Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
Research on Practice with Groups in Health Care Settings Irene E. Rutchick MSSS To cite this article: Irene E. Rutchick MSSS (1990) Research on Practice with Groups in Health Care Settings, Social Work in Health Care, 15:1, 97-114, DOI: 10.1300/J010v15n01_08 To link to this article: http://dx.doi.org/10.1300/J010v15n01_08
Published online: 26 Oct 2008.
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Research on Practice with Groups in Health Care Settings Irene E. Rutchick, MSSS
ABSTRACT. The theoretical underpinnings for group practice in
hcalth settings include theories pertaining to the individual, the small group, and systems. These theories rcmain largely untested due to attitudes of both the clinician and researcher, methodological problems related to the complexities of individual and group variables, the lack of a consistent common language, and limited availability of practical and sound empirical measures. Most of the literaturc is anecdotal. There are some descriptive and outcome studies but little research addresses the relationship of process to outcome. Suggestions are offered to begin bridging this gap.
Social work practicc and group intervention in health settings had separate beginnings in 1905 at Massachusetts General Hospital. Richard Cabot (1919), a physician, introduced the nonmedical activity of social work into the hospital because of his concern that due to many individual and family problems patients were unable to carry out medical treatment plans. He recruited Ida Cannon, who developed the first professional hospital social work departmcnt, to respond to the social aspects of illness by focusing on the needs of the individual patient. At the samc time, Joseph Pratt (1907), an internist, now widely considered the founder of group psychotherapy, initiated a group method. He provided educational lectures to enhance the treatment compliance of tuberculosis patients who were demoralized by their situation. As his classes progressed, he was impressed by the mutual sharing that took place among patients and Irene E. Rutchick is Associate Director, Social Sewice Department, Massachusetts General Hospital, Fruit Street, Boston, MA 02114. Social Work in Health Care, Vol. 15(1) 1990 O 1990 by The Haworth Press, Inc. All rights resewed. 97
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believed that supportive factors led to the successful treatment of a heretofore failed treatment population. Since those early years, thefe has been spotty but sustained interest, by a variety of health care professionals, in the use of groups to both "treat" the psychosomatic aspects of disease and to ameliorate the psychosocial stresses that accompany the life disruption of illness and its treatment (Lubin and Lubin, 1987). Recently this interest has burgeoned with the increase in the number of chronically ill patients, the growth in consumerism and concomitant increased attention to preventative approaches, and support for the belief that groups are a humanizing way to help individuals cope with "normal" life stresses. In recent years, social work has contributed a great deal to the growing body of knowledge in group practice. However, much of the available literature is descriptive or anecdotal, with virtually no research on outcome or process efficacy (Berkman et al., 1988; Rosenberg and Neill, 1982). In part, this is due to: (a) complex methodological problems involved in studying both therapeutic change and group processes; (b) the absence of consistent definitions of basic group constructs which could provide an organizing frame for differing treatment vocabularies and points of view; and (c) a lack of marriage of group theory (the exception being group curative factors) with theories that underly strategies for helping people cope. Recently this lack has been addressed by efforts to conceptualize group issues specific to health settings (Berkman et al., 1988; Carlton, 1986; Gitterman, 1982; Lonergan, 1982; Northen, 1983; Lurie and Shulman, 1983; Roback, 1984). For the most part, however, the development of theories for social work in health care and for group intervention have evolved as separately as they began and the lack of research in this area is not surprising. This paper examines the state of research on groups in health settings. Ideally, research and practice are mutually informative processes, one building on the other. Practice is based on theoretical formulations which are subject to empirical validation. Research findings enable fine tuning and modifications of theory which further informs practice. The paper begins with an overview of theory that serves as an underpinning for practice and research with groups. It continues with a discussion of methodological issues
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which help to explain why research in the field is limited, followed by a survey of current significant research findings. Finally, suggestions for beginning to bridge the gap between group practice and research arc offered.
THEORY The theoretical underpinnings for group practice in health settings fall into three areas: (1) theory pertaining to individual stress, coping, and adjustment, (2) small group theory, and (3) systems theory.
Theories on Individual Coping and Response to Stress While it is beyond thc scope of this paper to detail the many ways individual coping and response to stress are conceptualized, a few concepts that are particularly relevant to group practice are addressed below. Illness as a life crisis: Crisis theory begins with the assumption that individuals have a need to maintain physiological, psychological and social equilibrium. A crisis is defined as an "upset in a steady state" of the magnitude that renders habitual problem-solving mechanisms ineffective to restore balance (Caplan, 1964). This leads to a state of disorganization which is often accompanied by unpleasant feelings such as anxiety, fear, and guilt. Illness always represents an upset in physiological equilibrium and is frequently accompanied by social and psychological disequilibrium as well. I t represents a potential crisis for both the patient and the family. During a crisis, individuals are more willing to use others to learn new ways to cope. This openness makes group intervention a particularly potent form of crisis intervention. lllness as an nssault to selfesteem: Theories of human development and behavior offer differing pcrspectives on the formation and meaning of self esteem. Using the broadest definition, the term refers to one's sense of physical and psychological well being. It includes all aspccts of the self that are used to define an individual's sense of competence, self respect, and loveableness. Factors that
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contribute to the formation of self esteem are independent functioning and mastering abilities, degree of self acceptance, perceptions of how one is viewed by others and ego ideals. Illness, with its concommitant changes in physical status, appearance, or functional capabilities, often necessitates a revision of self image and disrupts one's sense of well being. Throughout the course of one's life, self esteem develops and is altered in an interpersonal context through relationships with significant others such as family, friends, and mentors. Group intervention, with its interpersonal focus, provides a natural environment for self esteem reparation (Lonergan, 1980a). Illness as disruption of roles and relationships: Illness affects the roles and relationships of both patients and families in several ways. Encounters with the health care system are disruptive to routine schedules and normal activities. Individuals must relate in new ways to multiple professional and technical strangers and, while hospitalized, they are physically separated from their usual sources of support and sustenance. In addition, patients and families are often plagued by fears of abandonment either through death or the withdrawal of support and contact. These can lead to major breakdowns in communication. For the patient, increased dependency is frequently accompanied by fears of alienating needed others, both professional and personal. Finally, families fear that they will add to the patient's burdens if they share their own troubles. Again, the group setting is particularly suited to repairing ruptured communication and enabling the discharge of disturbing feelings in a normalizing context. Small Group Theory
The predominant rationale for providing social work service through groups relates to the therapeutic forces or curative mechanisms available in groups (Yalom, 1975; Lonergan, 1980b). These are particularly useful to help mobilize individual coping strategies for dealing with crisis and damaged self esteem. They include:
Universalization: the shared understanding that one's experiences and feelings are not unique often diminishes feelings of isolation and alienation.
