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Group Work InterventionDr Chidambaram

Prakash Lead Consultant

Consultation-Liaison Psychiatry

Royal Children's HospitalMelbourne

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Acknowledgements

Jo WintherWendy Bunston

Tara Pavlidis

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SETTING THE CONTEXT

Anxiety disordersDepression

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Development of anxiety

• Difficulties mastering challenges in particular phase of development

• Compromise development in subsequent phases

• Underlying diathesis where one disorder transforms into another

• Specific developmental levels allow manifestation of specific behaviors leading to diagnoses

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Developmental issues of fear

• Young infants: Heights, loss of support, sudden unpredictable stimuli

• End of 1st year: Strange people, novel objects, separation (9 mos to 2 ½ yrs)

• Pre school: animals, storms, dark, doctors, imaginary creatures

• School yrs: bodily injury, loss, natural hazards, social & performance issues

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Developmental issues

• Older adol, adults: achievement, social, moral, religious, sexual, physical danger, being alone, death

• 3 main types: Physical injury, Natural & supernatural factors, Psychic stress (Miller)

• Fears of injury & psychic stress throughout life (Miller)

• Fears of natural events decreased with age

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Development of specific disorders

• Below 5 yrs: Separation, animals• Kazdin: 7.5 yrs: SAD, 8.2 yrs: Avoidant

disorder, 8.4 yrs: Simple phobia, 8.8 yrs: GAD, 11.3 yrs: Social Phobia, 14.1 yrs: Panic disorder

• AGOR, Other situational phobias: any age

• Age related difference in symptom types & severity

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Prevalence- anxiety disorders

• Second highest psychiatric disorder in c&a (Ialongo)

• 17% of 14-16 year olds (Kashani & Orvaschel)

• Second commonest diagnoses in 800 C &A (Cohen)

• Commonest diagnoses amongst 15 year olds (McGee-Dunedin)

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Anxiety & Depression

Community• Depn in Anx: 17% (Anderson), 13 %

(McGee), 14% (Costello), 49 % (Lewinsohn)• Anx in Depn: 71% (Anderson), 44 %

(Costello)Clinic• OCD (70%), PTSD & Others (30-50%)• Anxiety (7.2 yrs), DD (10.8 yrs), MDD(13.8

yrs)

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Anxiety & Disruptive behavior disorders (DBD)

• Anderson:23% anxious children had ADHD & 32% had CD or ODD

• Costello: 29%, Lewinsohn: 13% McGee: 4%• Rates of anxiety in DBD: 15-30% • SAD, OCD (16-53%), PD more likely to

develop a DBD• Abused children with PTSD: 1/3 ADHD• NIMH (ADHD) : 35% had anxiety disorder• Clark & Neighbours: SOP, PD assoc more

with substance use disorders

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MOOD DISORDERS

Major Depressive disorderDysthymia

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EpidemiologyEpidemiology•• MDD prevalence: MDD prevalence:

2% children, 4%2% children, 4%--8% 8% adolescents.adolescents.

•• Male: female ratio: Male: female ratio: childhood 1:1, childhood 1:1, adolescents 1:2adolescents 1:2

•• Cumulative Cumulative incidence by age 18 incidence by age 18 years: 20%years: 20%

•• Since 1940, each Since 1940, each successive successive generation at higher generation at higher risk for MDD risk for MDD

•• DysthymiaDysthymiaprevalence: 0.6%prevalence: 0.6%--1.7% children, 1.7% children, 1.6%1.6%--8% 8% adolescentsadolescents

•• Often underOften under--recognizedrecognized

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Complexities in Diagnosing MDD in Complexities in Diagnosing MDD in Children and Adolescents Children and Adolescents •• Symptoms overlap with co morbid Symptoms overlap with co morbid

conditionsconditions•• Developmental variations in symptom Developmental variations in symptom

manifestationsmanifestations•• Etiological variations of mood disorders Etiological variations of mood disorders

involving geneinvolving gene--environment interactionsenvironment interactions•• Are disorders spectrum or categorical Are disorders spectrum or categorical

disorders ?disorders ?•• Effects of medical conditionsEffects of medical conditions

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MDD Diagnostic Criteria: DSMMDD Diagnostic Criteria: DSM--IVIV•• At least 2 weeks of pervasive change in At least 2 weeks of pervasive change in

mood manifest by either depressed or mood manifest by either depressed or irritable mood and/or loss of interest and irritable mood and/or loss of interest and pleasure. pleasure.

