- Psychological Issues
Adolescents are social creatures, in the midst of learning their social skills, and are often more trusting of others their own age than of adults. This makes the group therapy for teens an ideal choice when counseling becomes necessary for this age group. They are excellent at being able to learn from one another while observing and teaching appropriate skills as they grow.
However, adolescents cannot be treated as merely young adults in the group therapy setting. They come with their own dynamics which must be acknowledged and understood in order to work effectively with them.
The group is a natural setting for adolescents. They are taught in groups, live in groups, and often play in groups. Group therapy for teens is an ideal choice, as social interaction is a key aspect of the developmental process, and as suggested by Bandura (1989) most social learning takes place by observing others and the results of their actions. Leader (1991) states that group therapy for teens provides the therapeutic environment where they can work through interpersonal problems and examine the four basic identity questions: Who am I? With whom do I identify? What do I believe in? and Where am I going? The activities in group therapy that adolescents can be exposed to that they don’t have the opportunity to in individual therapy include the chances to learn cooperation and deal with issues such as cooperation, envy and aggression, while comparing how their thoughts and behaviors compare to those of their peers. Most adolescents are referred to treatment because of problems they are having in relationships with others in their lives such as parents, teachers and peers (Kymissis, 1996, p. 30). Adolescence is a time of rising psychosocial vulnerability where either psychopathology or self-actualization can occur (Gunther & Crandles, 1998) and thus social learning may be the best treatment for them.
Adolescents are often reluctant to attend group therapy, though, for a number of reasons. They often are suspicious of anything recommended by their parents or other adults. They are also often fearful that if they enter a therapy group it means that they are crazy. Some fear that the therapist will interrogate them and tell them what to do. Others are frightened that they will encounter someone they know, and that they will be stigmatized (Gunther & Crandles, 1998). The younger the participant, the more likely they are to show less fear, and the greater likelihood that they will be more willing to enter group therapy with less reservations.
In the organization of therapy groups, the developmental characteristics, needs and abilities must be kept in mind. The major criteria the selection of the members of the groups include the ages, the diagnosis, the intelligence levels and the stage of development. Group of adolescents who are appropriately matched with respect to development form cohesion early and become therapy groups faster than groups organized only on the basis of biological age (Kymissis, 1996, p. 30). This is due to the fact that these adolescents share common goals and tasks, which are important in forming cohesive bonds.
Dies’ Group Process Theory
There are 4 different levels of group therapy that may be utilized, as outlined by Maclennan and Dies (1992, p. 70). These different levels may be applied to, or adapted for, any population of adolescents from those who are healthy, those that are at risk for a social problem or mental illness, or those with serious long-term problems. These are:
They also define a number of different groups for us.
Groups for prevention may be held in many settings, including schools, youth service centers, and family agencies. They may be strictly informational, concerned with providing information on subjects timely to adolescents such at drug abuse, sex and sexually transmitted diseases. Or, they may be designed to help the youth improve their coping skills though such techniques as problem-solving, learning to say no, or the reframing of situations.
Program information groups are designed to give specific information about programs and to aid in the referral to other programs, and to make the best use of programs. These may often be found in clinics and treatment centers as well as hospitals, and often take the form of lectures, with the chance for questions and answers afterwards. These groups serve to reduce isolation, guilt and anxiety by allowing the participants to recognize that theirs is not a singular situation, that others are experiencing the same thing. It allows them to refocus their views of their problems, and clarify their feelings about what courses of action they want to take.
While the first two groups are larger, and are mostly concerned with providing information to the consumer, Diagnostic groups are smaller and provide the opportunity for the therapist to observe the clients more intimately in order to help formulate a diagnosis. This process is both helped and hindered by the group process. It is helped in that the therapist is able to see how the client acts in relation to peers. It is hindered in that the group may quickly begin to relate closely, form transferences, and become a cohesive whole. It is suggested that the adolescents, if they are in a diagnostic group, stay with the same therapist if they move into a treatment group, as they begin to form attachments to the therapist, and often do not tolerate transfers from one therapist to another well.
Problem-specific and life crisis groups are short-term groups that deal with a specific issue. The goal of these groups is to help the adolescent understand the consequences of the problem, and to explore alternatives in dealing with it, and their own attitudes and feelings towards it. Then, a course of action can be developed.