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Models for identification: both the successes and failures of others provides a yardstick for measuring one's own performance. Sharing of information: inclusion of both didactic instruction from "experts" as well as shared experiences and knowledge among members facilitates mastery. Emotional catharsis: shared painful or "unacceptable" expericnces and feelings that are accepted by others can be liberating and growth producing. Reality testing: feedback from others, as well as the displaccd "confrontation" provided by observing others cope, can provide an accurate perception of one's strengths and liabilities. Peer support: the provision of advice and understanding to others helps to enhance self esteem by permitting an individual to be in a giving as well as a receivinddependent role. Hope: thc opportunity to see the progress of others in a similar situation permits comparisons and opens avenues of optimism. Practice in communication: group norms and support for communicating without condemning and for listening can improve the quality of interpersonal interaction. While groups can serve as a powerful mode of helpful intervcntion, therapeutic forccs do not necessarily occur spontaneously. The potential for the emergence of destructive group norms and dynamics is also present. A major task for the group leadcr is to crcate a group environment which maximizes constructive group mechanisms and minimizes those that are destructive. To do so in a consistently effective manner requires knowledge of, and the ability to apply, group theory to practice. A few examples of relevant areas of group theory include: (1) boundary management, (2) stages of group development, and (3) "group as a whole" dynamics. Bounda~yManagement: Boundaries mark the outer limits of a system and in so doing dcfinc and regulate what is "inside" and what is "outside." This occurs in groups on many levels. Membership selection, meeting space, length and frequency of meetings,
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group purpose, behavioral expectations for members and leaders, and the degree to which communication is confidential are all examples of group boundaries. The definition of boundaries enables group members to know what to expect and thereby to monitor their own participation. This enables members to maintain control and makes the group safe (Rice and Rutan, 1981). Careful attention to the management of boundaries is important for the success of any group (Singer et al., 1975). In medical settings this is a particularly challenging task because of the boundary fluidity that is often characteristic of these groups. For example, people come late, leave early, and the group may have a different composition each session. In groups that have a "stable" membership, patients may be unexpectedly hospitalized or even die. A major task of the group leader is to continually define and interpret the outer limits of the group in order to establish a climate where curative mechanisms can emerge. This is accomplished through such techniques as establishing ritual introductions and closings, acknowledging late arrivals, early departures or missing members, and setting norms. The latter, which refers to expectations regarding "proper" behavior or what one ought to say or do, is managed in several ways. For example, explicit contracts outline the purpose of the group and spell out the type of interaction that will be most helpful. The leader also models desired behavior such as asking questions or noticing and accepting differences of opinions. By keeping group boundaries a primary area of focus, the leader is not the agent of support or change but rather creates the setting in which support or change can take place. Stages ofgroup development: Theories of group development describe the task and social-emotional behavior of group members as the group moves over time. These theories provide a framework for understanding the behavior of individuals and the interactions among members as the group moves from its beginning to its end (Garland et a]., 1965; Schwartz, 1971; Tuckman, 1965). They also provide a guide for leader interventions (Rutchick, 1984). For example, decisions regarding when to add new members, whether to redirect content within a session, and how to silence a monopolizer or involve a silent member, are interventions that are informed by the stage of the group. While theories differ in the number of stages
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and their associated developmental leadership tasks, all describe the following three stages (many of which have been combined and abbrcviatcd): Beginning Phases: (Forming, Affiliation, Tuning In) in which the primary tasks of group members are to say hello, to test the safcty of thc group, to explore commonalities and assert differences, and to gain some sense of "fit" between individual needs and those of the group. Working Phases: (Norming, Intimacy, Cohesion, Differentiation) which are characterized by high levels of personal sharing, genuine empathy, and confrontation. Members attcnd to the predominant reasons for joining the group.
Ending Phases: (Separation, Transition) in which the primary tasks of group members are to say good-bye, to reflect on what they gained through the group experience, and to anticipate the future. Group a s a Whole Dynamics: Whole group theorists conceptualize the group as a system and direct their attention and interventions to thc group rathcr than to the individuals within it. Individual behavior is understood as reflecting a group issue or serving a group purpose (Rioch, 1970; Whittaker, 1987). While few clinicians would advocate that a "group as a whole" framework alone is sufficient for practice, these theories offer an understanding of, and a way to intervene in, group problems that are difficult to resolve by focusing solely on the individual group member (Bogdanoff and Elbaum, 1978). The group developmental issues described above are examples of whole group dynamics. Other examples include scnpegoating, in which an individual is targeted (usually because of his or her offending presentation) to receive the displaced aggression of othcr group members, and thegroup spokesperson, the individual who raises a "hot" (usually startling or offensive) issue that seems out of sync with othcr group mcmbcrs. In both examples, intervention on the individual level alone would isolate the "offending" group member and contribute to an unsafe group climate. Inclusion of the whole group values the deviant's perspective and
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affords other participants the opportunity to acknowledge thoughts and feelings that are projected or seem too risky to express.
