Learning Objectives
By the end of this section, you will be able to:
- Identify the functions of a group, particularly in the context of group therapy
- Discuss the seven characteristics of group dynamics
Group therapy is a treatment option available to help people experiencing mental health issues. This setting provides the opportunity to learn from others’ experiences, allows for support of one another, opens the floor to education, and encourages participants to share their feelings in a safe environment. Groups can be geared toward a particular problem or diagnosis. They can also be specific to teaching coping strategies or social skills (American Psychological Association, 2019).
Functions of a Group
Group therapy serves many purposes for its participants: a place of belonging, a forum to share/learn new knowledge, an appropriate outlet, and an opportunity to practice supporting others and receiving support. A therapeutic group works as a unit to support its members and make them accountable for participation within the group (American Psychological Association, 2019). Working together to learn from and gain sustenance from one another is the biggest strength of a group. Each member of the group brings their own experiences to it. Depending on the topic of the group, members may be encouraged to share their individual experiences. Sharing these experiences helps the group members feel a sense of comradery with others who may have similar experiences. The sharing helps them to realize they are not alone in what they are going through. The group leader (in some cases, this is a nurse) teaches the members how to support one another and how to accept the support of others. Attending groups may be the expectation of the facility, a recommendation of the individual’s therapist/provider, or their own personal treatment choice.
Group Dynamics
A group starts with everyone agreeing on a like purpose or objective. Then, there are several important factors (Figure 5.3) that further define how the group will operate and what it will look like when pursuing those objectives. These factors of group dynamics include roles, size, composition, leadership, cohesiveness, status, and norms.
Depending upon the type of group, some of these factors might change over time (if the group meets regularly over a set time period). If the group is a one-time group, then these factors would not change unless a participant gets up and leaves the room. If the group is a recurring group and is an open group (meaning that new members can join at any time), then there could be changes in size, composition, and cohesiveness over time. If the group is a recurring group that is a closed group (meaning that the same members attend for the duration of the group, such as a six-week group that meets each week on Tuesday), then there probably would not be a lot of change to these factors.
Member Roles in a Group
Typically, there is a group leader (facilitator)—this can be a peer support person or a trained health-care provider, such as a therapist or a psychiatric nurse—and group participants. The leader facilitates the direction of each group meeting, keeps order, and promotes healthy interaction between participants. The participants are often people with similar backgrounds in experience or diagnosis who have the chance to gain strength, skills, and perspective from being part of the group. If the group is a closed group, then the same members will be in the group from start to finish, for the specified duration of the group. In an open group, a new member can join at any time. This will change the dynamics and possibly the roles of the group members as new personalities join the mix.
Group Size and Composition
The group size and composition are usually decided upon by the facilitator prior to the beginning of the group. Depending on the topic of the group, it may be better to limit the number of participants in order to make the shared conversation more intimate. Choosing participants with similar concerns or symptoms helps them to feel a sense of belonging and connection with others within the group (Malhotra & Baker, 2022). Unless the group is focused on helping clients with a particular diagnosis, groups usually function better if its members are not currently in an acute state (i.e., psychotic or under the influence). Someone in an acute state would be better suited to individual therapy. Most inpatient units will have a morning meeting to start the day and an evening meeting to end the day. All clients are encouraged to attend these groups. There may also be specific groups offered if there are a lot of people currently in the unit with the same diagnosis. For instance, if there are many people with bipolar disorder who are experiencing auditory hallucinations (hearing voices), then there might be a group offered on this topic so that clients can learn/share coping mechanisms.
Group Leadership Styles
There are numerous leadership styles common across many environments, such as business, health care, and education. This section discusses several of those styles and how they affect the work of the participants in group therapy. No matter which leadership style, the leader must remain flexible and able to adapt to changing situations in order to meet group goals.
Clinical Judgment Measurement Model
Analyze Cues: Leadership Styles in Group Settings
To understand how well the different leadership styles work within the group therapy intervention, nurses must be able to identify the types of leadership styles. Each style represents a different way that a group’s leader will encourage members to interact with one another. Before facilitating a therapeutic group, the nurse needs to think about the leadership style that will work best to reach the intended outcome. The group leader is there to assist its members to learn about and understand both individual and interpersonal problems (Ezhumalai et al., 2018). In this way, group therapy is intended to bring about positive change through the sharing of information, ideas, lived experiences, and coping skills to apply to stressful situations.
For example, participative leadership is often used in the Wrap Up Group that ends the day in an inpatient behavioral health unit. At this meeting, clients are asked to share how their days went, what they accomplished, and are often asked to sign up for certain responsibilities in the unit, such as turning off the TV and straightening chairs in the TV room or returning all phones to the nurses’ station. This leadership style encourages everyone to work together.
Authoritative Leadership
The authoritative leadership (or autocratic) style is one in which the leader is in command and exerts control over the group members (Cherry, 2022). In authoritative leadership, the leader would be in complete control; it can be viewed as “bossy or dictatorial” (para 7). This style is best used when there needs to be quick decision-making. This leadership style might be used in a group setting in which participants are given a set time limit to complete a task.
