sound practice in action
Posted by Margit Pukonen on October 19, 2015 12:10 AM
Many administrators and clinicians think of group therapy as a means of increasing the number of children in service. This is true to a point but it will not increase numbers exponentially. There is a limit to the number of children a clinician can effectively treat at any one time due the planning and documentation requirements associated with service delivery. After many years of running speech and language therapy groups at The Speech and Stuttering Institute, we’ve come to the conclusion that the value and power of group therapy lies in the quality of service it offers.
Group therapy provides a very rich therapy environment and offers learning opportunities that are not present in individual therapy. Groups provide peer learning opportunities. Clinicians do not have to directly teach and reinforce all the skills a child may need to develop since the children learn by observing each other. Group activities also provide opportunities for children to practice new skills in more naturalistic conversational exchanges which support generalization into contexts outside the therapy room. An additional benefit is that children learn how to participate in a group setting. They develop skills such as maintaining a group focus of attention, taking and waiting for turns, responding to questions and comments, sharing information and asking questions. This experience will serve them well in school since most teaching occurs within groups.
Group therapy is a good intervention option when children have developed the behavioural and self regulation skills to wait for turns, delay gratification and follow adult directions. If these skills are not established, the clinician will spend more time supporting the child’s participation rather than addressing actual speech/language targets. Children in junior and senior kindergarten are typically ready for a group therapy approach. A group of two is an excellent starting point for clinicians who have not run groups before. Groups of three are ideal since there are enough children to create group dynamics yet children don’t have to wait too long for their turn. At this stage of development, children lose attention quickly if they have to listen and wait for any length of time. In terms of the child’s skill development, his/her therapy goals should be emerging and can be elicited through verbal or visual models or requests to imitate. Individual therapy is a more appropriate option when skills need to be established and the child requires consistent clinician support to elicit an appropriate response.
Clinicians may be intimidated at the thought of running groups because of concerns about behaviour management and/or the ability to meet each child’s individual needs within the group context. These challenges can be managed when clinicians understand two key concepts about group therapy: “the group” is a client and groups evolve.
Clinicians should view “the group” as one of their clients. For example, if there are three children in the group, “the group” is the fourth client and the clinician needs to plan for and support its functioning when planning and running therapy sessions. In fact, “the group” should be viewed as the primary client because when the group doesn’t function, it is challenging to meet the needs of the individual children.
An understanding of how groups evolve will provide clinicians with a set of strategies they can employ to support group development as well as an understanding of their role in facilitating the process. Children’s therapy groups undergo the stages of forming, storming, norming, performing just the same as adult groups (Tuckman, 1965). Children’s needs and abilities are different at each stage of the process so the clinician needs to provide the appropriate supports in order to guide the group to higher and more productive levels of group functioning.
At the forming stage, children are new to the group. They don’t know the others in the group, what to expect or what will be expected of them. The clinician’s role is to provide them with information about what will happen, when and how as well as what they are expected to do. This is achieved by providing a well-organized environment so the children know where to focus their attention, where to move and where to keep or find materials. Visual schedules help them understand and predict what will happen next and when the group session will end. Desired group behaviours or “rules” such as waiting for a turn, making transitions and positive peer interactions also need to be clearly explained, demonstrated and reinforced. Providing visual cues that can act as reminders of the target behaviours as well as reinforcing group members who demonstrate the behaviour facilitate the process.
Once children become more comfortable in the group they often start “storming” and push boundaries and challenge the clinician. This is when all of the structures and visual supports introduced in the forming stage become very helpful. The clinician’s role at this stage is to remind children of the rules and expectations or negotiate by referring to visuals and group rules (e.g. first we ….., then you can…..).
During norming, the children come to understand and accept the boundaries and expectations. As a proactive measure, clinicians continue to review rules, refer to visuals and reinforce desired behaviours.
The group is performing once children are managing their own behaviour fairly independently and the focus of the group shifts to working on specific speech-language goals within the group activities. These goals may have been introduced earlier but were often of secondary importance as the clinician focused on developing the group structure and processes.
It takes time for a group to reach the performing stage and it is natural for groups to move between storming, norming and performing within and across sessions. If the therapy block is too short, clinicians will spend most of the time guiding the group to the performing stage and then disband just as it reaches its maximum potential. Based on our experience with junior and senior kindergarten children, we recommend a ten to twelve week block at a minimum. It often takes at least 6 to 8 sessions to reach the performing stage and then children can focus their attention on practicing and generalizing individualized targets during weeks 8 to 12.
Groups are a rich and motivating intervention context for children. For clinicians, they are a more complex form of service provision because they require planning for several children as well as the group. By establishing a predictable group structure, routine and rules and guiding children through the process of learning how to participate and learn within a group, the potential of group therapy can be realized more consistently and successfully.
Reference: Tuckman, B. (1965). Developmental sequence in small groups. Psychological Bulletin 63 (6): 384-99.
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KAREN MACIVER LUX