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Systems Theory Systems theories offer a useful way to conceptualize the organizational issues that are omnipresent in establishing and leading groups in health settings. A system can be defined as a set of elements or activities in dynamic interaction (Von Bertalanffy, 1968). Each component is influenced by suprasystems and subsystems. For example, the development of a support group within a hospital is influenced by the clinic or unit of which it is a part as well as the members who comprise it. What distinguishes a system from a collection of unrelated activities is the regulation of all components into an integrated whole that relates process to output. In the hospital clinic all subsystems (e.g., laboratory work, physical examination and treatment, family support group) must be integrated to produce the same general outcome, that of effective patient care. The tasks of regulating these subsystems would often be divided between the clinic director and the management staff within the hospital suprasystem. The success or failure of a group program in a health setting is dependent upon understanding the connections among subsystems and paying careful attention to organizational hierarchies and administrative details (Gitterman, 1982). These include administrative and collegial sanction and support as well as resources for space, staffing and recruitment. The group leader must build collaborative relationships that support the overall treatment program already being implemented by others. METHODOLOGICAL ISSUES
The theoretical underpinnings upon which most group intervention in health care is based remain largely untested. This gap between research and practice reflects the current state of scientific inquiry in both social group work and other fields of clinical group practice. In a review of literature from 1975-1983, Feldman (1986) found that of the 302 group work articles, only 29 contributed to the
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knowledge base through research. Furthermore, only a few utilized statistical tests, control groups, or baseline data. Indeed, most group research has been conducted by social scientists who have studied task or nonpatient groups where experimental variables can be liniited and controlled more easily than in the clinical setting. The paucity of group practice research is related to several factors, some of which are methodological and others bascd on attitudes of both the clinician and researcher, each of whom hold negative views toward the other regarding research ventures. In an informal survey of group therapists about the impact of research on practices, Dies (1983) reported the following: many clinicians found research lacking in clinical relevance and of poor quality (e.g., small samples, "homemade" instruments of questionable validity), inadequately communicated (e.g., written in technical language that is difficult to understand, published in journals that clinicians do not read), and intrusive and disruptive to treatment. The last concern is compounded in medical settings where practitioners may identify with their patients' experience of trauma and do not want to "burden" them further. On the other side, researchers often find clinicians too tied to their pcrsonal approach, threatened by potential negative findings, and "unsystcmatic and overly speculative" (Dies, 1983, p. 7). This mutual suspicion precludes the kind of collaborztion rcquired for successful clinical research. On the methodological level, there are a number of problems in initiating research on group process in the health setting. First there is the problem of small sample size. Interactive, therapeutic groups are small by design. Numbers of groups are limited by the amount of indirect time expended in pre and post group activities, for example, obtaining institutional support and resources, member recruitment, providing feedback to team members not directly involved in the group, and collaborative planning and post-group processing with co-leaders. It is also difficult to increase the sample size by studying groups of varying populations or across scttings because the goals and structure of most health related groups are disease and setting specific and the training and expertise of leaders is variable. As mentioned earlier, there are no consistent definitions of terms. Clinicians using the same terminology (e.g., "support group") may be talking about quite different entities in practice.
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Scientific research is also confounded by the complexities of group processes and therapeutic change which makes it difficult to control variables or analyze variance, particularly when sample sizes are small. In the clinical setting, complicating variables include individual characteristics of group members such as preexisting coping skills and personality traits, pre-group expectations and motivation, prior experience with illness, current experience with health care providers, phase of illness, and extent of existing social support. These factors all contribute to an individual's unique response to a group situation as well as histher capacity to adapt to change. There is also some indication that individuals with certain kinds of illness' respond differentially to types or methods of psychosocial intervention (Karasu, 1979). Other factors inhibiting research include leadership characteristics such as relationship qualities and level of expertise as well as group variables such as boundary determinants and process. Boundaries include the overall purpose or type of group (e.g., education, support, behavioral change); whether a group population is homogeneous or heterogeneous and along what lines (e.g., illness, age, sex, patient andlor family mix); the structure of the group, including how members were recruited and prepared, the length and frequency of meetings, and whether the group is open or closed. Perhaps, the most complex and difficult to measure and control are group process variables, that is, the characteristics that define and describe the interactions within a group. These aspects are considered necessary but not sufficient to maximize the positive benefits of the group and include such ill-defined concepts as cohesion, norms, group climate, role relationships and developmental stage. in all^, group practice research is hampered by the limited availability of practical and sound empirical measures. While outcome measures have been used in a variety of scientific studies to assess the relationship between clinical interventions and changes in patient functioning, group process measures are not well developed. A useful collection of outcome measures is contained in the Core Battery, a self assessment kit designed for the practitioner's use (Cochk, 1983). The kit contains self report instruments for patients, leaders, and significant others, as well as practical advice about overcoming resistance to research and to determine the significance of change. Included in the Core Battery are the following:
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Self Repor? Symptom Inventory (Derogatis, 1977) provides
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scores for nine symptoms (e.g., depression, anxiety) plus summary indices.
Social Adjustment Scale (Weissman and Bothwell, 1976) focuses on adjustment to such areas as work, family, leisure; can be completed by patients or significant others. Emotional Profile Index (Plutchik, 1980) provides scores on eight personality dimensions (e.g., trustful, timid, dcpressed) and is geared toward the normal personality. Target goals (Kiresuk and Sherman, 1968) three pre-group treatment goals arc listed and then rated on a 7 point goal attainment scale post group or at intervals during the group; can be used by patients, leaders, or significant others. Group proccss measures utilize either external or internal instruments. External raters observe the group directly or rate audiotvideo recordings of group sessions. Most external measures are cumbersome, costly, and time-consuming to implement. For this reason and because group researchers value the "phenomenological set" (Lieberman, 1983, p. 193), self report rating scales are used frequcntly in clinical research. These instruments measure a specific group construct (e.g., change mechanisms, norms) rather than the actual interaction being studied. Two examples are the Group Climate Questionnairc (GCQ) and the critical-incidents approach (MacKenzie, 1983). The short form, GCQ-S, is scored on thrcc scales (engaged, avoiding, conflict) and is administered each session. It is frequently paircd with a "critical incident" rcport in which group membcrs record their perception of helpful therapeutic events.
