Occupational Therapy Group Process part 1

Occupational Therapy Group Process

1. Occupational Therapy the Group Process

2. Occupational Therapy and Groups  Groups provide a natural learning environment (through complex interactions)  Multiple layers of relationships (therapeutic potential)  Opportunity for sharing and support  Use of activities to develop interpersonal skills (Denton, and encourage social interaction  Doing rather than being  Group dynamics a source of energy and creativity  Social learning  Expression and exploration of emotion  Shapers of behavior (norms and pressures)  May be time efficient ( work with multiple clients in an effective way)

3. Group Dynamics  The forces that influence the interrelationships of members and ultimately affect group outcomes  Implications for OT  We need to understand stages of group development as this will impact on activity choices  Group dynamics impact how we may lead groups

4. Yalom’s 11 Curative/Therapeutic factors of Group Therapy 1. Instillation of hope:  Hope that treatment can be effective  Therapist conveys this 2. Universality:  Group members are not alone  Problems are not unique  Listening without judgement 3. Imparting Information:  Key learning (formal or informal) 4. Altruism:  Gaining benefit from giving

5. Yalom’s 11 Curative/Therapeutic factors of Group Therapy 5. Corrective recapitulation of primary family group:  Projection of feelings  Working through issues 6. Development of social skills:  Role-play, games and feedback 7. Imitative behavior:  Observing new ways of behaving (other group members or facilitator) 8. Interpersonal learning:  Self reflection  Social microcosm

6. Yalom’s 11 Curative/Therapeutic factors of Group Therapy 9. Group cohesiveness:  Like the ‘relationship’ in individual therapy  Unconditional acceptance  Shape behavior, increase self esteem, more stable and more attendance if cohesive 10. Catharsis :  Enhance free expression of feelings  Relief from getting things off chest 11. Existential factors:  Part of group = dealing with responsibility, basic isolation, contingency, recognition of mortality  realizations

7. 3 Stage Model of Change Unfreezing: Overcoming inertia and dismantling the existing "mind set". Defense mechanisms have to be bypassed. Change: Change occurs in second stage. This is typically a period of confusion and transition. One is aware that the old ways are being challenged but does not have a clear picture to replace them with yet. Freezing: In the third stage the new mindset is crystallizing and one's comfort level is returning to previous levels

8. Groups progress through 4 allocated stages 1.Forming 2.Storming 3.Norming 4.Performing 5.Adjourning STAGE 1:FORMING Interpersonal issues: ● Dealing with issues of coming together ● Trying to get to know each other ● Seeking leadership and direction Task Issues: ● Concerns include defining the purpose of the group and its goals ● Who has knowledge and information pertinent to those goals

9. STAGE 2: STORMING Interpersonal issues: ● A period of tension and conflict ● Subgroups may form based on interests/points of view ● Subgroups may clash  conflicts and disagreements Task Issues: ● Disagreements  the best way to proceed ● Disagreements about leadership and control

10. STAGE 3: NORMING Interpersonal issues: ● Conflicts have settled ● Group develops norms conducive to working together and cohesion Task Issues: ● Group members share interpretations and perspectives on tasks ● Members seek to reach consensus ● Co-operative working relationships are developed

11. STAGE 4: PERFORMING Interpersonal issues: ● Group is ready to work together as an effective unit ● Functional role relationships are established ● Time spent together is productive Task Issues: ● The group seeks solutions to task issues that bought them together as a group in the first place

12. STAGE 5: ADJOURNING ● Also referred to as Deforming and Mourning ● Adjourning is an adjunct to the original four stage model ● The break-up of the group ● Everyone can move on to new things, feeling good about what's been achieved ● Recognition of and sensitivity to people's vulnerabilities is helpful

13. Tuckman’s model What makes a group effective is more complex than this model  The model largely ignores context  If the context provides rules, task definitions, information and resources, a high functioning group can be formed within minutes  e.g. O lympic athletes changing teams, combat, etc.

14. Schutz 1958 1. Inclusion  Concern with being accepted into the group  Behaviors include over talking, attention seeking and individual self centeredness  Speak to leader rather than group 2. Control  Leadership struggles  Disagree about structure and subgroups may form  Leader needs to be able to facilitate 3. Affection  Stage of group cohesiveness  This is the goal for any therapy group.  Members feel safe and trust one another.