The final groups used with adolescents are life adjustment or change in life-style groups. These may be adolescents who are moving from one stage in their lives to another, teenagers needing or wanting to make more satisfactory adjustments in our lives, wanting to learn more about themselves, or to resolve serious long-term problems. The goals of these groups are to help members understand themselves, how they relate to others, what they want out of life, and how their own behavior and feelings intrude.
Gartner’s Group Process Theory
Another group theory with adolescents parallels their separation-individuation process. This was proposed by Gartner (as cited in Gunther & Crandles, 1998), who defines the group as a system that moves in levels of differentiation from undifferentiated to differentiated. It begins with no interrelationships – it is a room full of strangers. As it matures and relationships deepen, individuals become interdependent. The four stages of this theory are safety, dependency, counterdependency, and independence. He also believes that this is not a simple linear set of stages. The group can move back and forth between them.
The safety stage is a point in which the adolescents are figuring out what behaviors are acceptable are unacceptable, what might embarrass them, and what would make them feel comfortable. They are recognizing similarities and differences in each other and seeking commonalities between each other. They may experience the “hot potato” syndrome where they feel anxiety about focusing on talking about themselves, and defer to others and the therapist. The therapists questions and attempts to engage the members are felt and intrusive and interrogative.
Dependency, the second stage, is where the members become dependent on the therapist and believe they will be cured by them. The members are passive and lack initiative in starting discussions. They continue to work on issues of safety and trust. Rather than focus on issues of substance, the group may revert to scapegoating other members and talking about tangential issues to fill time.
In the counterdependency stage, while still being dependent on the therapist, the members begin to fight their dependency. This results in conflict with the group leaders. The group members at this point may express transference of anger toward other adults onto the group leaders to a great degree at this point.
Finally, in the independent stage, the members will achieve autonomy, and have a sense of who they are and how they can continue in their lives. The group members will begin choosing the topics of discussion and leading the group independently. The group will begin giving constructive feedback to one another, with little therapist intervention. Instead of spending their energies protecting and defending themselves from one another, they can reveal their feelings and work through their problems.
Adolescent Group Behavior
The behaviors that occur in adolescent group therapy fall into the same general categories as those in adult therapy, but there are significant areas that are different (Maclennan & Dies, 1992). The first of these is in the area of facing difficulties that arise within the group. Adolescents are prone to outbursts of threatening to leave a group, especially early in the beginning, if they feel they are being mistreated by the group. This results in the group becoming anxious and feeling guilty. The therapist must intervene appropriately so that the members are able to face their difference, express their opinions, and disagree. If not, the group will stagnate.
At this age, the members need to realize that difficulties and differences are normal, and that rather than ostracizing a member, they should be concerned for each other. This non-defensive posture needs to be modeled by the therapist by discussing their own behavior, teaching that they do not need to insist that they are always right, and being willing to admit if they make mistakes. If a mistake is made, examining the rationale behind the decision that was made with the members can encourage them to examine their own thinking when they make decisions. And viewing the therapist as a human capable of making mistakes will make it easier for them to face making their own.
Competition occurs normally and constantly in groups, with a pecking order especially being attempted to be established in adolescent groups. The members are not all attempting to compete for the top spot, however. Some are competing to be the person in the sick role, while others the stupid role, and yet others the troublemaker. All the members naturally tend to fall back into the roles they play in their natural life outside of the group.
Adolescents also use physical activity as a tension release. The therapist may find that their group members are easily restless, walking around, touching each other, or wrestling with each other, especially when issues become too anxiety laden. As long as these activities do not overly interfere with the flow of the group, they serve to help release tension, and allow the members to continue to relate to one another.
As well as reigning in physical activity, the therapist must also reign in inappropriate communication patterns through teaching how to communicate in a group setting at the outset. Adolescents have a tendency to be preoccupied with themselves and tend to talk at the same time, cut each other off and not listen to each other. They will direct their attention to the leaders, as if they are in individual therapy. The therapist must encourage active listening skills, and invite others to respond to a member instead of responding randomly about themselves (Crandles, Sussman, Berthaud & Sunderland, 1992).
Finally, while in all forms of therapy transference is a common reaction, in adolescents it can be especially prevalent. While not unique to the group setting, it deserves comment as adolescents and children in conflict with their parents may have the tendency to transfer onto the therapist their suppressed beliefs about, and wishes for, good parents (Gunther & Crandles, 1998).
