to sit in different chairs at each meeting. This openness and change creates a feeling of discomfort that encourages anxious and unsettled behaviors that can then be explored within the group.

Phase II Leader Expectations

The role of leader diminishes and becomes more one of facilitator during the working phase. Some leadership functions are shared by certain members of the group as they progress toward resolution. The leader helps to resolve conflict and continues to foster cohesiveness among the members while ensuring that they do not deviate from the intended task or purpose for which the group was organized.

Normative influence

This function relates to the ways in which groups enforce the established norms. As group members interact, they begin to influence each other regarding the expected norms for communication and behavior.

Development of socializing techniques

Through interaction with and feedback from other members of the group, individuals are able to correct maladaptive social behaviors and learn and develop new social skills.

Universality

Through universality, individuals come to realize that they are not alone in the problems, thoughts, and feelings they are experiencing. Anxiety is relieved by the support and understanding of others in the group who share similar (universal) experiences.

Family

Two or more individuals who depend on one another for emotional, physical, and economical support. The members of the family are self-defined.

Catharsis

Within the group, members are able to express both positive and negative feelings—perhaps feelings that have never been expressed before—in a nonthreatening atmosphere. This catharsis, or open expression of feelings, is beneficial for the individual within the group.

In psychiatry, work with clients and families often take the form of?

groups -clients learn from each other in a group setting

Altruism

is assimilated by group members through mutual sharing and concern for each other. Providing assistance and support to others creates a positive self-image and promotes self-growth.

Clark (2009) identified three types of groups in which nurses most often participate:

task, teaching, and supportive-therapeutic groups.

The functions of a group vary depending on?

the reason the group was formed.