15. Yalom 2005 1. Orientation  Importance of preparation prior to starting a group  Members size each other up and consider whether they fit 2. Conflict  Issues of power and control  Leader helps process the conflict  May be hostility towards the leader 3. Cohesive Maturity  Cohesiveness: group successfully resolves the conflict / positive feelings and trust  Maturity occurs once both positive and negative feelings may be discussed.

16. Cohesion  The degree of connectedness and closeness group members feel towards each other  High cohesion = clear sense of belonging and strong belief in the group  Low cohesion = more distant and critical of the group “a dynamic process that is reflected in the tendency of a group to stick together and remain united in the pursuit of its instrumental objectives and/or for the satisfaction of member needs”

17. Cohesion Advantages:  Loyalty, trust and warmth  Sense of security  Enables risk taking and self disclosure Disadvantages:  Group has influence over its members  Pressures to conform to group norms  An issue when group norms are ‘deviant’ or ‘unhelpful’  Members may become so attached to each other that their outside interaction is limited.

18. Cohesion Relevance to Occupational Therapy  The importance of trying to work towards a mature cohesive group to maximize effectiveness for participants  Corey et al. (1998) gave these guidelines to help members get the most out of groups.  These guidelines might help you get the most out of your group work  Have a focus  Pay attention to feelings  Be an active participant  Give feedback  Be open to feedback  Take responsibility for what you want to accomplish

19. Group Norms Standard customary ways of performing in groups Norms allow expression of group’s central values = sense of identity Create a distinctive identity  Members can understand how they are different from others  Gives them criteria to evaluate deviant behavior within the group Coordinate activities for group members  Make behavior predictable Group Norms  social standards and acceptable behaviors;  collectively held expectations of group functioning;  provide regularity and predictability to group functioning

20. Types of Norms  Standards relate to:  conduct;  work performance/attendance;  rearranging personal space;  assisting co-workers;  loyalty;  dress codes;  rewards.

21. How do group norms impact on behavior? 1. Personality characteristics predict conformity  Low self confidence more likely to conform 2. The clarity of the norm  The more clear and specific the norm, the more likely members will conform 3. Cohesion of group contributes to conformity

22. Formation of Norms • Mutual influence and interactions of group members • Previous experience of group members • Outside standards • Strongly influenced by events in early development of group • Make norms explicit early to avoid development of inappropriate norms and to set expectations Signs of problems with Group Norms  Topics are avoided  Irrelevant conversations or activities keep occurring  No one acknowledges or follows norms  Conflict over the meaning of group norms

23. When norms are detrimental Defensive/Institutionalized Stuck in patterns of behavior that Reduces creativity Narrow the group’s viewpoint Motivation in Groups Motivation may vary according to  Tasks  ↑ motivation when the task is interesting  How performance is evaluated and rewarded  Related to the goals of team and team members’ sense of commitment or belonging

24. Increasing Motivation • Tasks are interesting, challenging and meaningful • Experience of responsibility • Knowledge of results • Task interdependence • Distribution of required skills across members • Each member believes their contribution is unique and valuable  Power is shared amongst members  Each member must feel independent and group responsibility  Results must be based on interdependence not individual performance  Group goals and reward systems, balanced with individual based rewards

25. Increasing Motivation  Individual contributions to a team are identifiable and linked to performance evaluation and reward system  Goal setting is crucial  Need to set challenging, relevant but attainable goals Conformity  Conformity is not based on power, but rather on the subjective validity of social norms  A feeling of confidence and certainty that the beliefs and actions described by the norms are correct, appropriate, valid, and socially desirable Social loafing  Reduction of individual contribution when people are working in groups rather than alone  Across genders and cultures and tasks  ‘free rider’’ and ‘sucker effect’

26. Developing group cohesion 1. We’ rather than ‘I’ 2. Climate that respects members feelings and opinions 3. Explicit group goals = group identity and purpose 4. Openly invite individuals participation from early 5. Try to prevent individuals from becoming ‘observers’ 6. Model and reinforce self-disclosure and risk taking as necessary 7. Foster group interaction rather than member as facilitator 8. Make group attractive (activities etc.) 9. Activities that foster interaction and cooperation 10. Activities which foster sense of commonality 11. In talking based groups – focus on here and now, not past 12. Have frequent meetings 13. Friendly competition with outside groups