Group Life Cycle
The adolescent group has its own special place in therapy. It is not quite a children’s group, and not quite an adult group. It is different from children’s groups in that the adolescents are more readily able to engage and understand the deeper issues in therapy, to sit through a full therapy session, and to challenge the therapist and each other. It undergoes the group life cycle similar to that of an adult group, yet there are distinct differences. Dies (1996, pp. 35-51) defines the 5 stages an adolescent group undergoes.
The first is the initial relatedness, which centers on the clarifying of expectations, educating members regarding group processes, and addressing issues of engagement. This period is very important, as many members will enter group therapy with differing expectations of how the therapy will proceed: they will talk about problems with people in their lives; they will talk about just person and historical events; they will direct their comments only to the group leader who will correct or “heal” their problems; that the group leader will be there to simply to lead a question and answer session that will lead to a quick solution. They need to be made aware that it is the here and now, not the history that is important, and it is the group, not the therapist that is the agent of change. They need to come to the understanding that it is a process of self-disclosure and feedback that will lead to self-understanding, increased self-worth, and increased coping strategies. Thus, this phase is centered on building appropriate expectations for what is to be accomplished during the time the group is to be together. Additionally, connections must be formed during this stage, and the therapist instills a positive climate for the group. This is done by modeling behaviors that they hope to see within the group. They demonstrate an appropriate level of openness and self-disclosure, but must be careful not to threaten the adolescents who are naturally more cautious of adults when entering group therapy, than are adults when entering group therapy.
There are changes from adult group therapy to adolescent group therapy when dealing with other situations as well. For instance, if one member is monopolizing a group, in an adult group, we might say rhetorically “I wonder why the group is allowing X to do this?” This would be seen as appropriate and act to mobilize an adult group. In an adolescent group however, it can be seen as punitive, and as a reprimand, and thus can create a negative climate for the group. Instead, we might address the member in a non-threatening manner such as “X, can you stop a minute? Your saying a great deal, and it’s difficult to take it all in. Can we stop and look at some of these issues?” This maintains a positive, safe environment during the beginning of the group. More confrontational comments like the first one can be made more safely during later stages in the group’s development.
The second stage in the adolescent groups development is the testing of the limits. This is an extension of the normal adolescent challenge of separation and individuation. In this phase, the group process approximates the struggle the adolescent goes through in their daily lives. During this phase, the central pursuit of the therapist is to create a safe environment that is conducive to the exploration of the members options in which they can select aspects of their identity that are complementary to their self-views. During this process, they look to the therapist and to each other for acceptance and validation as they go through the process of trying on and discarding different aspects of their identity. The developmental task of this stage is the adolescents are attempting to determine whether the therapist will be available to them, or if they will fall into negative patterns toward them that other authority figures in their lives have. Essentially, they are testing the therapists commitment to the group and group process.
Resolving authority issues is the third stage. This occurs after the group members have accepted the therapists capacity of withstanding the challenges of the individual members and the group of the whole to tolerate their expressions of anger, frustration and concerns. An example of the challenges of this stage is the group challenging rules that were set down in the pre-group contract. They may ask questions such as “Whose group is this anyway?” By giving explanations and using openness in clarification of the reasons for the contract rules, but not changing the rules, the therapist is maintaining firm boundaries, but is acknowledging and accepting the groups feelings. This allows the group members the knowledge that they have the right to self-assertion without penalty, retains trust in the group, and allows the group to continue moving forward.
The fourth stage is work on the self. This is a time for the therapist to decrease their level of participation, and create the opportunity for the members to assume great responsibility. In part, this is due to the fact that adolescents often experience more comfort in learning from one another than from adults. It is important for the therapist to inform the teens that they are going to reduce their involvement, so that their decreased interventions and interactions are not misunderstood and a negative climate result. The central events are increased member-to-member activity, behavior practice to acquire more interpersonal skills and more efforts to enhance self-understanding while attempting to generalize from the group to their lives outside of the group. The success of this phase of the group lifecycle is determined by the self-report of the members on how well they have been able to generalize their learning from within the safety of the group to their lives in the outside. This is often encouraged through “homework assignments” suggested by other members. This stage of self-disclosure, feedback, acknowledgement, practice and generalization is where most of the major work of the group occurs.
The last stage of the group is the moving-on stage. This termination stage has two parts, the consolidation of acquired learning and the integration of feelings of loss that accompany the ending of the members’ time together. As with adults, adolescents may resort to denial to avoid confronting the pain of the loss of the group, and suggest reunion get-togethers. The therapist takes a role at the forefront again during this time, with support and encouraging the expression of all emotions from sadness to happiness to regret. They model appropriate behavior by expressing their own emotions as well. An appropriate expression and termination of group therapy helps the adolescent to learn to be able to move on in the future, as they will have to do with many things as they continue to grow.
