Group Therapy for People with ID/MI

Robert J. Fletcher, DSW, ACSWCEO, NADD

(National Association for the Dually Diagnosed)

January 24, 2006Phoenix, Arizona

Dr. Fletcher, 2006

Consideration in Forming A Group

Homogeneous vs. Heterogeneous Open vs. Closed Time Limited vs. Ongoing Selecting Members Group Facilitator(s) Size of Group Selecting Members Confidentiality Issues

Dr. Fletcher, 2006

Homogeneous vs. Heterogeneous

Homogeneous Groups Members have similar problem(s) Mutual support based on common problem(s) Group cohesion can develop easily Membership derived from mutual problem(s)

Examples

Women’s Issues & ID Bi-Polar & ID

Substance Abuse & ID Grieving Adults

Adolescents & ID

Dr. Fletcher, 2006

Homogeneous vs. Heterogeneous

Heterogeneous Groups

Members have different problem(s)

Members are at different life stages

Add diversity

Adds depth to the group dynamics

Examples

Adults with ID and MI

Group with sheltered workshop members who

have ID

Dr. Fletcher, 2006

Open vs. Closed Groups

Open Groups Membership changes New members enter as others leave Micro sin of the way life really is New group dynamic with each change in membership

Closed Group Not open to new members Usually runs for a set period of time Provides miniscule of safety and security Promotes group cohesion

Dr. Fletcher, 2006

Time Limited vs. Ongoing

Time Limited Set number of session Clear course of beginning, middle and

termination stages Usually appropriate for homogeneous

Closed Group Not open to new members Usually runs for a set period of time Provides miniscule of safety and security Promotes group cohesion

Dr. Fletcher, 2006

Selecting Members

Homogeneous vs. heterogeneous Location and availability Readiness

Minimum level of interpersonal skills Motivation for treatment Basic ability to relate to and be influence by

others• Goals

– General group goal - Individual goal

• Interview potential group members

Dr. Fletcher, 2006

Group Facilitator(s)

• Facilitates InteractionsEncourages Interaction

• Active Leader• Establishes Ground Rules

• Accepting Individual• Warming, Caring

• Multiple Rules• Therapist Teacher Role Model

• Two Facilitators are the Ideal• One Male/One Female

Dr. Fletcher, 2006

Size of Group

How Large Should a Group Be?

Variables• Depends on Purpose of the Group

• Single Facilitator or two Facilitators

• Six to ten MembersSix for Single FacilitatorTen for ten facilitated group

Dr. Fletcher, 2006

Confidentiality Issues

• What a person reveals in group must not be disclosed outside the group

• Confidentiality must be a ground rule• Members can and should talk about themes/topics with significant others, but members must comply with:

• Preserve anonymity of members when referring to them

• Mask details of what was revealed by making them general rather than specific

• Share their own reaction to what was revealed, not what was already revealed

Dr. Fletcher, 1984

THERAPEUTIC EFFECTSOF

GROUP THERAPY

• HELPS DECREASE FEELINGS OF: INADEQUACY, ISOLATION AND DEFEAT

• PROMOTES PEER SUPPORT

• FOSTERS A SENSE OF SECURITY

• PROMOTES GROUP COHESIVENESS

• ESTABLISHES SENSE OF TRUST

Dr. Fletcher, 1984

THERAPEUTIC EFFECTSOF

GROUP THERAPY

• FOSTERS MEANINGFUL RELATIONSHIPS

• INCREASES RELATIONSHIP SKILLS

• PROMOTES PROBLEM SOLVING SKILLS

• ENABLES LEARNING THROUGH OBSERVATION

Tomasulo, 1998

Typical Model Interactive Model

Blatner, 1973

Group TherapyAction Method Techniques

Founder: Dr. J. Moreno (psychiatrist)

Technique: Psychodrama (Moreno, 1921)

“refers to an enactment involving

problem-solving in terms of one

person’s conflict.”

