Introduction:

The purpose of this assignment is to critically discuss the literature on groupwork, and its relevance in occupational therapy with children. I will discuss some of the current literature surrounding groupwork and the merits of its use in occupational therapy. I will then analyse and discuss some of the factors in groupwork which influence the outcomes and effectiveness of the group including the group composition, the establishment of long-term and short-term goals, and the therapist’s style of leading the group. I will apply these factors to a specific condition for the purpose of demonstration. Finally, I will reflect on my learning of groupwork and how it will influence my future practice.

Groupwork theory and use in therapy:
Groups are defined by Mosey(1973) as ‘an aggregate of people who share a common purpose which can be attained only by group members interacting and working together’( as cited in Finlay, 2001, p.3). Acording to Blair(1990, as cited in Finlay, 2001) groups are ‘intrinsic to existence’. We are involved in family groups, classroom, peer, sport, work tasks and other groups.
Group work is an approach that is widely used across occupational therapy and healthcare settings. ‘Only in more recent times have group practitioners and researchers begun to explore the use of group activities as a therapeutic approach’(Barnes, Howe & Schwartzbeg, 2008). This is in line with the renewed focus on occupation-based, client-based and evidence based practice(Barnes et al., 2008). According to Yalom(1995), there is much support for group therapy in response to available research indicating the effectiveness of group therapy. Results from a survey conducted by the American Occupational Therapy Association on randomly selected practicing occupational therapists regarding the scope and nature of the groups that formed part of their treatment program, revealed that 60% of the 120 who responded reported the use of groups in treatment(Duncombe & Howe, 1985). The survey was anonymous and was in questionnaire format and gathered information on the types of clients the therapist treats, whether they include groupwork or not, and an open-ended question asking for the types of groups that they used to be described. The therapists worked with all age groups and clients with 27 different diagnoses. A conclusion from this research(Duncombe & Howe, 1985) is that ‘groupwork is included in many areas of occupational therapy practice’(p.165).
There are many types of groups used by occupational therapists, ‘each with its own therapeutic function and purpose’(Finlay, 2001, p.7). Finlay(2001) classifies groups under activity groups and support groups and differentiates between the two.Task groups focus activity groups are comprised of tasks aimed developing skills which are an end product of the group process, and social activity groups which aim to encourage social interaction through engaging in an enjoyable activity for example dance.
The reasoning behind the use of group therapy is founded on the curative dynamics of group activity in which many complex interactions occur(Finlay, 2001), and also the‘best current research and evidence available as to the effectiveness of intervention approaches’(Barnes et al., 2008, p.39). These factors can be facilitated through the therapist’s skilful management of the group process (Carson, 2013).
• Groups instil hope in its members as they are encouraged by other members who have dealt with a similar issue to themselves. They also feel encouraged in knowing that others have similar concerns and experiences. As a result they may feel less isolated and their emotional outlook may improve(Carson, 2013).
• Members may learn from one another through observing others performance of skills, receiving advice and listening to others discuss what they have learned(Carson, 2013).
• Development of basic social skills and social occupational nature can occur through practicing skills in groups, a natural environment, and receiving feedback on how they came across(Finlay, 2001).
• ‘Members can learn about their own capabilities in proximity to an externally designated leader, thereby stretching to their highest performance level’(Barnes et al., 2008, p. 39).

Groupwork in occupational therapy with children and adolescents:

Group work is an approach that is widely used as a form of treatment when dealing with children and adolescents. Through interaction with peers, children develop their cognitive, motor and socio-emotional skills, also children enjoy interacting with other children and so may be encouraged to engage in a variety of development promoting activities in a group setting(Soloman, 2013). Because the peer group has enormous power for influencing behaviour, group therapy should be considered a primary rather than an auxiliary form of child psychotherapy(Shechtman, 2004, as cited in Mazur-Elmer, 2004).
According to Clifford O’ Brien and Vroman (2013), ‘group based interventions that occupational therapy practitioners provide to adolescents address the development of the performance skills required to participate successfully and to meet the demands of this developmental stage to assume the roles of adult life’(p. 91). According to Finlay(2001), a group setting is where they ‘learn, develop and seek support’ (p. 92). A group intervention setting is particularly advantageous in children with special needs or disabilities as this may limit their ability or willingness to participate in groups, the negative effect of which being ‘less engagement in the broad range of activities and tasks that promote skill development in adolescence’(Finlay, 2001, p. 92). Adolescents can benefit from the curative factors of groupwork which I have discussed.
The effectiveness of child and adolescent group treatment was examined based on the outcomes of 56 studies on this topic carried out between 1974 and 1997(Burlingame & Hoag, 1997).These studies examined the effectiveness of group treatment in a variety of different child and adolescent populations and included variables in the domains of child, therapist, methodological and treatment. ‘This meta-analysis demonstrated that children and adolescents treated in group treatment improved significantly more than wait-list or placebo controls’(Burlingame & Hoag, 1997, p.242). It was however noted that 62% of the variables examined with one way ANOVAs produced non-significant results with low power, due to a weakness in child and adolescent group research literature(Burlingame & Hoag, 1997).