In attempting to describe the adolescents perception of curative factors in therapy, Corder, Whiteside, and Haizlip (1981) used a Q-Sort, which is a sorting method in which the participant sorts statements into piles of agreement or disagreement multiple times to obtain final statements that are most and least agreed with. This Q-sort was of Yalom’s description of potential curative factors in group psychotherapy with adolescents. There were similarities to Yalom’s previous results with adults, but the adolescents had a definite difference:
Items Most Helpful to adolescents:
Items less helpful to adolescents:
There have been a number of studies of different group types ranging from anger management to post-traumatic stress disorder (ptsd) to support groups for medical problems. These groups have employed a variety of different techniques and met with a great deal of success.
Medically Related Psychosocial Groups
Project HOPE, according to Gunther and Crandles (1998), is a psychosocial support group for non-infected children of HIV-positive parents. The main goal of this group is the development of a support system for the grieving adolescent. The group involves children and adolescents from ages 9 to 17 years old and the stages of the group parallels the four stages of the adolescent separation-individuation process. Noting the difference in age ranges, and in keeping with the earlier discussed information, children ages 9-11 attend art therapy and homework groups, while the older children attend psychotherapy groups. These are augmented by individual and family therapy sessions as needed.
Children are referred to the groups for one of two reasons. The first is behavior changes after disclosure of their parents HIV status, while the second is parent initiated for wanting their child to have support and education for their child.
In this group, there are the expected stages of group development of an adolescent group, however there is extreme testing of the therapist and group resistance in the early stages. The therapist must also not be maneuvered into the role of real parent or other “hated adult”.
The participants are at different stages in their grief processes in this group, as it is an open group. Some are in denial, while others are angry. Others have magical beliefs that their parents will beat the disease and live. This presents challenges to the group, as the older members attempt to help the newer members, who may displace anger on them, the therapist, or anyone near them. The longest participants have remained in the group is three years. On average, they generally remain in the group for 6 months to one year after the death of their parents to have support as they begin the grieving process.
Group psychotherapy can also be useful for adolescents with chronic medical illnesses by providing them opportunities for growth, understanding, meaning and adaptation. They may struggle with poor self-image, depression, hopelessness, fear of illness, healthcare workers and medical procedures, and a preoccupation with death. Additionally, they can experience isolation, dependence on caretakers, withdrawal from relationships with peers and sometimes family. Psychotherapy group work can provide support by providing a forum for discussion with peers subjects and feelings that they cannot talk about with healthy friends, parents or healthcare professionals. It provides a place to find common experiences, to cope with feelings of loss, and to better understand that feelings of isolation are a common reaction. The group also facilitates social and emotional growth through exploring and working through individual developmental needs (Stauffer, 1998).
Psychologically Oriented Groups
Hayward, Varady, Albano, Thienemann, Henderson and Schatzberg (2000) describe the use of cognitive-behavioral group therapy for social phobia in female adolescents, and its effect on risk for major depression. Social phobia has a peak age of onset during adolescence, with a range of 5 to 10%. It is associated with significant impairments such as poor school achievement, difficulties in intimate relationships and alcohol use. It has been shown to persist into adulthood, and increasingly, the literature shows comorbidity with major depression.
They study showed that after 16 weeks of group treatment there was significant improvement in interference in daily activities and reduction of symptoms in social phobia, and decreased risk for major depression at 1 year follow-up versus the non-treatment group. Group therapy was delivered based on a set protocol. The first 2 session provided group members with members about social anxiety and the rational for treatment, while sessions 3 through 8 introduced skill-building such as social skills, social problem-solving, assertiveness and cognitive restructuring. Sessions 9 through 15 were in vivo and simulated within-session exposure to feared social situations, with each group member working through a hierarchy of feared social situations. The final meeting was a final exposure, discussion of termination, and plans for termination.
Another issue that has been shown to be responsive to group therapy for teens is anger. Snyder, Kymissis and Kessler (1999) describe brief group therapy (4 sessions) for anger and its efficacy for adolescents. The group therapy was provided over a two week period while the adolescents were in a psychiatric facility, and the resultant behaviors were evaluated in 3 situations: by nurses in the facility; by teachers in the special education classroom; and by parents in the home/community environment 4-6 weeks after discharge. The treated vs. control individuals exhibited significant increases in anger control in this abbreviated anger management therapy.