•• Other symptoms: changes in appetite, Other symptoms: changes in appetite, weight, sleep, activity, concentration or weight, sleep, activity, concentration or indecisiveness, energy, selfindecisiveness, energy, self--esteem esteem (worthless, excessive guilt), motivation, (worthless, excessive guilt), motivation, recurrent suicidal ideation or acts.recurrent suicidal ideation or acts.

•• Symptoms represent change from prior Symptoms represent change from prior functioning and produce impairmentfunctioning and produce impairment

•• Symptoms attributable to substance abuse, Symptoms attributable to substance abuse, medications, other psychiatric illness, medications, other psychiatric illness, bereavement, medical illness bereavement, medical illness

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Need to Recognize Developmental Need to Recognize Developmental Variations of MDDVariations of MDD•• CHILDREN:CHILDREN:•• More symptoms of More symptoms of

anxiety (i.e. phobias, anxiety (i.e. phobias, separation anxiety), separation anxiety), somatic complaints, somatic complaints, auditory hallucinationsauditory hallucinations

•• Express irritability with Express irritability with temper tantrums & temper tantrums & behavior problems, behavior problems, have fewer delusions have fewer delusions and serious suicide and serious suicide attemptsattempts

•• ADOLESCENTS:ADOLESCENTS:•• More sleep and More sleep and

appetite appetite disturbances, disturbances, delusions, suicidal delusions, suicidal ideation & acts, ideation & acts, impairment of impairment of functioningfunctioning

•• Compared to adults, Compared to adults, more behavioral more behavioral problems, fewer problems, fewer neurovegativeneurovegativesymptomssymptoms

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DysthymiaDysthymia: Other symptoms not included : Other symptoms not included in DSMin DSM--IV CriteriaIV Criteria-- May affect recognitionMay affect recognition

•• Feelings of being unlovedFeelings of being unloved•• AngerAnger•• SelfSelf--deprecationdeprecation•• Somatic complaintsSomatic complaints•• AnxietyAnxiety•• Disobedience Disobedience

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Complexities of Co morbidity: May AffectComplexities of Co morbidity: May Affect

•• Recognition & diagnosis of MDDRecognition & diagnosis of MDD•• Types and efficacy of treatmentTypes and efficacy of treatment•• Psychosocial outcomesPsychosocial outcomes

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Co morbidityCo morbidity

•• Present in 40%Present in 40%--90% of youth with MDD; two or 90% of youth with MDD; two or more co morbid disorders present in 20%more co morbid disorders present in 20%--50% 50% youth with MDDyouth with MDD

•• Co morbidity in youth with MDD: Co morbidity in youth with MDD: DysthymiaDysthymia or or anxiety disorders (30%anxiety disorders (30%--80%), disruptive disorders 80%), disruptive disorders (10(10--80%), substance abuse disorders (20%80%), substance abuse disorders (20%--30%)30%)

•• MDD onset after co morbid disorders, except for MDD onset after co morbid disorders, except for substance abusesubstance abuse

•• Conduct problems: May be a complication of MDD Conduct problems: May be a complication of MDD & persist after MDD episode resolves& persist after MDD episode resolves

•• Children manifest separation anxiety; adolescents Children manifest separation anxiety; adolescents manifest social phobia, GAD, conduct disorder, manifest social phobia, GAD, conduct disorder, substance abusesubstance abuse

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Prospective Studies: MDD Risk Factor for Prospective Studies: MDD Risk Factor for Suicidal Tendencies in Children/Suicidal Tendencies in Children/AdolescAdolesc. .