CURRENT FINDINGS Given the methodological problems discussed above, research in thc area of group practice in health care is in the infancy stage. The beginnings include attempts to classify descriptive and anecdotal literature into important variables that lend themselves to the development of hypotheses which can be empirically tested (Roscnberg and Neill, 1982; Northen, 1983; Schopler and Galinsky, 1984;
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Berkman et al., 1988). A further development includes descriptive studies which examine in more detail some of the relationships between identified variables. Two studies by Galkinsky and Schopler (1985, 1987) are examples. Although their work is not specific to health care, their studies of "Patterns of Entry and Exit in OpenEnded Groups" and of "Practitioners Views of Assets and Liabilities in Open-Ended Groups" are pertinent to the field and include data from practitioners in health care settings. Studies of self-help groups represent another area in which findings are of interest to social work practice. Examples include studies of leadership patterns (Yoak and Chessler, 1985), links between change mechanisms and types of benefit (Lieberman and Borman, 1979), and an examination of the relationship of member and group characteristics to the perceived value of the group (Chesney et al., in press). Finally, there are a few studies which use experimental design. Subramanian studied the effect of a multimethod group approach with chronic pain patients on physical and psychosocial dysfunction and negative mood states (Subramanian and Rose, 1985). She found that treatment subjects improved significantly on both measures. This study was part of a comprehensive research program (Rose et al., 1986; Rose, 1986), which was tailored to the rigors of experimental design. Ferlic et al. (1979) compared the effect of a structured educational and psychological support program for newly diagnosed advanced cancer patients to a control group and reported significant improvement in patient perception and self concept in the treatment group. Other studies of homogeneous disease groups (e.g., Cancer, [Spiegel et al., 1981; Spiegel and Bloom, 19831; Myocardial Infarction, [Rahe et al., 1979; Horlick et al., 1984; Stern et al., 39831 and Diabetes [White et al., 19861) measured outcome by monitoring physiologic signs and symptoms and/ or using psychosocial measures. For the most part, the use of group intervention did not yield significant results on physiologic measures but it did elicit impressive results on psychosocial indices. Research on the relationship of process to outcome is extremely limited. While some studies (Roskies, 1978; Walls and Meyers, 1984-85) did attempt to compare the effects of different types of groups (e.g., education, support, behavioral or "traditional" therapy), these groups were poorly defined and lacked process mea-
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surcmcnts. Other studies (Stcrn et al., 1984; Lieberman and Borman, 1979) have explored the relationship between outcome and mechanisms of change but these were static concepts which did not examine interactional processes. Only onc study (Lieberman, 1989) of spousal bereavement sclf hclp groups examined the linkage behvccn norms and patient outcome. Although the generalizability of the results needs to be tested, this study represents an important step in process research. While empirical research in health related group practice is limitcd, rcsearch findings, in general, support group intervention as an effective method of service delivery. Toscland and Siporin (1986) in a review of 32 classical experimental design studies comparing individual and group treatment, found that in 75 pcrcent of the studics, group treatment was as effective as individual treatment and more effective in 25 percent. What this review and other outcome studies have not addressed is the qucstion of who benefits under what conditions.
FUTURE DIRECTIONS While we are a long way from applying rigorous experimental research to the investigation of basic qucstions that lead to a sophisticated understanding of group practice, it is incumbent upon both researchers and clinicians to begin bridging the gap that exists between research and practice. With greater and greater mandates for accountability from policy-makers, third party payors and consumers, we need to be systematic in our efforts to pull together the rich body of dcscriptive clinical data into empirical documentation. One way to begin building this bridge is to standardize definitions and dcscriptions of key group practice concepts which will make comparisons of reports possible. The recent efforts to classify the body of descriptive group literature need further refinement as well as definitions that arc agrccd upon by both researchers and practitioners. A model for defining practice was created for the Hospital Social Work Information System in a monograph (Coulton et al., 1988) which describes standard terminology, definitions and data elements for hospital social work practice. The major purpose for the development of this common language was to enhance pro-
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fessional accountability by enabling social workers to define, understand and compare practice. Another area that is receiving increased attention is the use of the single subject design for evaluative research. This type of research is particularly suited for use with the repeated, short-term groups that often characterizes practice in health settings because it provides clinicians with practical feedback which is both immediate and generalizeable to similar groups. This method makes use of systematic observation and instrumentation to study a group pre, post, and during treatment for possible relationships between process variables and outcome. A number of instruments described in the CORE battery provide useful process and outcome measures and are easy to integrate into practice. Such research methodology follows the practice model of hypothesis formulation, intervention, and validation which should make its application acceptable to clinicians. In addition, as clinicians gain experience with instrumentation and learn that it does not have to be burdensome or intrusive, and can in fact be helpful, they could become more open to formal scientific research. While clinicians need to be more open to integrating research methodology into their practice, researchers, in turn, need to expend efforts in areas of concern to clinicians and those to whom clinicians are accountable. They must focus on implications for practice, spend time understanding issues of clinicians, and help clinicians learn to exolain instrumentation to oatients and imolement the research. ~ i i a l l there ~ , is the need td publish such c h i cally relevant research articles in clinical journals. REFERENCES Berkman, B., Bonander, E., Kemler, B., Marcus, L., Rubinger, M., Rutchick, I. and Silverman, P. Social Work in Health Care: A Review of the Literature, Chicago: American Hospital Association, 1988, 21-32. Bogdanofi, M. and Elbaum, P.L. Role lock: Dealing with monopolizers, mistrusters, isolates, helpful Hannahs, and other assorted characters in group psychotherapy. International Journal of Group Psychotherapy, 1978,28 ( 2 ) : 247-
