Group processes

One of the central areas of exploration in group research remains the question of how individuals achieve change within a group setting. A basic assumption underlying group processes is that people will behave differently within groups compared to outside of a group. In the literature there are numerous definitions and descriptions of group processes.

Schneider-Corey et al. (2014) define group processes as the dynamics that govern the group interactions and how they are manifested. They state group processes consist of cohesion, trust, and how resistance and conflict occur in the group. Furman et al. (2014) state task and maintenance structures are key elements which occur in group processes. Tasks are defined as what the group is aiming for; while maintenance focuses on how the aims are achieved. Garvin (1981) lists five processes which occur between participants within groups. The first process is communication which considers who said what to whom, and under what circumstances. The next process is the sociometric structure which addresses who liked or disliked whom within the group. The third process identified by Garvin (1981) is the power structure within the group and who influences whom, and in what way. The fourth process concerns the leadership structure which develops within the group. This is based upon which individual is accomplishing most of the group tasks or who is working the hardest. The last process centers on roles. These may be official roles, such as a group leader, or unofficial roles based on

Therapeutic Groups 29 Achieving client change is fundamental in all clinical practice. Yalom’s

therapeutic factors (Yalom & Leszcz, 2005) have been widely cited and influential in identifying how the group process brings about improvement for clients. Essentially, the therapeutic factors emerge during the group process. The more factors present during the sessions, the more overall positive outcomes ensue. The individual, group members, and facilitators all influence whether these factors emerge. Table 1 (next page) outlines the therapeutic factors, with a brief description of key characteristics and the stage in which they predominantly (although not exclusively) occur.

As well as the therapeutic factors and group processes mentioned previously, other factors exist in the group process literature that is relevant to this study. These include group cohesion, participants’ characteristics and facilitators’ characteristics which are discussed in the following sections. Specifically, how these particular group processes may have impacted on participant change.

Table 1

Yalom’s Curative Therapeutic Factors (Schneider-Corey, 2014; Yalom & Leszcz, 2005) Therapeutic Factor Stage Occurring Key Characteristics

Installation of hope Beginning Phase Faith the therapy will help. Enables individual to continue attendance so that the therapy can be effective

Universality Beginning Phase Disconfirmation of feelings of uniqueness. Realising they are not suffering alone

Imparting information Beginning Phase Middle Phase

Formal instruction, psycho-education. Includes direct advice and didactic instruction

Altruism Members gain in self-esteem by helping other group members

The corrective recapitulation of the primary family group

Members learn to interact in a more healthy manner rather than functioning in a manner reminiscent of their family of origin

Development of socialising techniques

Social learning and developing basic social skills

Imitative behaviour Group members learn behaviours from observing group leaders and other group members

Interpersonal learning Middle Phase The group members learn to develop distortion free or more adaptive relationships based on

understanding interpersonal relationships, corrective emotional experiences and the group as a microcosm

Group cohesiveness Beginning Phase Middle Phase

Member feels part of the group and connected to other participants

Catharsis Middle Phase Being able to share and experience strong feelings Existential Beginning Phase Confronting and recognising human frailty

Therapeutic Groups 31 4.2.2.1 Group cohesion.

A primary rationale for therapeutic groups is that it provides an important setting for establishing beneficial social relationships in treatment. Because participant to participant relationships and member to group relationships are considered one of the primary therapeutic mechanisms, an important construct is the concept of group cohesion (Yalom & Leszcz, 2005). A body of research supports the concept that the quality of group cohesion is correlated directly to eventual group outcomes (Burlingame et al., 2001; Gallagher, Tasca, Ritchie, Balfour, & Bissada, 2014; Yalom & Leszcz, 2005). Cohesion is a group’s ability to work and relate to each other (Burlingame et al., 2001).

According to Burlingame et al. (2001) the construct of cohesion is complex and difficult to define. But it includes two fundamental dimensions of relationship quality and relationship structure, and encapsulates the essence of the relationships in a group between all of the members including participants and leaders (Burlingame, Cox, Davies, Layne, & Gleave, 2011). Group cohesion affects members’ ability to relate to each other, leads to more meaningful interactions, promotes disclosure, and helps members tolerate potential conflicts within the group (Burlingame et al., 2001).