Delegative Leadership
The delegative leadership style relies on the group members to do the work at hand. This style is also referred to as laissez-faire. Here, the leader offers little direction to group members, often leaving them without needed guidance. This leadership style might be beneficial for a team building group in which the leader is actually trying to get group members to work together to problem-solve. This leadership style would be stressful to a group of people who have OCD or anxiety.
Participative Leadership
The participative leadership style (also known as democratic) entails listening to group concerns and allowing members to help with decision-making. This style of leadership encourages the group members to participate actively. They feel heard and part of the decision-making process even though the leader has the final say (Cherry, 2022).
Servant Leadership
The servant leadership style works toward the greater good of the members of the group, placing emphasis on learning and growth, contentment of group members, and feelings of ownership by group members. Chobanuk and James (2015) suggest that this style of leadership motivates others and gains positive results.
Transactional Leadership
In transactional leadership, the leader uses a reward and punishment system in order to get results from the group and achieve group goals (Chobanuk & James, 2015). Studies have concluded that this type of leadership does get results. This leadership style is sometimes used to make learning fun, such as playing a bingo game to teach about medication and then offering a small prize to the winner. This is especially useful when treating children. This leadership style might have the opposite effect for people experiencing paranoia as they might feel that the leader is against them if they are not the winner and do not receive a prize.
Transformational Leadership
The transformational leadership style involves being a change agent; leaders view group members as valuable and change as positive. Transformational leaders possess four attributes to varying degrees. They are charismatic (highly liked role models), inspirational (optimistic about goal attainment), intellectually stimulating (encourage critical thinking and problem-solving), and considerate (Bass et al., 1996). They encourage participation through “adapt[ing] to the environment, demonstrat[ing] flexibility for change and resolution of issues” (Chobanuk & James, 2015, p. 114). Many leaders are now using this style to help participants in group therapy settings feel more included/supported.
Group Cohesiveness
Cohesiveness refers to the belonging that each member feels to the group or “interpersonal support, acceptance and esteem within the group” (Bryde et al., 2021, p. 1). It is what brings the members together to work on the task at hand. Participants often feel closer to one another than they do to the group leader and that is expected as a therapeutic point because the ultimate goal is for the participants to feel like they are not alone in what they are experiencing. The group leader will often read a list of expectations prior to the start of the group. This list might include the necessity to treat all with respect and the possibility of being asked to leave the group if these expectations are not followed. By setting up the group expectations, the leader is helping to ensure that the group members feel supported by one another. The leader also makes sure that everyone who wants to speak or participate gets an equal opportunity to do so by using positive reminders or a timer to ensure that no one monopolizes the conversation.
Group Status and Norms
Within any group will be a hierarchy of group members and norms by which the group abides. Hierarchy represents each member’s status within the group and can be based on time they have been in the group (longer time = more experience with the process), similarities to other group members, differences from other group members, educational level, and group role. Cultural and ethnical differences may also play a part in determining an individual’s status within the group, and they will certainly influence the group norms. Norms are beliefs that people learn over time from their family, cultural and religious upbringing, and the people with whom they interact daily. Groups create their own norms. In groups with less diversity, there will be a higher chance of shared norms (Meeussen et al., 2018). As a group’s size and diversity increases, common norms decrease. It is the job of the leader to mitigate any conflict that may arise and create common norms specific to the group setting. Beginning each session with a review of the group’s ground rules is helpful so that all members understand acceptable behavior while participating.
Group Types
Some of the types of therapeutic groups include psychoeducational, support, skills, cognitive behavioral, and self-help. Depending upon the needs of the client, the clinician will suggest which group type might be most helpful. Psychoeducational groups offer teaching and can be led by a nurse or a therapist. A support group offers encouragement to clients who have all experienced the same sort of issue, such as a grief support group or a cancer support group. A skills group is designed for clients who have not developed certain skills needed for optimal functioning. These skills could include coping strategies or socialization (Malhotra & Baker, 2022). Cognitive behavioral groups help clients reframe their thinking to lead to positive behavior changes. Self-help groups, such as Alcoholics Anonymous (AA), are geared for clients motivated to change.
Cultural Context
Overcoming Cultural Barriers
Nurses must recognize that cultural barriers can make or break the effectiveness of therapy. In “Overcoming Cultural Barriers on the Road to Recovery” (2021, October 7), Roselin Dueñas describes going to family therapy to deal with her mental health symptoms. “Being a gay, Latina woman who grew up in a religious household of immigrants, I had to overcome many obstacles in order to get the help that I needed” (para 2). During her attempt at group therapy, she not only had to deal with her parents’ backlash for coming out to them as bisexual, but she also faced language and financial barriers. Instead of relying on her therapist to help bring her and her parents together, she had to act as an interpreter, which reinforced the divide. This challenge made her lose confidence in her recovery. Roselin was an immigrant with no documentation; paying for appointments and obtaining medication were difficult without health insurance. These were also learning experiences for her as she continued her road to recovery and shared her story with others. Refer to the NAMI blog for more information.