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Cabot, R. Social Work: Essays on rhe Meeting-Ground of Docror and Social Worker. Boston: Houghton Mifflin Co., 1919. Caplan, G . Principles of Preventive Psychiatry. New York: Basic Books, 1964. Carlton, T.O. Group process and group work in health social work practice. Social Work wirh Groups, 1986, 9 (2), 5-20. Chesney, B.K., Rounds, K.A., and Cheder, M.A. Support for parents of children with cancer: the value of self-help groups. Social Work wirh Groups, in press. Cochi, E. Changc mcasurcs in clinical practice in group psychotherapy. In R.R. Dies and K.R. MacKenzie (Eds.) Advances in Group Psychotherapy: Integrating Research and Practice, New York: International Universities Press, 1983. Coulton, C., Friedrnan, A., and Keller, S. A Minimum Data Set for Hospiral Social Work. HSWIS monograph series, report no. 1. Society for Hospital Social Work Directors, American Hospital Association, Chicago, IL, 1988. Dies, R.R. Bridging the gap between research and practice in group psychotherapy. In R.R. Dies and K.R. MacKenzie (Eds)Advancesin Group Psychotherapy: lntegraring Research arld Practice, New York: International Universities Prcss, 1983. Derogatis. L.R. The SCL-90-R: Administration, Scoring and Procedures Manual, I. Baltimore: Clinical Psychometric Research, 1977. Feldman, R.A. Group work knowledge and research: a two-decade comparison. Social Work witl~Groups, 1986, 9 (3): 7-14. Ferlic, M., Goldman, A. and Kennedy. B.J. Group counselling in adult patients with advanced cancer. Cancer, 1979, 43: 760-76. Galinsky, M.J. and Schopler, J.H. Patterns of entry and exit in open-ended groups. Social Work wirh Groups, 1985, 67-79. Galinsky, M.J. and Schopler, J.H. Practitioners' views of assets and liabilities of open-ended groups. In J. Lassner, K. Powell, and E. Finnegan (Eds.) Social Group Work: Competence and Values in Practice, Ncw York: The Haworth Press, 1987, 83-98. Garland, J.A., Jones, H.A. and Kolodny, R. A model for stages of development in social work groups. In S. Bernstein, (Ed.) Explorations in Croup Work: Essaw in Theory and Practice. Boston: Milford House, Inc., 1965, 17-71, Gittcrman, A. Thc usc of groups in health settings. In A. Lurie, G. Rosenberg and S. Pinsky (Eds.) Sociol Work Wirh Groups in Healrh Setting, New York: Prodist, 1982, 6-24. Horlick, L., Cameron, R., Firor, W., Bhalcrao, U. and Balkan. The cffecrs of education and group discussion in the post myocardial infarction patient. Journal of Psychosontatic Research, 1984. 28 ( 6 ) :485-492. Karasu, T.B. Psychotherapy of the medically ill. American Journal oJPsychiatry, 1979, 136 (I): 1-11. Kiresuk, T.J. and Sherman, R.E. Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Contnruniry Mental Heolrk Journal, 1968, 4 , 443-453.
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Lieberman, M.A. Group properties and outcomes: A study of group norms on self help groups for widows and widowers. International Journal of Croup Psychotherapy, l989,39 (2): 191-208. Lieberman, M.A. Comparative analyses of change mechanisms in groups. In R.R. Dies and K.R. MacKenzie (Eds.) Advances in Group Psychotherapy: Integrating Research and Practice, New York: International Universities Press, Inc., 1983. Lieberman, M.A. and Borman, L.D. Self-Help Croups for Coping with Crisis. San Francisco: Jossey-Bass, 1979. Lonergan, E.C. Group intervention for medical patient- a treatment for damaged self-esteem. Group, 1980a, 4 (2):36-45. Lonergan, E.C. Humanizing the hospital experience: Report of a group program for medical patients. Health and Social Work, 1980b, 5 (4): 53-63. Lonergan, E.C. Croup Intervention: How to Begin and Maintain Groups in Medical and Psychiatric Settings. New York: Jason Aronson, Inc., 1982. Lubin, Bernard and Lubin, Alice W. Comprehensive Indev of Croup Psychotherapy Writings. Madison: International Universities Press, Inc., 1987. Lurie, A. and Shulman, L. The professional connection with self help groups in health care settings. Social Work in Health Care, 1983, 8 (4):69-78. MacKenzie, K.R. The clinical application of the group climate measure. In R.R. Dies and K.R. MacKenzie (Eds.) Advances in Croup Psychotherapy: Integrating Reseanh and Practice, New York: lnternational Universities Press, Inc., 1983. Northen, H. Social work with groups in health settings: Promises and problems. Social Work in Health Care, 1983, 8 (3): 107-121. Plutchik, R. Emotions: A Psychoevoluntionay Synthesis. New York: Harper and Row, 1980. Pratt, J.H. The class method of treating consumption in the homes of the poor. Journal of the American Medical Association, 1907, 49: 755-759. Rahe, R.H., Ward, H.W., and Hayes, V. Brief group therapy in myocardial infarction rehabilitation: Three to four year follow-up of a controlled trial. Psychosomatic Medicine, 1979, 41 (3): 229-242. Rice, C.A. and Rutan, J.S. Boundary maintenance in inpatient therapy groups. lnternational Journal of Group Psychotherapy, 1981, 31 (3): 3 11-328. Rioch, M.J.The work of Wilfred Bion on groups. Psychiatry, 1970, 33: 56-66. Roback, H.B. (Ed.) Helping Patients and Their Families Cope Wirh Medical Problem. San Francisco: Jossey-Bass, Inc., 1984. Rose, S.D., Tallant, S.H., Tolman, R. and Subramanian, K. A multimelhod group approach: Program development research. Social Work With Croups, 1986, 9 (3): 71-88. Rose, S.D. Fourteen practice research dissertafions and how they grew. Presented at the Annual conference of the Group for Advancemenl of Doctoral Education in Social Work, New York, October 10, 1986. Rosenberg, G. and Neill, G. Group services and medical illness a review of the
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literature- 1964-1978. In A. Lurie, G. Rosenberg, and S. Pinsky (Eds.) Social Work With Groups in Healrh Serrings, New York: Prodist, 1982, 39-53. Roskics, E., Spevack, M.,Surkis, A,, Cohen, C. and Gilman, S. Changing the coronary-prone (Type A) behavior pattern in a nonclinical population. Journal of Behavioral Medicine, 1978, 1 (2): 201-216. Rutchick, I. The Single Session Group in Medical Settings: Group Development, Curative Factors and Leadership Tasks. Presented at the Northeastern Society for Group Psychotherapy Annual Conference, Wellesley, Massachusetts, June 1984. Schopler, J.H. and Galinsky, M.J. Meeting practice needs: conceptualizing the open-ended group. Social Work Wilh Groups, 1984, 7 (2): 3-21. Schwark, W. On the use of groups in social work practice. In W . Schwartz and S.R. Zalba (Eds.) The Practice of Group Work, New York: Columbia University Press, 1971, 13-18. Singer, D.L.,Astrachan, B.L., Gould, L.J. and Klein, E.B. Boundary managcment in psychological work with groups. The Journal of Applied Behavioral Science, 1973, 11 (2): 137-176. Spiegel, D., Bloom, J.R. and Yalom, I. Group support for patients with metastatic cancer: A randomized prospective outcome study. Archives of General Psychiarr)., 1981, 