While brief therapy has been shown to be effective for anger in an inpatient setting, brief group therapy for anger has also been shown to be effective for anger with adolescents in an outpatient setting. McWhirter and Page (1999) combined this with a co-occurring goal-setting group for their clients, and had positive results. The anger group met for 9 sessions over 5 weeks, while the goals setting group met for 6 sessions over the same 5 weeks. These meetings occurred during the school day, as all participants were students at an alternative high school. The control group was students at the same school who were assessed but not placed in the group sessions.
The anger management curriculum consisted of activities for distinguishing between appropriate and inappropriate expressions of anger, recognizing anger cues, and learning better coping self-statements. Homework was given that included maintaining anger logs, identifying anger in specific interpersonal interactions, and worksheets designed to help change faulty thinking. Role-playing activities and group discussions around specific topics were also used, and the students were asked to share how the topics and activities related to their personal experiences. The goal setting group focused on issues related to career planning, decision making, and setting and evaluating goals. Group activities included a values auction, learning about and setting short- medium- and long-term goals, and imagery exercises on career futures. Homework assignments included worksheets on exploring occupational and life goals and barriers, acquiring information on community colleges and training schools, and other activities. Similar to the anger management group, it also included role-playing and interpersonal discussions around the presented topics.
Adolescent depression has been shown to be responsive to cognitive-behavioral group therapy, especially when combined with booster sessions when full recovery was not attained at the end of the initial therapy (Clarke, Rohde, Lewinsohn, Hops & Seeley, 1999). This finding is important as it emphasizes the efficacy of booster sessions with adolescents, which have been shown to work with adults, but have not been studied with teens in the past. In the acute phase interventions, there was a high didactic portion, with emphasis on the teaching of mood monitoring, improving social skills, increasing pleasant activities, decreasing anxiety, reducing depressogenic cognitions, improving communication, and conflict resolution. The 1-2 session booster groups attempted to addressed 3 factors in the maintenance of treatment gains: continued self-monitoring of relevant behaviors and situations, pervasive lifestyle changes designed to cope with future stressful events, and high levels of social support. Additionally, they addressed specific concerns of the individual adolescents in the group.
Ellensweig-Tepper (2000) describes the use of time-limited trauma group psychotherapy for adolescent females. Trauma victims suffer a sense of social losses and disconnections that may lead to them feeling humiliated, isolated, vulnerable, unable to concentrate, and sometimes disoriented. They may lose the ability to make interpersonal connections, and thus they prevent the satisfactory attachment formation with others either by desperate clinging to or distancing from others.
The group setting can also provide what the family cannot, as they often do not know how do deal with the trauma victim. The group can provide a forum where expression of past commonalities of trauma experience can lead to effective connection formation. The goal is to provide social interdependence and a sense of community for the victim.
This is a difficult population to deal with, as the client of trauma is being asked to take a risk and give up their self-protective behaviors and strategies that have evolved since the trauma, in order to develop new behaviors. Thus, it requires an integrated framework of emotional, behavioral, maturational and developmental, psychological, cognitive, and solution-focused strategies.
Ellensweig-Tepper holds four guiding principles in her treatment of trauma victims: support the victim, protect the victim, hold the offender responsible, and assess if there are other institutions that are accountable. The therapist must hold onto these principles, but also hold these standards up for other group members. If a member begins to violate one of the principles towards another member, the therapist must protect the attacked member. The group is a combination process, support and psychoeducational group, that remains flexible with process and content issues with only a basic structure format. The structured/planned exercises emphasize group interaction, and the structure allows the opportunity for group members to share in the leadership role, which benefits them by increasing their self-esteem and motivation. The resulting feelings of group ownership communicate leadership skills to the group members, and they learn leadership skills through modeling and role modeling.
As noted before, adolescents are going through developmental stages that adults have already completed. They are not “little adults” when it comes to psychotherapy, and their groups must reflect this. They have their own differing life cycles for their groups versus those of adults, and this must be respected when working with the population.
The diversity of the disorders for which these groups have been studied for with adolescents demonstrates the efficacy of the group therapy for teens. As we continue to research and work with the children and adolescents, and as managed care moves us toward briefer therapy and more cost-effective therapies, we will see that group therapies are useful in many, although not the answer to all, clinical situations.
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