The drama (problem-solving) may shift among the many facets of one’s life –

Past, present, and future

Blatner, 1973

Group TherapyAction Method Techniques

I. The Protagonist and Double

II. Technique used to explore a problem presented by a group member

I. Protagonist

Person who expresses problem in group

- Interpersonal conflict

- Intrapsychjc conflict

Blatner, 1973

Group TherapyAction Method Techniques

2. Double (alter ego or auxiliary ego)

Person who reflects the feelings/experiences of the protagonist

- Expresses the feelings

of the protagonist

- Approximates the emotional state of

protagonist

Blatner - 1973, Tomasulo - 1998

Group TherapyAction Method Techniques

Five Therapeutic Purposes of the Double:

1. Provides emotional support

2. Gives emotional expression

3. Reorganizes perceptions

4. Promotes empathy

5. Sets the stage for entharsis

Opportunity for change is enhanced if the protagonist feels supported and understood as expressed by the double

Tomasulo, 1998

Group TherapyAction Method Techniques

Choosing the Double:

A. Facilitator can choose

B. Protagonist can choose

C. Group member can volunteer

D. Facilitator can be double

E. Protagonist can double

Razza and Tomasulo, 2005

Group TherapyAction Method Techniques

Processes and Techniques Used in Doubling

•Restarting (to demonstrate understanding of protagonist)

•Speaking the unspoken (to express what protagonist feels but cannot say)

•Exaggerating (to assert loudly what protagonist presents timidly)

•Amplifying (to highlight key parts of protagonist’s statements)

Razza and Tomasulo, 2005

Group TherapyAction Method Techniques

Processes and Techniques Used in Doubling (continued)

•Verbalizing the resistance (to clarify impediments to therapeutic change)

•Clarifying conflict (to voice competing emotions or ambivalence)

•Introducing alternatives (to voice ways to reframe protagonist’s perception of self or situation)

Note: The member doubling checks accuracy of each doubled statement with protagonist; protagonist may repeat key statements.

Tomasulo, 1998

Group TherapyAction Method Techniques

Role of Facilitator

1. Facilitate group interaction

2. Facilitates interaction between protagonist

- asking the double how protagonist feels

- checking with protagonist on expressions from the double

3. Facilitator may need to role model both roles

4. Suggest that “I” statement be used

- I feel ……

Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP

THERPAY (IBT)

STAGE 1: ORIENTATION

STAGE 2: WARM-UP

STAGE 3: ENANCTMENT

STAGE 4: AFFIRMATION

Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF

GROUP THERPAY (IBT)

STAGE 1

ORIENTATION AND COGNITIVE NETWORKING

OBJECTIVEFACILITATE GROUP INTERACTION

TECHNIQUESPHYSICAL WARM-UP

DISCUSS THEIR MORNINGHAVING MEMBERS REPEAT WHAT WAS SAID

Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP

THERPAY (IBT)

STAGE 2

WARM-UP FOR ENACTMENT AND SHARING

OBJECTIVEPROMOTE GROUP PROCESS

TECHNIQUESSELF DISCLOSURE AND TAKING TURNS

BRINGING GROUP TOGETHER (GROUPNESS)

MEMBERS ASKING OTHERS TO SPEAK

Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP

THERPAY (IBT)

STAGE 3ENACTMENT

OBJECTIVEPROBLEM SOLVING AND GROUP INTERACTION

TECHNIQUESACT OF POSSIBLE ROLE PLAYED BY ANOTHER GROUP MEMBER AS HE/SHE GIVES VOICE TO

THE FEELINGS AND THOULGHTS OF ANOTHEREMPY CHAIR

ROLE REVERSAL

Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP

THERPAY (IBT)

STAGE 4AFFIRMATION

OBJECTIVEVALIDATION OF PARTICIPATION

TECHNIQUESREINFORCEMENT THERAPEUTIC INTERACTIONS

MEMBER ACKNOWLEDGEMENT OF PARTICIPATIONDECOMPRESS FROM GROUP EXPERIENCE AND

SIGNAL CLOSURE OF GROUP SESSION

2006

FOR MORE INFORMATION CONTACT

Dr. Robert J. FletcherNADD (The National Association for the Dually

Diagnosed)132 Fair Street, Kingston, NY 12401Telephone 845 331-4336E-mail rfletcher@thenadd.org

Thank you!