38, 527-533. Spiegel, D. and Bloom, J.R. Group therapy and hypnosis rcducc metastatic breast carcinoma pain. Psycltosomaric Medicine, 1983, 45 (4): 333-339. Stcrn, M.J., Gorman, P.A. and Kaslow, L. The group counselling v. exercise therapy study: a controlled intervention with subjects following myocardial infarction. Archives of I n t m a l Medicine, 1983, 143: 1719-1725. Stern, M.J., Flionis, E., Kaslow, L. Group process expectations and outcome with post myocardial infarction patients. General Hospifal Psychiafry, 1984,6 (2): 101-108. Subramanian, K. and Rose, S.D. Group treatment for the management of chronic pain. Social Work Research and Abstracrs, Research Note 21, Fall 1985, 2930. Toseland, R.W. and Siporin, M.When to recommend group Ireatment: a review of the clinical and the research literature. ln~ernationalJournal of Group Psychorherapy, 1986, 36 (2): 171-202. Tuckman, B.W. Developmental sequence of small groups. Psychological Bullefin, 1965, 63 (6): 384-399. Von Bertalanffy, L. General System Theory, New York: Braziller, 1968. Walls, N. and Meyers, A.W. Outcome in group treatments for bereavement: Experimental results and recommendations for clinical practice. Infernational Journal of Mental Healfh, 1984-85, 13 (3-4): 126-127. Weissman, M.M. and Bothwell, S. Assessment of social adjustment by patient self report. Archives of General Psychiarry, 1976, 33: 11 11-1115. Whitaker, D.S. Connections between group analytic and group focal conflict per-
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spective. International Journal of Group Psychotherap, 1987, 37 (2): 20121 R White, N., Carnahan, J., Nugent, C.A.. Iwaoka, T.and Dodson, M.A. Management o f obese patients with diabetes mellitus: Comparison o f advice education with group management. Diabetes Care, 1986,9 (5): 490-496. Yalom, I.D.The Theoty and Practice of Group Psychotherapy. New York: Basic Books, 1975. Yoak, M. and Cheder, M. Alternative professional roles in health care delivery: Leadership patterns in self-help groups. Journal of Applied Behavioral Science, 1985,ZI: 427-444.
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Research on Practice with Groups in Health Care Settings Irene E. Rutchick MSSS To cite this article: Irene E. Rutchick MSSS (1990) Research on Practice with Groups in Health Care Settings, Social Work in Health Care, 15:1, 97-114, DOI: 10.1300/J010v15n01_08 To link to this article: http://dx.doi.org/10.1300/J010v15n01_08
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Research on Practice with Groups in Health Care Settings Irene E. Rutchick, MSSS
ABSTRACT. The theoretical underpinnings for group practice in
hcalth settings include theories pertaining to the individual, the small group, and systems. These theories rcmain largely untested due to attitudes of both the clinician and researcher, methodological problems related to the complexities of individual and group variables, the lack of a consistent common language, and limited availability of practical and sound empirical measures. Most of the literaturc is anecdotal. There are some descriptive and outcome studies but little research addresses the relationship of process to outcome. Suggestions are offered to begin bridging this gap.
Social work practicc and group intervention in health settings had separate beginnings in 1905 at Massachusetts General Hospital. Richard Cabot (1919), a physician, introduced the nonmedical activity of social work into the hospital because of his concern that due to many individual and family problems patients were unable to carry out medical treatment plans. He recruited Ida Cannon, who developed the first professional hospital social work departmcnt, to respond to the social aspects of illness by focusing on the needs of the individual patient. At the samc time, Joseph Pratt (1907), an internist, now widely considered the founder of group psychotherapy, initiated a group method. He provided educational lectures to enhance the treatment compliance of tuberculosis patients who were demoralized by their situation. As his classes progressed, he was impressed by the mutual sharing that took place among patients and Irene E. Rutchick is Associate Director, Social Sewice Department, Massachusetts General Hospital, Fruit Street, Boston, MA 02114. Social Work in Health Care, Vol. 15(1) 1990 O 1990 by The Haworth Press, Inc. All rights resewed. 97
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believed that supportive factors led to the successful treatment of a heretofore failed treatment population. Since those early years, thefe has been spotty but sustained interest, by a variety of health care professionals, in the use of groups to both "treat" the psychosomatic aspects of disease and to ameliorate the psychosocial stresses that accompany the life disruption of illness and its treatment (Lubin and Lubin, 1987). Recently this interest has burgeoned with the increase in the number of chronically ill patients, the growth in consumerism and concomitant increased attention to preventative approaches, and support for the belief that groups are a humanizing way to help individuals cope with "normal" life stresses. In recent years, social work has contributed a great deal to the growing body of knowledge in group practice. However, much of the available literature is descriptive or anecdotal, with virtually no research on outcome or process efficacy (Berkman et al., 1988; Rosenberg and Neill, 1982). In part, this is due to: (a) complex methodological problems involved in studying both therapeutic change and group processes; (b) the absence of consistent definitions of basic group constructs which could provide an organizing frame for differing treatment vocabularies and points of view; and (c) a lack of marriage of group theory (the exception being group curative factors) with theories that underly strategies for helping people cope. Recently this lack has been addressed by efforts to conceptualize group issues specific to health settings (Berkman et al., 1988; Carlton, 1986; Gitterman, 1982; Lonergan, 1982; Northen, 1983; Lurie and Shulman, 1983; Roback, 1984). For the most part, however, the development of theories for social work in health care and for group intervention have evolved as separately as they began and the lack of research in this area is not surprising. This paper examines the state of research on groups in health settings. Ideally, research and practice are mutually informative processes, one building on the other. Practice is based on theoretical formulations which are subject to empirical validation. Research findings enable fine tuning and modifications of theory which further informs practice. The paper begins with an overview of theory that serves as an underpinning for practice and research with groups. It continues with a discussion of methodological issues
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which help to explain why research in the field is limited, followed by a survey of current significant research findings. Finally, suggestions for beginning to bridge the gap between group practice and research arc offered.