Moderating factors affecting group cohesion include intrapersonal and interpersonal concepts. Intrapersonal elements include a sense of belonging and

acceptance, such as attachment anxiety (Gallagher et al., 2014). Interpersonal concepts include factors like compatibility among the group members, and collective

commitment to the group. An example of this is forming impressions of each other and the apprehension felt at the beginning of attending a group (Marcus & Holahan, 1994).

4.2.2.2 Client characteristics.

Client characteristics such as personality and personal attributes are regularly investigated in group research as research consensus recognises that these factors affect outcomes (Fuhriman, & Burlingame, 1990). Crowe and Grenyer (2008) found in their study on depression that the participants’ perception of the therapist alliance was not related to outcomes. However, group processes, such as the levels of conflict in a group, and the members’ ability to work actively in treatment, predicted outcomes (Crowe & Grenyer, 2008).

Piper (1994) reports on two areas of client characteristics, namely, the persons’ expectancies and the persons’ interpersonal approach. Both are predictive of group process, attrition, and outcome (Piper, 1994). Yalom & Leszczk (2005) state client intrapersonal skills are important. These skills include having a capacity to examine their interpersonal behaviours, introspection, valuing personal change, being highly motivated for group work and genuinely desiring treatment. Furthermore, a person’s interpersonal approach is also significant. Interpersonal characteristics include how a person interacts with others, is able to self-disclose, and has the capacity to be able to give and receive feedback (Yalom & Leszcz, 2005).

Baker, Burlingame, Cox, Beecher, and Gleave (2013) consider that client

characteristics are indicators of group “readiness” and suggest group clinicians consider these in their group preparation. Further, they state clinicians should monitor

participants during the early stages of the group to reduce potential drop-out rates and session non-attendance. Yalom and Leszcz (2005) report participants are more likely to drop-out of groups because of general dissatisfaction with the group experience.

Therapeutic Groups 33 Further, participants who dropped out also display characteristics such as having

problems with intimacy, lower psychological mindedness, lower motivation, are reactive rather than reflective, have less positive emotion, experience greater denial, have substance abuse problems, express greater anger and hostility, possess lower intelligence, and have a lower understanding of how a group works (Yalom & Leszcz, 2005).

4.2.2.3 Facilitator characteristics.

Group psychotherapy research has also identified general facilitator characteristics. Research has focused on how group members consider the group facilitator and the alliance with the facilitator, the characteristics and attributes of a facilitator, and the impact of leadership on group processes.

Group members place facilitators in a central position, and at the start of groups are dependent on the facilitators. Members assume the facilitators are skilled,

knowledgeable and have responsibility for the group (Garvin, 1981). Furman et al. (2014) comment that the facilitator has many roles such as being an active listener, sharing information, helping members make connections with each other, reflecting and guiding group discussions, and aiding the development of insight. They maintain that a facilitator empowers the group by balancing, and being directive, but not taking over the group. An important task they state is the need for the facilitator to reflect on their role in the group, and their overall participation. Facilitators need to have a clear idea of what causes change and what therapy would facilitate that change (Furman et al., 2014). Schneider-Corey et al. (2014) report that the key personal characteristics of a facilitator include adaptability, a willingness to model change, display genuineness, have a belief

in the group process, and show openness and empathy with participants. As a facilitator they need to be able to link material to group processes, including their therapeutic alliance with individuals, and confront, support and assess participants’ responses throughout the sessions (Schneider-Corey et al., 2014).

The HCPS used two clinicians who co-facilitated the therapeutic groups. Luke and Hackney (2007), in their literature review on co-leadership, comment it is unclear whether co-leadership is more or less effective than single leadership. Current research into co-leadership is inadequate. However, benefits for co-leadership of groups have been identified. Schneider-Corey et al. (2014) state having a second facilitator allows an opportunity for a more in depth observation of the group participants and group

processes to occur. It provides an opportunity to offer feedback on participants’ progress, and helps facilitators by being able to add to each other’s interventions. On a practical level, having co-leaders means there is help available if there is a problem with a participant or they need individual attention. Also, the group can continue if a leader is absent. They suggest facilitators need to have a high degree of interrelatedness to avoid potential problems occurring between the leaders. Also, co-leading a group requires planning and discussion prior to the sessions, especially concerning what issues are expected to arise (Schneider-Corey et al., 2014).