Adolescent Group Therapy
Article originally published in the California Society for Clinical Social Workers newsletter Winter 2020 edition.
The developmental work of adolescence is clinically rich and vital to successful transition to adulthood, healthy connections, and life satisfaction. In this article, I explore the form and potential of adolescent group therapy. This will be a brief overview of a topic that requires more depth to fully understand and implement.
There are many aspects to the group process that I enjoy bearing witness to: connection amongst unlikely adolescents or isolated teens, altruism (you gain through helping others), universality (you are not alone), a corrective family experience, improved social skills, learning from each other, identity formation in relation to others, and the magic of group cohesiveness/belonging that provides light and hope for troubled youth. There is a particular place for clinical social workers in this modality—groups have a practical, down-to-earth approach, are strengths-based and holistic in nature, require authenticity of the leader, effect more individuals in the same ninety minutes, and offer a lower-cost alternative to families struggling to cover rising individual therapy costs or that have no health insurance.
The main developmental tasks of adolescence include: Separation- Individuation from parents, Identity-Formation (gender, career, sexual orientation, racial/ethnic/religious identity), Establishment of Peer Group, and Emerging Sexuality and Establishment of Intimacy (cv.sduhsd.net, 2019 ). Most teenagers spend the majority of time with their peers and they rely on other adolescents to help them accomplish their developmental tasks, which makes group therapy an ideal environment for support and change. Within the group therapeutic context, adolescents can work through the four main identity questions: Who am I? With whom do I identify? What do I believe in? Where am I going? (Leader, 1991). The group, which provides a container and support for members, comes to be felt as a “mother group” and becomes a transitional object for troubled teens (Scheidlinger, 1974).
In general, the literature is lacking on the benefits of adolescent group therapy and the specific differences that group therapy provides to teens versus individual/family therapy models—however, many of us intuitively know that our clinical work is truly more of an art than a science. It is hard to measure effectiveness and yet it is useful to still try. One study analyzed 56 outcome studies from 1974-1997 and found that the average adolescent treated by group treatment is better off than 73% of those in control groups (Hoag & Burlingame, 1997). We know that adult process groups have achieved success (think of the Alcoholics Anonymous model, Domestic Violence support groups, Batterer’s Treatment groups etc.) and that many of those successes are likely occurring in adolescent group therapy models as well, even if not well researched at this point. In recent years, I have noticed a rise in CBT and DBT group therapy options for teens in our South Bay area in Southern California...and groups have been used for years in psychiatric hospitals, residential treatment centers, substance abuse programs, and schools. Anecdotally, I have witnessed the group holding environment to be hugely positive for many adolescents that I have worked with over the years. There is something transformative about sharing your pain and struggles in a group setting, particularly for adolescents as they are hard wired to belong and establish strong peer connections.
The following are my thoughts and considerations from my experience conducting groups in a private-practice setting over the last few years. Many of these ideas are important to consider about group therapy, no matter what setting you are employed. A disclaimer: my recent groups have been Open-ended, Adolescent Girls’ process groups (separate Middle School and High School aged groups), that were dynamically oriented with primarily depressed, anxious, quirky, introverted, sensitive girls, some with internalizing behaviors and some with externalizing behaviors, mixed sexuality orientations, and in a middle class to upper class community. I have run these groups on my own, as I’ve been in a solo private practice setting (have had support and guidance from my consultation groups). Some girls have been in group for a short period and some have remained much of their high school experience. I have definitely adjusted parts of my process over time, made mistakes, and learned some lessons the hard way so I will share my general tips below.
Develop Group--Type of Group, Goals of Group, Theoretical Orientation, Open-Ended or Closed Group
Some groups are Task-oriented (ex. CBT Anxiety reduction group) and some are Process-oriented (ex. High school process group, dynamically oriented). This decision should largely be based on the needs of the clients, clinician’s style, personality, training, goals of group, and setting. Task-oriented groups or CBT/DBT groups may lend themselves to a Closed Group (meaning fixed number of weeks for the group to exist) and short-term goals and time frames. Process-oriented groups tend to be longer-term and open-ended. As a clinician, it is important to be mindful of the theoretical thrust of your particular group—many orientations can be utilized to run an effective group—CBT, DBT, Psychodynamic, Social Learning Theory, Strengths-Based, Trauma Theory, or Psychoeducational. The general goals of group therapy are to create safety among members, decrease problematic behaviors and feelings, relieve isolation, and establish peer connections.
Group characteristics: Size, One gender or Mixed gender, Balance/timing/personalities
In general, it has been suggested that eight group members is optimum (Yalom, 1985). In my experience, between six to eight members is ideal and allows for group cohesion, energy in the room, and balance of personalities. A group can start with as few as three members, if the plan is to continue to add more members as the referrals come in.
It is helpful to have some heterogeneity in terms of grade, age, and level of maturity. Separating younger adolescents from older adolescent is wise as there are major differences in what middle school students need and discuss versus high school students. However, within those groups, it is useful to have a range of ages, grades, and personalities. Depending on the type of group, there will be pros and cons to having a one gender or mixed gender group. I have enjoyed having girls’ groups, as they often discuss themes around their sexuality/boundaries/decision making that might be altered if boys were in the room. However, mixed gender groups offer different opportunities for the teens to discuss, empathize, and practice their social skills with the opposite gender.