27. Group Leadership Lewin described 3 leadership styles:  Autocratic  Democratic  Laissez-faire Group Leadership  Transformational Leadership lead by example, create a vision  Give followers the encouragement and resources needed to follow this vision 4 key behaviors 1. Idealized influence 2. Inspirational motivation 3. Intellectual stimulation 4. Individualized consideration

28. Cole: 3 types of OT group leadership styles  Directive  OT defines a group, selects activities and goals and structures the group  Needed for lower functioning clients (e.g. low cognition)  Facilitative  Allows group members to make choices with facilitators guidance  OT a resource person for supplies , equipment etc.  OT discusses purpose and goals of the group  Members share in leadership  Most suitable for clients who have self awareness, intelligence and insight  Advisory  May use with community or professional groups  OT may provide expertise on a subject but not structure or goals  Group members are seeking the advice of an OT e.g. prevention work

29. Task Roles Roles that are about getting the work done The different roles needed to move from initial conception through to action  Initiator/Contributor : Proposes new ideas  Information Seeker : Asks questions  Information Giver : Offers Facts  Opinion Seeker ; Asks for clarification of values  Evaluator/Critic : Compares the accomplishments of the group to some standard  Energizer : Arouses the group into action  Procedural Technician : Carries out routine tasks for the group  Recorder : Acts as the secretary or Minute-keeper records decisions  Coordinator : Clarifies relationships and pulls ideas together  Orienter : Considers the group position in relation to its goals  Opinion Giver : States his or her beliefs  Elaborator : Spells out and expands ideas

30. Maintenance Roles These roles contribute to the positive functioning of the group.  Encourager : Praises and understands others points of view  Harmonizer : Mediates differences between members, relieving tensions  Compromiser : Meets other half way to maintain the group harmony  Timekeeper/Expediter : Facilitates the flow of communication and encourages others to participate.  Observer/Commentator : Notes, interprets and presents information about the group process  Follower : Goes along with group ideas and actions

31. Individual/ Self interest roles These roles disrupt group progress and weaken its cohesion.  Aggressor: Deflates and attacks others expresses disapproval  Blocker: Tends to resist and be negative  Recognition Seeker : Calls attention to him/herself by boasting or acting in unusual ways  Self-confessor : Uses the group as an audience to expand on personal feelings and philosophies  Disrupter : Uses group meetings as fun, distracts other people in the group  Dominator : Tries to control the conversation, often exaggerates his or her knowledge  Help Seeker : Actively looks for sympathy by expressing feelings of inadequacy.  Special Interest Pleader : Makes suggestions based on what others would think or feel, avoids revealing his/her own opinion.

32. Group leader functions Task – activity functions:  Teach  Supply equipment  Organize  Give feedback Social-emotional functions:  Give support and meet members needs  Enable communication and self-expression  Motivate and facilitate group cohesion

33. Parallel Group Each member:  Engages in some activity, but acts as if this is an individual task as opposed to a group activity  Is aware of others in the group  Initiates some verbal or nonverbal interaction with others  Appears to be relatively comfortable in this situation Leader role:  Chooses and assists with task  Meets all social-emotional needs of members  Enforce inappropriate behavior such as engaging in the task, Answering questions, shape behavior by giving praise and ignoring inappropriate behaviors

34. Project (Associative) Group Each member:  Occasionally engages in the group activity, moving in and out according to his or her own wish  Seeks some assistance from others  Gives some assistance when directly asked to do so  Competes, cooperates with therapist prompting Leader:  Assists group with task and meet members needs  reinforces behaviors when two or more members work together or interact

35. Egocentric-Cooperative Group Member behaviors:  Aware of group’s goal relative to the task  Acts as if he belongs in the group  Willing to participate  Responsible for organizing their activity  Not overly competitive Leader  Less of director role and more of a role model  May make suggestions and give assistance  Meet love and safety needs

36. Cooperative Group Meets needs of other members and express feelings Leader  Consultation  Participant  Makes own wishes, desires, and needs known  Participates in group activity  Both members and leader have mutual responsibility for the group activities and reinforcing behavior

37. Mature Group  Flexibly take on various roles Leader  Acts as group member  Responsive to all group members  Take a variety of task roles  Take a variety of social-emotional roles  Able to share leadership  Promotes a good balance between task accomplishment and satisfaction of group members’ needs

