Working With Groups Under
ATAPS CMHS
10th October 2013
10am-12pm
PRESENTERS:
Tom O’Brien FACSW
Principal Psychotherapist, Mater CYMHS
Senior Lecturer, School of Medicine, University of Queensland
Karen Story
Child and Adolescent Psychotherapist, Social Worker and
Family Therapist (The Bouverie Centre ABI team).
Carol Woolcock
Child and Adolescent Psychotherapist and Social Worker
Facilitator: Bella Saunders, Senior Psychologist APS
INTRODUCTION
• Groups in the ATAPS CMHS context
• ATAPS CMHS Operational Guidelines:
– Up to 12 group therapy services within a
calendar year involving 6-10 people
– Approved interventions
– Evidence-based interventions.
3-Layers of Interventions
Indicated
Selective or
Targeted
Universal
INDICATED INTERVENTIONS
• ATAPS CMHS approved interventions are for
those in the indicated and/or selective/
targeted range i.e. for those at ‘increased or
higher than average risk’.
• Many programs available are evidence based,
however “universal” (e.g. whole class) and not
group programs.
WHAT IS EVIDENCE-BASED PRACTICE?
• There is much debate about what defines
‘evidence-based’ practice.
• A more complete definition (APA, 2005).
WHICH TREATMENTS ARE EVIDENCEBASED?
Useful resources:
• http://www.kidsmatter.edu.au/primary/progra
ms-guide/
• http://www.kidsmatter.edu.au/ec/resources/pro
grams-guide/
WHY CHOOSE GROUP WORK?
Group based interventions:
•
More cost effective than individual interventions.
• More opportunity for social interaction between the
participants.
• More opportunity to observe the specific strengths
& limitations of each participant.
• Outcomes from individual interventions & group
based interventions are similar.
CAVEATS
• Group leaders require training and supervision
• It’s advisable for a new group leader to co-lead
with an experienced group leader
• Comprehensive assessment of each participant is
required to establish needs and goals
• Group selection is vital
• Liaison with pre-school/ school teachers is
important
WHO ARE GROUPS FOR?
• Children with “mild to moderate” symptoms of
anxiety, depression, social withdrawal
distractible/inattentive behaviour, aggression,
social withdrawal & peer relationship
difficulties.
• Parents who can make a commitment to attend
every session.
WHO ARE GROUPS NOT FOR?
• Children with severe externalising behaviours
or severe Autism Spectrum Disorder.
• Parents with untreated severe mental health
problems.
RESOURCES
• Venue
• Leaders
• Materials
• Back-up
• Administrative assistance
• Supervision
Group Dynamics
• Forming
• Storming
• Norming
• Performing
• Adjourning/Mourning
CLINICIANS’ TIPS
• Take care with group participant selection
• Allow ample time to set up
• Allow ample time to debrief
• Practise with your co-leader
• Deal with process issues as they arise
• Be mindful of group dynamics
• Manage your own anxiety if content is not covered.
Groups with Parents
WHY DO CLINICAL WORK IN GROUPS?
• Normalizes the problem
• Credibility – often peers have more
• Peer support - inside and outside group
– Group cohesion best indicator of outcome
• Members can help others as well as be helped
• Clinician rewards – No, not money!
GROUP CBT DIFFERENT FROM
INDIVIDUAL CBT?
• Research evidence that Group CBT & Individual
CBT have equivalent outcomes
• Fundamental strategies & principles are the
same
• More co-therapists, more problem solvers
• Process issues are where the difference lies.
GROUPS WITH PARENTS
OF CHILDREN 0-12 YEARS OLD
• Programs that run Groups with Parents in
parallel with Groups for Children
• Programs that use Groups for Parents
PARENT GROUPS IN PARALLEL
CHILDHOOD ANXIETY, PTSD
• “involving parents in treatment does provide an
additional benefit, although the effects may be
small” (Cresswell, C., & Cartwright-Hatton, S., 2007. Family treatment of child anxiety:
Outcomes, limitations and future directions. Clinical Child and Family Psychology Review, 10, 232–
252).
• learn strategies that they are able to apply in
their own lives and to reflect upon the ways in
which they are parenting their anxious children
and whether or not these current strategies are
effective… a combined parent and child traumafocused CBT condition results in the best
outcomes for children (Cobham, V.E. et. al., 2012. Involving parents in
indicated early intervention for childhood PTSD following accidental injury. Clinical Child and Family
Psychology Review 15,345-363).
PARENT TRAINING PROGRAMS
BEHAVIOUR PROBLEMS, ADHD
• Essentially Behavioral approaches
• Triple P is local variant
– Highly organized, well promoted, researched, active in
training clinicians and para-professionals
• “reliable positive effects of Triple P—across all
settings, initial levels of problems and countries—
for child behavior problems, parenting behavior,
and parental well-being. There is also a strong
tendency for parents’ relationship quality to
improve…. Many of the present findings may
be relevant to other evidence-based
parenting programs.” Nowak, 2008. A comprehensive meta-analysis
of Triple P. Clinical Child and Family Psychology Review. 11, 114-144.