The balance of group members is important to keep in mind. Over time I have found that it is helpful to have a variety of personalities at the table—a mix of introverted, extroverted, mature, immature, a variety of diagnoses, varied family constellations, and a range of intelligence/motivation/interests. This makes for interesting conversations, increased opportunities to empathize with one that is different from you, and a chance for learning from one another when they all have different skill sets. It is important to consider “goodness of fit” with each new group member, keeping in mind that some with budding personality disordered traits may be difficult to incorporate into group (or certainly not too many with complicated personality issues would be tricky). Clinicians should consider timing in their process, when to begin/end group and when to incorporate new members. Group cohesion will be impacted by these important considerations.
Screening/Intake process:
It is well worth your time to do a thorough bio-psycho-social-spiritual assessment before permitting a new adolescent to join your group. In my experience, a brief telephone screening with the teen/or parent will give you an idea of whether the adolescent will be an appropriate referral for your group. If the teen seems a fit from the details gathered over the phone, I then schedule an Intake session with adolescent and parent to review history, sign consent and release forms, go over the goals and rules of group, review confidentiality (between therapist and client and importance of confidentiality between group members), and review reporting laws. This is often my opportunity to hear the parent’s concerns and observe the interaction between the adolescent and their parents. During this session, I assess for ego strength, mental status, level of sophistication/character to insure that there is enough commonality to be a strong addition to the group.
Before an adolescent begins group, I contact outside collaterals that are working with the teen or family. It is important to know their observations, goals for group treatment, and whether the adolescent has any strange/anxious behaviors that might impact the other group members. Further, it is important to review pertinent IEPs, psychological evaluations, and hospital records to provide a clear clinical picture. Once a teen has begun group, it would be clinically harmful to not allow them to continue treatment (thus it is extremely important to do your due diligence before allowing them into group).
During the Intake session, discuss the importance of attendance and commitment to the group and how group members come to depend upon one another. Finally, the clinician should outline the parameters of how/when the therapist has contact with the parents. In recent years, I have begun emailing the parents a general summary of themes covered on a monthly basis. This doesn’t break confidentiality, but alerts them to the important topics that we are covering. Lastly, we look at the Group Contract and sign the agreement together.
Role of Leader:
“Being an adolescent group therapist is demanding…Of great importance for adolescent group therapists is a specific awareness and alertness to detect countertransference tendencies and reactions in themselves. They must also be able to tolerate the frustrations and lack of immediate positive results that is incumbent in treating adolescents due to their emotional volatility and experimental behavior” (Leader, 1991). Adolescent group therapists wear many hats, all in the space of one group session—limit setter, educator, parent, container of safe environment, therapeutic role, and instiller of hope. One must be authentic, genuine, and comfortable with one’s self. Clinicians must know how to manage affection and sexuality when working with adolescents—and know how to address these tricky gray areas with vulnerable youth.
In my experience, one of the most important tasks of the adolescent group therapist is to foster belonging. These are often the teens that have poor social skills, don’t get invited to birthday parties and sleepovers, are the black sheep in their families, and spend much of their time feeling isolated (whether it is real or imagined). Fostering a sense of belonging is key in healing. In my groups, we have snacks and make hot tea; we celebrate birthdays and the birthday person picks their desired treat; we create comforting rituals, such as weekly check-ins, passing out inspiration cards at the end of each group, and incorporating breathing/relaxation/mindfulness/setting intentions. If a teen is struggling and has been hospitalized or sent to residential, we make cards for them. If it’s been a particularly heavy group session, we end with something hopeful and a group hug. They always leave feeling like they belong in group. When an adolescent has achieved more success and stability, then we celebrate their graduation from group and have some rituals associated with that ending/new beginning.
The Group Life Cycle:
There is a rhythm with an established group that is healing and optimistic in and of itself. The concept of the five stages of adolescent group therapy is a helpful way to conceptualize the process. Members can move in and out of different stages fluidly. The first stage is the initial relatedness, which addresses group expectations and engagement. Next, the group develops into the testing of limits—a normal extension of the teen’s developmental task of separation and individuation. The therapist provides the space needed to explore and challenge. The third stage focuses on resolving authority issues, where the adolescents often question the group norms and rules, without penalty. The fourth stage is the work of self; during which therapists can decrease their role and let the adolescents assume more responsibility for their group and discussion. The final stage of the group is the moving on stage. Group members consolidate their learning, process feelings of termination, and internalize the feelings they had belonging to this group (Dies, 1996). As a clinician, it is truly remarkable to watch this process and be part of this process with youth.
References
(cv.sduhsd.net, 2019). Developmental Tasks of Adolescence.
Dies, D. R. (1996). The Unfolding of Adolescent Groups: A five-phase model of development. In P. Kymissis & D. A. Halperin (Eds.), Group therapy with children and adolescents (pp. 35-53). Washington, DC: American Psychiatric Press.
Hoag, Matthew J. & Burlingame, Gary M. (1997). Evaluating the Effectiveness of Child and Adolescent Group Treatment: A Meta-Analytic Review. Journal of Clinical Child Psychology, Vol. 26, No. 3, p. 234-246.
Leader, Elaine (1991). Why Adolescent Group Therapy? Journal of Child and Adolescent Group Therapy, Vol. 1, No. 2, p.81-93.
Scheidlinger, Saul (1974). On the Concept of the “Mother-Group.” International Journal of Group Psychotherapy, Vol. 24, Issue 4.
Yalom, Irvin D. (1985). The Theory and Practice of Group Psychotherapy, 5th edition, New York, NY: Basic Books.
