Group Therapy for People with ID/MI Robert J. Fletcher, DSW, ACSW CEO, NADD (National Association for the Dually Diagnosed) January 24, 2006 Phoenix, Arizona

Consideration in Forming A Group Homogeneous vs. Heterogeneous Open vs. Closed Time Limited vs. Ongoing Selecting Members Group Facilitator(s) Size of Group 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 Closed Group  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 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 Interactions Active Leader Encourages 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 Members Six for Single Facilitator Ten 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, 2006

THERAPEUTIC EFFECTS OF 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 EFFECTS OF GROUP THERAPY FOSTERS MEANINGFUL RELATIONSHIPS INCREASES RELATIONSHIP SKILLS PROMOTES PROBLEM SOLVING SKILLS ENABLES LEARNING THROUGH OBSERVATION Dr. Fletcher, 1984

Typical Model Interactive Model Tomasulo, 1998

Group Therapy Action 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 Therapy Action Method Techniques The Protagonist and Double Technique used to explore a problem presented by a group member Protagonist Person who expresses problem in group - Interpersonal conflict - Intrapsychjc conflict Blatner, 1973

Group Therapy Action 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

Group Therapy Action Method Techniques Five Therapeutic Purposes of the Double: Provides emotional support Gives emotional expression Reorganizes perceptions Promotes empathy Sets the stage for entharsis Opportunity for change is enhanced if the protagonist feels supported and understood as expressed by the double Blatner - 1973, Tomasulo - 1998

Group Therapy Action Method Techniques Choosing the Double: Facilitator can choose Protagonist can choose Group member can volunteer Facilitator can be double Protagonist can double Tomasulo, 1998

Group Therapy Action 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 Therapy Action 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. Razza and Tomasulo, 2005

Group Therapy Action Method Techniques Role of Facilitator Facilitate group interaction Facilitates interaction between protagonist - asking the double how protagonist feels - checking with protagonist on expressions from the double 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 OBJECTIVE FACILITATE GROUP INTERACTION TECHNIQUES PHYSICAL WARM-UP DISCUSS THEIR MORNING HAVING MEMBERS REPEAT WHAT WAS SAID Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP THERPAY (IBT) STAGE 2 WARM-UP FOR ENACTMENT AND SHARING OBJECTIVE PROMOTE GROUP PROCESS TECHNIQUES SELF DISCLOSURE AND TAKING TURNS BRINGING GROUP TOGETHER (GROUPNESS) MEMBERS ASKING OTHERS TO SPEAK Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP THERPAY (IBT) STAGE 3 ENACTMENT OBJECTIVE PROBLEM SOLVING AND GROUP INTERACTION TECHNIQUES ACT OF POSSIBLE ROLE PLAYED BY ANOTHER GROUP MEMBER AS HE/SHE GIVES VOICE TO THE FEELINGS AND THOULGHTS OF ANOTHER EMPY CHAIR ROLE REVERSAL Tomasulo, 1998

THE INTERACTIVE BEHAVIORAL MODEL OF GROUP THERPAY (IBT) STAGE 4 AFFIRMATION OBJECTIVE VALIDATION OF PARTICIPATION TECHNIQUES REINFORCEMENT THERAPEUTIC INTERACTIONS MEMBER ACKNOWLEDGEMENT OF PARTICIPATION DECOMPRESS FROM GROUP EXPERIENCE AND SIGNAL CLOSURE OF GROUP SESSION Tomasulo, 1998

FOR MORE INFORMATION CONTACT Dr. Robert J. Fletcher NADD (The National Association for the Dually Diagnosed) 132 Fair Street, Kingston, NY 12401 Telephone 845 331-4336 E-mail rfletcher@thenadd.org Thank you! 2006