38. Leader roles- Support Groups  Creation and maintenance of the group  Culture building  Activation and process illumination  Dealing with transference Directive Leadership is Appropriate When:  Members have cognitive impairment, poor capacity for insight, immaturity, poor verbal skills, or low motivation  Specific goals and activities are desired  Topic is educational and requires therapist expertise/demonstration  Most group roles are performed by the leader  Feedback to members given mostly by the leader

39. Facilitative Leadership  Leader gathers support from members  OT earns their support by giving them choices and asking them to collaborate in reaching goals  Presumes a certain level of ability and rational thought  Allows group to experience advanced levels of group development

40. Facilitative Leadership is Appropriate When:  Members have a middle-high level of cognition and capacity for insight  Members have at least a medium level of maturity, verbal skills and motivation  Members are capable of making choices of activity, topic, structure  Members can learn from experience  Therapist can delegate some leadership roles to members  Members are encouraged to give each other feedback  Therapist/leader does not do anything for the group that they can do for themselves

41. Advisory Leadership  Assumes high level of functioning  Appropriate for more informal activities  Assumes motivation of members  OT leader acts as resource  OT imparts information as needed Advisory Leadership is Appropriate When:  OT’s role is consulting, wellness, or care-giver education  Members have high cognition, verbal skills, insight capacity, and motivation  Members have selected a specific activity or topic area  Members can seek advice from leader on as-needed basis  Members lead their own group and experience natural consequences from the environment

42. Role of OT Group Leader  Select members  Design group based on client needs  Set goals, write group protocol  Determine best leadership style based on client needs and preferences and purpose of the group  Oversee group roles, maintain therapeutic norms, support positive efforts of members  Process group according to member needs  Evaluate progress and determine group outcomes

43. Co-Leadership Advantages:  Offers mutual support  Increases objectivity  Uses collective knowledge  Modeling for each other  Taking on different roles Examples:  Male and female  COTA /OTR

44. Co-Leadership Disadvantages  Splitting – Member subgroups ally themselves with one or the other  Competition – Need to downplay and recognize one another’s assets as leader  Unequal contribution – Use supervision to discuss how to redistribute responsibilities  Need to meet on a regular basis to coordinate leadership and support one another

45. Co-Leadership Studied the development of the co-therapy relationship. They identified four developmental stages that parallel the group’s development A. Formative Stage . In this stage, co-leaders are pre-occupied with their feelings of self-worth as a leader, and plagued by fears of inadequacy. These feelings naturally lead co-leaders to compete with one another. By trying too hard to be “good” leaders, they could end up in a power struggle with one another, or a popularity contest with the group members B. Development Stage . This stage requires much interpersonal discussion and the recognition of differences. This stage must be resolved if the co-therapy team is to work effectively together C. Stabilization . After having their fights and talking it out, co-therapists view each other as individuals and recognize each other’s strengths and weaknesses as well as their own. They are able to capitalize on their differences by taking on different leadership roles, and discussing their perceptions openly during the group as well as afterwards

46. Co-Leadership D. Refreshment. From the process of the first three stages, a relationship between co-leaders forms that allows each to grow in their role as leader. Their interaction results in renewed enthusiasm for the group experience and it’s potential to help others. They may experiment with new ideas, do research together, or present their group experiences at professional meetings. They take pride and enjoyment from working with each other, and this energizes the group members with a sense of hope and anticipation

47. Group Intervention Process Step 1: Introduction a. Names  Acknowledge each member by name  Self as OT leader, title of the group activity  Ask members to greet each other by saying their names in turn  Important even if members know each other  Shows recognition of each individual as important  Reinforces inclusion in the group  Creates a friendly atmosphere

48. Group A collection of two or more individuals , who meet in face to face ( or other) interaction , interdependently, with the awareness that each belongs to the group and for the purpose of achieving mutually agreed upon goals ... Groups have power to influence in healthy and unhealthy ways A group can be defined as individuals who share a common purpose that can be attained only by group members interacting and working together

49. Group Work All types of activities performed by organized groups Giving of help or accomplishment of tasks in a group setting. Application of group theory and process by a suitable practitioner to assist an interdependent collection of people to reach their mutual goals, which may be personal, interpersonal or task-related in nature.

50. Occupational Therapy and Groups Occupational Therapy Groups are formed to address specific intervention goals Members usually have similar issues (motor/psychological/cognitive) Members may share similar experiences (e.g. mothers, school aged children) Similar age cohort May have specific diagnosis (stroke, hip fracture, CP)