TOM’S RULES FOR GROUP THERAPISTS
• Groups not (just) useful for saving time/money.
They can get to places individual work can’t!
• Work hard in the group but hardest outside the
group (Boundary riding)
– Put most effort into planning, development and
recruitment of the group.
– Make sure colleagues (esp. Bosses) are onside.
– Liaise with referrers
– Attend to dropouts, no shows and cancellations
– Pre group interviews?
PLANNING DILEMMAS
•
Groups are for patients not for clinicians
– Unless they also need to be in a group
• Where are the referrals going to come from?
– your practice, colleagues, knowledgeable
referrers
• Do I need a co-therapist?
• Practical arrangements
– Venue, time of day, refreshments
DO I REALLY NEED TO BE IN A GROUP?
• Isn’t my child the problem not me?
• Why do we have to air our dirty linen in
front of others?
• I’m not really a group kind of person
• You are just trying to make more
money
THE GROUP IS HERE. NOW WHAT?
• Program is important
– Training, confidence, white coat effect.
• BUT even more important
– “A group is a group is a group”
• Get supervision
– Expert or peer.
I WANT TO GET ON WITH THE PROGRAM
BUT THIS PARENT JUST KEEPS BLOCKING
ME?
• Parent MAY have own Mental Health issues
– May need you help identifying an appropriate
treatment plan.
• Personality styles (Personality or Group
pressures?)
– Dominant, Silent, Argumentative, and…
• But this is where the clinical skill and experience
comes in. Use it!
TOM’S FINAL ADVICE
• Groups can be the most rewarding
part of clinical life… but also some of
the toughest.
• Have fun!
PRE-SCHOOL GROUPS
For children aged 3.5 - 6 years
WHAT’S DIFFERENT?
• Smaller number of participants
• Activity based
• Shorter group time or a break
• Possibly parental interaction
WHICH GROUP FOR WHOM?
• Are you considering a group for children
already on a ML waiting list?
• Are you considering a group for a particular
disorder & will gather potential participants
over time?
• Check the KidsMatter website for options.
POSSIBLE OUTCOMES
• No further intervention required
• Referral for specialised assessment
• Referral for further intervention
-child
-parent(s)
HOW TO INVOLVE PARENTS
• Pre-group selection interview
• Transporting their child to and from the group
• Information session (max 10-15 mins) at the end of
each group
• Consider holding an information session about half
way through the group
• Individual feedback sessions for each family post
group
DEVELOPMENTAL ISSUES
Delay in fine & gross motor skills
Delay in receptive & expressive language
Absence of imaginative play
Attachment concerns
Peer relationships
Some still at parallel play, others cooperative
play developed
• Cognitive delays
• Medical conditions
•
•
•
•
•
•
POTENTIAL DIFFICULTIES
• Separation issues
• Aggression between children
• Tantrums
GROUPS FOR CHILDREN
AGED 7-11 YEARS
WHICH GROUP FOR WHOM?
• Are you considering a group for children
already on a ML waiting list for this
intervention?
• Are you considering a group for a particular
disorder and will gather potential participants
over time?
• Check the KidsMatter website for options
WHICH GROUP?
• Interactive groups for children & their parents
are usually considered where there is a concern
about the relationship.
• Check the KidsMatter website for options.
GROUP SELECTION
• Number of participants
• Need to ensure a workable group
• Issue specific or a mix of issues?
• Age range
• Gender mix
• Exclusions
POSSIBLE OUTCOMES
• No further intervention required
• Referral for specialised assessment
• Referral for further intervention
-child
-parent(s)
HOW TO INVOLVE PARENTS
• Pre-group selection interview
• Transporting their child to and from the group
• Consider holding an information session about
half way through the group
• Individual feedback sessions for each family
post group.
POTENTIAL DIFFICULTIES
• Separating from parent
• Aggression between the children
• Absences from the group
INTERACTIVE GROUPS
Children and parents together
BENEFITS OF INTERACTIVE GROUPS
Opportunity for:
• Leaders to observe the parent/child relationship
• The parent and child to participate in enjoyable
activities
• Parents to practise new ways of relating to their
children
• Support from other parents
• Learning new techniques and being
coached/supported in implementation.
GROUP SELECTION
• Number of participants
• Need to ensure a workable group
• Issue specific or a mix of issues?
• Age range
• Gender mix
• Similar socio-economic status
POSSIBLE OUTCOMES
• No further intervention required
• Referral for specialised assessment
• Referral for further intervention
POTENTIAL DIFFICULTIES
• Conflict between the parents
• Conflict between parent and child requiring
leader support & intervention
• Non attendance
• Possible mental health concerns in the parent
QUESTIONS & ANSWERS
Panel Discussion
REMINDERS
•
Contact The ATAPS CMHS Clinical Support Service. Phone on
1800 031 185 or email clinicalsupport@psychology.org.au
•
Two more child mental health webinars are planned for 2013 and
a further series in 2014
•
A recording of the webinar will be available on the APS website
shortly. See
http://www.psychology.org.au/ATAPS/networking_CMHS/
•
Please complete the Exit Survey – your feedback is appreciated!