•• Kovacs et al. (1993): 9 year FU of pre Kovacs et al. (1993): 9 year FU of pre pubertal children: FU of initial 58 MDD pubertal children: FU of initial 58 MDD 74% SI, 28% SA, 23 74% SI, 28% SA, 23 dysthymiadysthymia 78% SI, 78% SI, 17% SA, 18 adjust disorder with 17% SA, 18 adjust disorder with depressed mood 50% SI, 6% SA, 48 depressed mood 50% SI, 6% SA, 48 without mood disorder 48% SI, 8%SA without mood disorder 48% SI, 8%SA

•• PfefferPfeffer et al. (1993): 6et al. (1993): 6--8 year FU pre 8 year FU pre pubertal inpatients: 5 times risk for SA pubertal inpatients: 5 times risk for SA in adolescents with pre pubertal mood in adolescents with pre pubertal mood disorder disorder

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3 stage model to guide the treatment of 3 stage model to guide the treatment of depression depression ((OverholserOverholser, 2003), 2003)

•• Stage 1Stage 1–– AllianceAlliance–– AssessmentAssessment–– DiagnosisDiagnosis

•• Stage 2 (target areas)Stage 2 (target areas)–– Reduced activityReduced activity–– Ineffective copingIneffective coping–– ProblemProblem--solving deficitssolving deficits–– Social impairmentSocial impairment–– Cognitive biasesCognitive biases–– Inadequate selfInadequate self--esteemesteem

•• Stage 3Stage 3–– Relapse preventionRelapse prevention

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GROUP INTERVENTIONS

RationaleProcess

Examples

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OUTLINE TO THE PRESENTATION

• What are challenging or unhelpful behaviours?• Why use group work?• Content versus Process • Therapeutic group work principles• Phases of group development• Cycle of change• Example of group work

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What are challenging/unhelpful behaviours?

Children display a wide range of behaviours that can be classified as normal.

It is important not to mistake the things that children habitually do wrong at school as more severe emotional and behavioural disturbance (e.g. being unpunctual, lazy, rude, or untidy) but requires assessment if persistent.

When an unhelpful pattern of behaviour occurs frequently, persists over time, interferes with daily functioning, and is associated with other symptoms of psychological disturbance a referral for assessment is warranted.

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What are challenging/unhelpful behaviours?

• Externalising problems – generally “acting out” behaviours – eg disobedience, stealing, aggression.

• Internalising problems – intense fears, worrying, depression,

anxiety, withdrawal.

• High co-morbidity between the two.

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Types of Intervention Programs

• Intervention should be multi-system– Child, parent, family, school, community.

• Child-focussed interventions– designed to improve children’s capacity to regulate their

feelings, emotions & behaviour.

• Family/Parent interventions– designed to improve parenting skills and family relationships.

• School-based interventions– designed to improve classroom and playground behaviour at school.

This includes teacher skill development, class wide interventions, curriculum-based interventions, individual therapy and multi-component interventions.

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Why intervene at a school level?• Certain classroom conditions and teacher reactions

make behavioural difficulties more likely.

• Academic success is a critical resilience factor.

• A lot of teacher time is spent dealing with discipline problems.

• Majority of behaviour problems are not caused by students funded for emotional/ behavioural problems.

• Most students benefit from interventions aimed at general behaviour change.

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Why use group work?• Most of our waking hours are spent in the

company of other people – normalises / emulates life.

• By joining a group, we gain the resources of other people, which we can add to our own –children, especially adolescents, are more likely to listen to their peers and try their ideas.

• Peers can challenge each other.27

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• “Group work offers children and adolescents a powerful therapeutic arena in which they can explore and experiment with a range of different situations that mirror the often difficult dynamics that operate within families and other relationships”.

(Bunston, Pavlidis & Leyden, 2003)

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Content versus Process• Whilst the content of the program is

important, what happens in the group is even more important.

• The content of the program allows the process to occur.

• The groups are set up to evoke process issues.

• Focus on dealing with issues as they arise in the group.

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Therapeutic group work principles(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

An acknowledgment / awareness of Group Process underpinning interventions

• All groups will test limits:- It is important to not just react to what is

happening, but digesting its meaning and delivering it back to the group in a form that offers the group a different experience.