Facilitation of the group:

The potential therapeutic factors of using groups that emerge are neither random nor inevitable(Finlay, 2001).The outcomes will depend on ‘the purpose of the group, the functional levels of members, the ability of the members to interact with each other, and the group leader’s skill at guiding the group process so that appropriate therapeutic factors are embraced by the group members’(Carson, 2008, p. 32).Groups ‘can be destructive as well as beneficial and therapists must learn to support patients and clients both in their selection of the group, and in their group learning experience’(Finlay, 2001, p.7). I will discuss some of the factors in groupwork which influence the outcomes and success of the group and demonstrate how these influence groupwork by applying them to a group of 7 adolescents who have been diagnosed with moderate social anxiety disorder (S.A.D.).‘Social anxiety has been defined as anxiety resulting from the prospect or presence of personal evaluation in real or imagined social situations, in which the person is the focus of attention’(Damer, Latimer & Porter, 2009, p.7). Studies demonstrate that group therapy, is efficacious in treating paediatric S.A.D.(Khalid-Khan, Santibanez, McMicken, & Rynn, 2007). It is effective to choose members for the group who have similar problems or needs, or who are united in their need to improve their function, allowing the therapist to develop goals and intervention plans to effectively meet the needs of each member(Barnes et al, 2008).
The therapist must formulate long-term and short-term goals for both the group as a whole, and each individual on a continuing basis(Barnes et al., 2008).These can be formulated through gathering information about the client regarding their ‘current performance areas, strengths and deficits in motor, processing, communication, and interaction skill, and possible underlying conditions of impairments related to body structures and functions’(Barnes at al., 2008, p.109). Goals should be measurable. I identified a deficit in the social skills in the adolescents in my S.A.D. group through use of structured diagnostic interviews. The setting and resources available to the group should also be ‘considered to determine if certain contextual aspects will influence the group’s goals’(Banes et al. 2008, p.109). Limited resources such as materials, space, finance, staff and time can limit the scope of the group design(Barnes et al., 2008). I chose to hold the S.A.D. group sessions in the local community centre as it is a well-lit, spacious setting which is familiar to the participants, reducing anxiety.
The activity must be carefully chosen and structured to work towards the goals set and must be meaningful to the members(Finlay, 2001). Barnes et al.(2008) maintain that a flow experience must be created, meaning that the demands are in balance with the person’s skills. I chose expressive art as an intervention activity for my S.A.D. group. Through using the Model of Human Occupation as a guide, I identified that this would appeal to the adolescents and they would be competent in this activity. Their social skills would be developed as a result of interacting while sharing intentionally limited art supplies.
Effective leadership skills ‘can make possible the formation of a cohesive group capable of continued development’(Barnes, et al., 2008, p.155). The leader can motivate members to participate through explaining the goals and benefits of the group, and through modelling a positive attitude(Barnes, et al., 2008). If successful, leaders facilitate the development of the group process by creating a climate in which members feel safe and willing to interact with and get to know other members and share group experiences(Barnes et al., 2008). A skilled therapist will promote the development of skills within the group by providing opportunities for members to share information learned, and to help each other in their tasks(Carson, 2013). A leader should adapt their participative styles depending on ‘the cognitive and psychosocial abilities of the group members’(Carson, 2013, p.32). The leader of the S.A.D. group will inform members of the goal of the session, for example initiate conversation with one other member. In the early stages of group formation the therapist would participate more in the group until the members begin to get to know each other, at which stage dependence on the leader decreases and the leader will become less involved in the task, allowing members to work on their social skills together.