THEORY The theoretical underpinnings for group practice in health settings fall into three areas: (1) theory pertaining to individual stress, coping, and adjustment, (2) small group theory, and (3) systems theory.
Theories on Individual Coping and Response to Stress While it is beyond thc scope of this paper to detail the many ways individual coping and response to stress are conceptualized, a few concepts that are particularly relevant to group practice are addressed below. Illness as a life crisis: Crisis theory begins with the assumption that individuals have a need to maintain physiological, psychological and social equilibrium. A crisis is defined as an "upset in a steady state" of the magnitude that renders habitual problem-solving mechanisms ineffective to restore balance (Caplan, 1964). This leads to a state of disorganization which is often accompanied by unpleasant feelings such as anxiety, fear, and guilt. Illness always represents an upset in physiological equilibrium and is frequently accompanied by social and psychological disequilibrium as well. I t represents a potential crisis for both the patient and the family. During a crisis, individuals are more willing to use others to learn new ways to cope. This openness makes group intervention a particularly potent form of crisis intervention. lllness as an nssault to selfesteem: Theories of human development and behavior offer differing pcrspectives on the formation and meaning of self esteem. Using the broadest definition, the term refers to one's sense of physical and psychological well being. It includes all aspccts of the self that are used to define an individual's sense of competence, self respect, and loveableness. Factors that
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contribute to the formation of self esteem are independent functioning and mastering abilities, degree of self acceptance, perceptions of how one is viewed by others and ego ideals. Illness, with its concommitant changes in physical status, appearance, or functional capabilities, often necessitates a revision of self image and disrupts one's sense of well being. Throughout the course of one's life, self esteem develops and is altered in an interpersonal context through relationships with significant others such as family, friends, and mentors. Group intervention, with its interpersonal focus, provides a natural environment for self esteem reparation (Lonergan, 1980a). Illness as disruption of roles and relationships: Illness affects the roles and relationships of both patients and families in several ways. Encounters with the health care system are disruptive to routine schedules and normal activities. Individuals must relate in new ways to multiple professional and technical strangers and, while hospitalized, they are physically separated from their usual sources of support and sustenance. In addition, patients and families are often plagued by fears of abandonment either through death or the withdrawal of support and contact. These can lead to major breakdowns in communication. For the patient, increased dependency is frequently accompanied by fears of alienating needed others, both professional and personal. Finally, families fear that they will add to the patient's burdens if they share their own troubles. Again, the group setting is particularly suited to repairing ruptured communication and enabling the discharge of disturbing feelings in a normalizing context. Small Group Theory
The predominant rationale for providing social work service through groups relates to the therapeutic forces or curative mechanisms available in groups (Yalom, 1975; Lonergan, 1980b). These are particularly useful to help mobilize individual coping strategies for dealing with crisis and damaged self esteem. They include:
Universalization: the shared understanding that one's experiences and feelings are not unique often diminishes feelings of isolation and alienation.
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Models for identification: both the successes and failures of others provides a yardstick for measuring one's own performance. Sharing of information: inclusion of both didactic instruction from "experts" as well as shared experiences and knowledge among members facilitates mastery. Emotional catharsis: shared painful or "unacceptable" expericnces and feelings that are accepted by others can be liberating and growth producing. Reality testing: feedback from others, as well as the displaccd "confrontation" provided by observing others cope, can provide an accurate perception of one's strengths and liabilities. Peer support: the provision of advice and understanding to others helps to enhance self esteem by permitting an individual to be in a giving as well as a receivinddependent role. Hope: thc opportunity to see the progress of others in a similar situation permits comparisons and opens avenues of optimism. Practice in communication: group norms and support for communicating without condemning and for listening can improve the quality of interpersonal interaction. While groups can serve as a powerful mode of helpful intervcntion, therapeutic forccs do not necessarily occur spontaneously. The potential for the emergence of destructive group norms and dynamics is also present. A major task for the group leadcr is to crcate a group environment which maximizes constructive group mechanisms and minimizes those that are destructive. To do so in a consistently effective manner requires knowledge of, and the ability to apply, group theory to practice. A few examples of relevant areas of group theory include: (1) boundary management, (2) stages of group development, and (3) "group as a whole" dynamics. Bounda~yManagement: Boundaries mark the outer limits of a system and in so doing dcfinc and regulate what is "inside" and what is "outside." This occurs in groups on many levels. Membership selection, meeting space, length and frequency of meetings,
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group purpose, behavioral expectations for members and leaders, and the degree to which communication is confidential are all examples of group boundaries. The definition of boundaries enables group members to know what to expect and thereby to monitor their own participation. This enables members to maintain control and makes the group safe (Rice and Rutan, 1981). Careful attention to the management of boundaries is important for the success of any group (Singer et al., 1975). In medical settings this is a particularly challenging task because of the boundary fluidity that is often characteristic of these groups. For example, people come late, leave early, and the group may have a different composition each session. In groups that have a "stable" membership, patients may be unexpectedly hospitalized or even die. A major task of the group leader is to continually define and interpret the outer limits of the group in order to establish a climate where curative mechanisms can emerge. This is accomplished through such techniques as establishing ritual introductions and closings, acknowledging late arrivals, early departures or missing members, and setting norms. The latter, which refers to expectations regarding "proper" behavior or what one ought to say or do, is managed in several ways. For example, explicit contracts outline the purpose of the group and spell out the type of interaction that will be most helpful. The leader also models desired behavior such as asking questions or noticing and accepting differences of opinions. By keeping group boundaries a primary area of focus, the leader is not the agent of support or change but rather creates the setting in which support or change can take place. Stages ofgroup development: Theories of group development describe the task and social-emotional behavior of group members as the group moves over time. These theories provide a framework for understanding the behavior of individuals and the interactions among members as the group moves from its beginning to its end (Garland et a]., 1965; Schwartz, 1971; Tuckman, 1965). They also provide a guide for leader interventions (Rutchick, 1984). For example, decisions regarding when to add new members, whether to redirect content within a session, and how to silence a monopolizer or involve a silent member, are interventions that are informed by the stage of the group. While theories differ in the number of stages
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and their associated developmental leadership tasks, all describe the following three stages (many of which have been combined and abbrcviatcd): Beginning Phases: (Forming, Affiliation, Tuning In) in which the primary tasks of group members are to say hello, to test the safcty of thc group, to explore commonalities and assert differences, and to gain some sense of "fit" between individual needs and those of the group. Working Phases: (Norming, Intimacy, Cohesion, Differentiation) which are characterized by high levels of personal sharing, genuine empathy, and confrontation. Members attcnd to the predominant reasons for joining the group.