– it is how we respond that will either reinforce the inappropriate behaviours, or show that there can be different ways of relating to others.

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Classrooms versus therapeutic groups

• Can sometimes be difficult to adapt .

• Group is set up to evoke problems.

• Both have rules and consequences – but they may differ.

• Therapeutic groups involve problem- solving of issues at the time they occur and a demonstration of how to resolve the issue.

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Creating Safety(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• Creating safety is critical – emotional, physical and social

• Structure and Reliability

• Familiarity - rituals of opening, closing

• Group expectations/rules

• Consistency in managing behaviours

• Confidentiality

• Child-centred

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Supervision(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• Ideally begin prior to group beginning to create safety amongst facilitators

• Integrating theory with practice

• Understanding our own responses

• Understanding the children that we work with

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Use Of Self(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• Play and Engagement

• Interaction

• Responding differently

• Understanding your reactions

• Listening

• Position of not knowing, but seeking to find out

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Attunement to process(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• The balance between leading a group and being led by the group – both are important.

• Need to hear what the group is telling you which requires listening beyond that which is spoken.

• If we are too quick to respond to overt behaviours, and fail to see the underlying communication, we may jeopardise future opportunities.

• Our capacity to be attuned to the processes occurring can be hampered by our performance anxiety, our need to be ‘ín control’, or trying to get through all the content.

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The importance of the individual(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• It is important to also hear the voice of each young person in the group.

• Wanting to feel connected to the group, as well as wanting to feel special in the eyes of the facilitator is a normal part of the group process.

• How facilitators respond to each individual is observed by other group members.

• Identifying something unique in each of the participants can assist.

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The importance of play(Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• The capacity to play is critical.

• Play provides children with an important transitional space through which they can explore the fit between their internal and external world, as well as developing their capacity for reflection, abstract thinking and creative problem solving.

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Some aims of children’s groups are to help children gain:

• more understanding of their own behaviour

• more understanding of how their behaviour impacts on others

• more control over their behaviour

• more positive self-esteem

• more positive social relationships

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Phases of group development(Adapted by Bunston, Pavlidis & Leyden (2004) Putting the GRO into group work)

• Warming stage – (pre-group) laying the foundations

• Forming stage – assessments, establish expectations, purpose and process of group

• Storming stage – when safe members may express themselves, group appears resistant

• Norming stage – consensus about group goals, group cohesion

• Performing stage – productivity / mutuality• Mourning stage – reactions to group ending• Transforming stage – (post-group) change

implemented / experience growth / follow up 39

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Trying to change behaviour – Cycle of change

• Changing ones’ behaviour is not easy and is a fluid process.

• Children are motivated to change when they sense that change is possible.

• Six stages of change occur when people try to change behaviours. The stages include:Pre-contemplation, contemplation, determination,

action, maintenance, and relapse.

• At each stage teachers can respond differently to help a student work through the stages.

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Readiness to changeProchaska & DiClemente

Pre-Contemplation (not thinking about it)

Planning(decision making)

Contemplation(thinking about change)

Action(making changes)

Maintenance (change for over 6 months)

Relapse

Exit

Choice

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Stages of change - therapists and teachers tasks

Stage Therapists and teachers motivational tasks

Pre-contemplation Raise doubt – increase perception of risks and problem with current behaviour.

Contemplation Tip the balance – evoke reasons to change, risks of not changing; strengthen their motivation to change.

Planning Help them to determine the best course of action to take in seeking change.

Action Help them take steps towards change.

Maintenance Help them to identify and use strategies to prevent relapse.

Relapse Help them to renew the processes of the stages without becoming stuck or demoralised because of relapse.

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Examples of groups

Child Group

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Child Group Content – CBT• Cognitive-Behavioural Therapy (CBT)

– Children receiving behavioural and cognitive-behavioural approaches in particular show the greatest improvement when compared with other treatments.

• Cognitive treatments– View abnormal child behaviour as the result of deficits

and distortions in the child’s thinking in interpersonal situations.