Group verses individual work:

Groupwork as a form of intervention in place of individual therapy can have a variety of positive outcomes for its members, provided that the group is designed and facilitated effectively by the therapist. Groupwork can result in enhancement and development of skills through observing an obtaining feedback from the leader and other members, facilitation of self-expression and exploration, and obtaining social support. It is also cost effective. It is important to note that although there are many advantages to using groupwork, it is not always suited to the needs of the client. Clients who are not at an acceptable level of daily functioning may benefit more from individual therapy due to an increased need for individual attention (www.lifescipt.com). However, the greater part of the population would be eligible to benefit from groupwork as ‘a group context can be adapted to their needs and level of ability’(Barnes at al.,2008, p.103). The meta-analysis of the effectiveness of child and adolescent group treatment which I have described in brief earlier on in this essay observed from results of surveys that results of psychotherapy with children did not differ in overall effectiveness(Burlingame & Hoag, 1997), indicating that the intervention plan is more influential on the outcomes than whether group or individual therapy is employed.

Reflection on learning:

Through reviewing the various literatures related to groupwork I discovered the potential therapeutic benefits of group therapy which can be an effective approach in facilitating performance and participation in a wide range of clients. I would like to further increase my knowledge regarding the group process so that I can become competent to design and facilitate groups where appropriate in my practice as an occupational therapist so that clients achieve their desired outcomes. I realised the extent to which the therapist must plan their group in order to develop a group structure and plan that will enable both group and individual goals to be met. I intend to develop my clinical reasoning skills in order to gather the relevant information regarding the client, the setting and the activity in order to be able to develop a group that will successful in its outcomes and decide on the best way to apply myself to ensure the success of the group though my therapeutic use of self.

Conclusion:

Although there is a current lack of research surrounding the topic of groupwork in occupational therapy, the literature that is present is supportive of groupwork as a therapeutic approach in a variety of areas of occupational therapy practice. I have discussed the general theory underpinning groupwork including the potential merits of its use in therapy. I have learnt that the therapist must skilfully design and implement the group so that the client can embrace these therapeutic factors and that their goals are met. I applied some of the variables involved in the design and facilitation of a group though using a social anxiety group as an example. I also discussed my learning about groupwork and identified specific areas of proposed personal development in this area.

References:

Barnes, M., Howe, M.C., & Schwatzberg, S.L. (2008). Groups: Applying the functional group model Philadelphia, PA: F.A. Davis.

Blair, S.E.E. (1979). Supportive psychotherapy groups with the elderly. British Journal of Occupational Therapy, June 1979, 137-138.

Burlingame, G.M. and Hoag, M.J. (1997). Evaluating the effectiveness of child and adolescent group treatment: a meta-analytic review (1997). Journal of clinical child psychology, 26(3) 234-246.

Carson, N. (2013). Interpersonal relationships and communication. In Clifford O’ Brien & Soloman, J.W. Occupational analysis and group process (1st Ed. pp. 25-35). St. Louis, Missouri: Mosby.

Clifford O’Brien, J. and Vroman, K. (2013). Occupational and group analysis: Adolescents. In Clifford O’ Brien & Soloman, J.W. Occupational analysis and group process (1st Ed. pp. 91-105). St. Louis, Missouri: Mosby.

Diana E. Damer , Kelsey M. Latimer & Sarah H. Porter (2010): “Build Your Social Confidence”: A Social Anxiety Group for College Students, The Journal for Specialists in Group Work, 35(1), 7-22. Retrieved from http://dx.doi.org/10.1080/01933920903463510

Duncombe, L. W. & Howe, C.M. (1985). Groupwork in occupational therapy: a survey of practice. American journal of occupational therapy, 39(3) 163-170.

Finlay, L. (2001). Groupwork in occupational therapy. Cheltenham: Nelson Thornes Ltd. (Original work published 1993).

Khalid-Khan, S., Santibanez, M., McMicken, C., & Rynn, M. (2007). Social anxiety disorder in children and adolescents. Paediatric Drugs, 9, 227-237.

Mosey, A.C. (1973). Activities therapy. Raven press: New York.

Soloman, J.W. (2013). Occupational and group analysis: Children. In Cliford O’ Brien & Soloman, J.W. Occupational analysis and group process (1st Ed. pp. 81-90). St. Louis, Missoui: Mosby.

www.lifescript.com/soul/self/growth/weighing_the_pros_and_cons_of_group_therapy.aspx. Retrieved 22nd February 2013.

Yalom, I. (1995). The theory and practice of group psychotherapy. New York, NY: Basic Books.