• Behavioural approaches– Assume that abnormal child behaviours are learned.

• Cognitive behavioural treatments– View psychological disturbances as partly the result of

faulty thought patterns, and partly the result of faulty learning and environmental experiences.

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The Assessment Process• Parent and teacher SDQs• Parent-teacher interviews• Family assessments

– Interview with parents– CBCL, Eyberg, PSI, Arnold Parenting Scale (parent ratings)– HoNOSCA, CGAS, FIHS (Clinician ratings)

• Child assessments– Interview with child– IQ assessment (WISC/ WPPSI), academic assessment

(WRAT)– Classroom observation

• Discussion with other relevant professionals• Final consultation with Action Team re: final group

selection

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Warm-up activity

• Four Corners (Audette and Bunston, 2006).

• When to use: Around session 6 of child group.

• Therapeutic value: This is a good game for working together with a partner, making decisions with a partner and reading non-verbal cues. This game can be a fun illustration of what happens when pairs do not ‘read’ or ‘attune’ well to the other, whether they invade the space of the other or whether they pull in different directions.

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Warm-up activity• Circle Name and Action (Audette and Bunston,

2006)

• When to use: At the beginning of a program.

• Therapeutic value: This game begins to create a sense of trust and safety. This game encourages children to personalise the way they present themselves. It encourages listening and memory skills and confidence building.

• Issues: If participants are uncomfortable using movement then it can be limited to a hand gesture or movement while sitting.

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Warm up activity

• Partners bean bag game.

• When to use: Session 5 of child group.

• Therapeutic value: This activity is an exercise in working well with a partner. It is a great problem solving activity as each participant not only needs to be aware of their partner, but also the other dynamics around them.

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Week 1 – Getting to Know You

Rewards and closing7Unstructured play6Strengths5Warm-up activity4Group rules and consequences3Introduce ourselves/Group name2Introduce the program1Activity

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Sample Week 1• Getting to know others in the group

Children are encouraged to introduce themselves to someone they have not socialised with much during the year using the step by step introduction process.

• Strengths of group members Children are taught the concept of personal strengths. Children make a strength card.

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Week 2 – Identifying Feelings, Strong Emotions, Fears

Warm-up activity1

Rewards and closing7Unstructured play6Body maps activity5

Managing strong emotions of fears or moods

4

Connecting feelings and rationales for feelings

3Identifying feelings2

Activity

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Feelings sessions

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Sample Week 2• Identifying Strong Emotions

– Children consider the consequences when their feelings become strong and intense.

• Bodily Reactions to Fear, mood swings– Children are taught to tune into their

physiological responses to fears or mood swings as a warning to stop and think. This involves children making stop signs and using them as props for a story.

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Week 3 – Managing Strong Emotions

Rewards and closing7Unstructured play6Relaxation using guided imagery5Calming down space4

Calming down strategy-blowing bubbles

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Brainstorm ways to manage fears & moods

2Warm-up activity – feelings practice1Activity

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Sample Week 3• Managing Strong Emotions in the group

– Children are taught techniques for managing strong emotions. They are taught a “calming down strategy” and participate in an activity to familiarise themselves with the steps.

– Children are required to identify how they could implement the strategy

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Week 4 – Introducing FEAR

Clarifying Expectations4

Rewards and closing7Unstructured play6

Drawing a circle to list the Actions taken & the Rewards or Responses

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Identifying Feelings 3Body Maps activity2Warm-up activity – stop game1Activity

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Sample Week 4• Problem-Solving

– Children are taught the FEAR problem-solving strategy.

– Posters are made of the circle they have drawn

• Problem Identification– Children participate in role plays displaying social

problems. Children learn that there is more than one way of perceiving a problem. Children are encouraged to recognise that certain perceptions are associated with certain feelings.

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Week 5 –Social Problem Solving

Rewards and closing5Unstructured play4REWARDS/RESPONSES3

ACTIONS- Clancy the Clown –connecting feelings and rationales for feelings

2Warm-up activity1Activity

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Sample Week 5• More Problem-Solving

– Children are taught the steps of the ACTIONS/ATTITUDES section of the strategy, which involves techniques to generate more than one response to problematic situations.

– Children practice applying the ACTION steps in a role play scenario.

_ Children complete a worksheet which encourages them to focus on how various ACTIONS reinforce certain FEELINGS.

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Week 6 – COOL, WEAK, FEARFUL, AGGRO: Assertiveness Training

Introducing COOL, WEAK, FEARFUL AGGRO

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Rewards and closing7Unstructured play6Plan for group performance5Discuss group finishing4

COOL, WEAK, FEARFUL, AGGRO activity

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Warm-up activity1Activity

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Sample Week 6• Assertiveness Training

– Children are taught skills to be able to stand up for themselves in a prosocial way, rather than behaving in an anxious or moody manner.

– Children are required to identify the likely consequences of assertive vs aggressive vs fearful & passive styles of interaction.

– Children are taught how to behave assertively– Children complete worksheets to practice

identifying assertive behaviours as an alternative to aggressive and passive behaviours.

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Week 7 – Negotiation & Cooperation

Rewards and closing5Practice the group performance4Discuss the group finishing3

Introduction to cooperation and negotiation

2Warm-up activity – pass the parcel1Activity

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Sample Week 7• Negotiation

– Children are taught the steps of the negotiation strategy.

– Children practice applying the steps of the negotiation strategy in a role play scenario with their teacher.

• Negotiation Practice– Children practice applying the steps of the

negotiation strategy in a role play scenario with a partner.

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Week 8 – Group Performance & Closing

Superhero closure game5Distribution of certificates6

Rewards4Closure3Group performance2Warm-up activity1Activity

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Behavioural Management Plan• Establish group rules• Rewards for desirable behaviours

– Labeled praise– Reward menu – points, stickers, visual aids,

lollies, ‘lucky dip’– Team rewards

• Consequences for undesirable behaviours– 6 step process: remind, tips for self management

provide warning, sit out from the activity, sit out from the group, leave the room if too disruptive

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Reflective guidance(Drost & Bayley, 2001)• Use continually during the session.• Make comments about the things that you as

a facilitator observe or experience.• For example, If a child does something

desirable then praise it & explore why this was desirable & encourage more. If a young person behaved in a negative way, refrain from directly saying “don’t do it”, instead explore the behaviour in a conversation with the other facilitator - translate the message they are conveying and suggest the different ways in which it could be dealt with more constructively.

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Reflective guidance cont...• It’s about giving the young person

control of their behaviour – creating an environment where the they can become aware of their own choices.

• Positively reframe negative behaviour as an attempt to convey a message or a need – give words to their messages.

• Provide an adult model that differs from what they are used to – we work together in a calm and reasonable way.

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Parent Group

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Outline of parent programWEEK 1: Strategies for encouraging desirable behaviour

WEEK 2: Managing other child-related issues (sibling conflict, boredom-busters and high-risk situations, family rules)

WEEK 3: Strategies for responding to unhelpful behaviours

WEEK 4: Cognitive coping skills and fear & anger management

WEEK 5: Parent well-being, pleasant events, social support, and problem solving

WEEK 6: Individual session

WEEK 7: Feedback and Evaluation

WEEK 8: Combined child and parent group

COMPONENT RELATED TO THE CHILD PROGRAM

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Session 1

Overview of child’s group8

Labelled Praise6Attention top-ups7

Rewards5

Identifying child behaviour to increase

4Explaining attachment3The causes of unhelpful behaviour2Welcome and agenda1

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Session 2

Strategies to help engage children6Overview of child’s group7

Family rules5High risk situations4Family problem solving worksheet3Managing sibling conflict/anxiety2Advanced reward strategy1

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Session 3

Overview of child’s group5Responding to unhelpful behaviour4

Planned ignoring (not reinforcing fears)

3Logical consequences2Consequences1

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Session 4

Overview of child’s group6Relaxation5Managing strong emotions4Thinking reports3Using coping self-talk2Cognitive coping skills1

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Session 5

Overview of child’s group8

Communication with the school6Relapse prevention7

Separated families5Partner problem solving techniques4Partner support3

Things that impact on effective parenting

2Parent self care1

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Session 6

Individual sessions

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Session 7

Group participates in evaluation2Individual feedback1

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Session 8Combined parent and child group performance and celebration• Behaviour management

strategies

• Relationship between parent and child

• Children’s program material

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Section 4:

Group issues

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Contingency Planning

• When is a contingency plan needed?

• The worst case scenario– Children who walk out– Time out outside the room– Absences

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Confidentiality & Duty of Care

• What is confidentiality?• Why is confidentiality important?• Who can we talk to?• What information can be given to classroom

teachers ?• What if there is a disclosure?• Who has duty of care of the children & their

safety?-Need to clarify this

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Group Dynamics• Parent group

– Parents who go off track– Conflicts– Dominating parents / quiet parents– Confrontations

• Child group– Dominating children / reserved children– Rules and consequences– Fights

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Setting up a group• How many children?• How many facilitators?• What should the age range be?• Where will the sessions be held? Is the room

containable, private, free of distractions, safe?• Should the group be mixed genders?• Should it be a closed or open group?• What is the structure / format of the group going to be?• What are the aims and objectives of the group?• What time will be allocated to run the group?• What is the best time to host the group?• Who will provide supervision?• When and where will supervision be held?

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Group session structure• The structure of the group is an important

way of providing predictability and securityExample 1:

– Outline of the session.– News (something about their week, a

strategy that they tried and worked).– Discussion.– Activity.– Discussion.– Unstructured play.– Review – what was today about?– Closing activity.

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Structure and FormatExample 2:

– Introduce new theme– News - recap last week– Warm up activity– Discussion– Related Activities– Game– Reflection time– Stickers / Feedback

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Co-facilitation

Can all facilitators commit to the entiregroup process?

• pre planning phase• assessment interviews• group sessions• parent information sessions• post feedback • debriefing • supervision

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Planning• How much planning time do you need?• How, when and where will you do your

planning?• Expectations of own and others role in group.• Do you need written notes or can you leave it to

memory?• Do you want to pre-allocate sections or topics or

roles?• What resources do you need and who will get

them?• What time do you think you should arrive for the

group session?• What will each of you do on arrival?

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During the session• Where will each of you sit?• What roles will each of you take, what functions will

each of you attend to?• How will you change leadership during the sessions?• What if one of you thinks the other is getting off track,

how will you let each other know?• How will you communicate with each other and what

cues will you give each other?• Can you agree to disagree?• How can you use and encourage each other’s energy?• What is non-negotiable with each of you as co-leaders?• Can you support each other even if you don’t

necessarily agree with what they are doing?

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Issues that may come up:• How are you going to manage people’s strong

emotions (fear, anger, crying, conflict)?• What are you going to do if a group member

attacks or challenges you, what do you want your co-leader to do?

• How will you handle the possibility of members playing you off against each other?

• How will you respond if the group queries the relevance of the program?

• How will you deal with absentees?• How should you respond to calls or requests for

discussions outside the group sessions?

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De-briefing

• How and when will you de-brief the sessions?• Making a contract to have frank discussions.

These may include:– In what ways did we work effectively together?– In what ways could we improve?– What feedback do we want from each other?– Did we meet our objectives?– Are there any issues we should pick up next

time?– Do we have any particular concerns about

anything or anyone?

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Some tips:

• Be clear with each other.

• If there is conflict between co-facilitators then the group member will pick it up and their experience will be affected as a result.

• Wherever possible see difficulties as opportunities for learning and improvement.

• Keep talking …. Have fun …. Good luck.

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Exercise – Group Process Role Play• What we need:

– Two group facilitators– Six group members– Rest of group are observing and will reflect

back to the group

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Exercise• The group facilitators and group members sit in the

middle of the room in a circle. The observers sit around the outside of the circle.

• The group facilitators lead the group in an exercise to work out the group rules.

• The rest of the group are to observe the process and feedback to the group using a reflective team approach.

• Once the observers feedback, the group members reflect on the feedback.

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