Ending Phases: (Separation, Transition) in which the primary tasks of group members are to say good-bye, to reflect on what they gained through the group experience, and to anticipate the future. Group a s a Whole Dynamics: Whole group theorists conceptualize the group as a system and direct their attention and interventions to thc group rathcr than to the individuals within it. Individual behavior is understood as reflecting a group issue or serving a group purpose (Rioch, 1970; Whittaker, 1987). While few clinicians would advocate that a "group as a whole" framework alone is sufficient for practice, these theories offer an understanding of, and a way to intervene in, group problems that are difficult to resolve by focusing solely on the individual group member (Bogdanoff and Elbaum, 1978). The group developmental issues described above are examples of whole group dynamics. Other examples include scnpegoating, in which an individual is targeted (usually because of his or her offending presentation) to receive the displaced aggression of othcr group members, and thegroup spokesperson, the individual who raises a "hot" (usually startling or offensive) issue that seems out of sync with othcr group mcmbcrs. In both examples, intervention on the individual level alone would isolate the "offending" group member and contribute to an unsafe group climate. Inclusion of the whole group values the deviant's perspective and
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affords other participants the opportunity to acknowledge thoughts and feelings that are projected or seem too risky to express.
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Systems Theory Systems theories offer a useful way to conceptualize the organizational issues that are omnipresent in establishing and leading groups in health settings. A system can be defined as a set of elements or activities in dynamic interaction (Von Bertalanffy, 1968). Each component is influenced by suprasystems and subsystems. For example, the development of a support group within a hospital is influenced by the clinic or unit of which it is a part as well as the members who comprise it. What distinguishes a system from a collection of unrelated activities is the regulation of all components into an integrated whole that relates process to output. In the hospital clinic all subsystems (e.g., laboratory work, physical examination and treatment, family support group) must be integrated to produce the same general outcome, that of effective patient care. The tasks of regulating these subsystems would often be divided between the clinic director and the management staff within the hospital suprasystem. The success or failure of a group program in a health setting is dependent upon understanding the connections among subsystems and paying careful attention to organizational hierarchies and administrative details (Gitterman, 1982). These include administrative and collegial sanction and support as well as resources for space, staffing and recruitment. The group leader must build collaborative relationships that support the overall treatment program already being implemented by others. METHODOLOGICAL ISSUES
The theoretical underpinnings upon which most group intervention in health care is based remain largely untested. This gap between research and practice reflects the current state of scientific inquiry in both social group work and other fields of clinical group practice. In a review of literature from 1975-1983, Feldman (1986) found that of the 302 group work articles, only 29 contributed to the
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knowledge base through research. Furthermore, only a few utilized statistical tests, control groups, or baseline data. Indeed, most group research has been conducted by social scientists who have studied task or nonpatient groups where experimental variables can be liniited and controlled more easily than in the clinical setting. The paucity of group practice research is related to several factors, some of which are methodological and others bascd on attitudes of both the clinician and researcher, each of whom hold negative views toward the other regarding research ventures. In an informal survey of group therapists about the impact of research on practices, Dies (1983) reported the following: many clinicians found research lacking in clinical relevance and of poor quality (e.g., small samples, "homemade" instruments of questionable validity), inadequately communicated (e.g., written in technical language that is difficult to understand, published in journals that clinicians do not read), and intrusive and disruptive to treatment. The last concern is compounded in medical settings where practitioners may identify with their patients' experience of trauma and do not want to "burden" them further. On the other side, researchers often find clinicians too tied to their pcrsonal approach, threatened by potential negative findings, and "unsystcmatic and overly speculative" (Dies, 1983, p. 7). This mutual suspicion precludes the kind of collaborztion rcquired for successful clinical research. On the methodological level, there are a number of problems in initiating research on group process in the health setting. First there is the problem of small sample size. Interactive, therapeutic groups are small by design. Numbers of groups are limited by the amount of indirect time expended in pre and post group activities, for example, obtaining institutional support and resources, member recruitment, providing feedback to team members not directly involved in the group, and collaborative planning and post-group processing with co-leaders. It is also difficult to increase the sample size by studying groups of varying populations or across scttings because the goals and structure of most health related groups are disease and setting specific and the training and expertise of leaders is variable. As mentioned earlier, there are no consistent definitions of terms. Clinicians using the same terminology (e.g., "support group") may be talking about quite different entities in practice.
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Scientific research is also confounded by the complexities of group processes and therapeutic change which makes it difficult to control variables or analyze variance, particularly when sample sizes are small. In the clinical setting, complicating variables include individual characteristics of group members such as preexisting coping skills and personality traits, pre-group expectations and motivation, prior experience with illness, current experience with health care providers, phase of illness, and extent of existing social support. These factors all contribute to an individual's unique response to a group situation as well as histher capacity to adapt to change. There is also some indication that individuals with certain kinds of illness' respond differentially to types or methods of psychosocial intervention (Karasu, 1979). Other factors inhibiting research include leadership characteristics such as relationship qualities and level of expertise as well as group variables such as boundary determinants and process. Boundaries include the overall purpose or type of group (e.g., education, support, behavioral change); whether a group population is homogeneous or heterogeneous and along what lines (e.g., illness, age, sex, patient andlor family mix); the structure of the group, including how members were recruited and prepared, the length and frequency of meetings, and whether the group is open or closed. Perhaps, the most complex and difficult to measure and control are group process variables, that is, the characteristics that define and describe the interactions within a group. These aspects are considered necessary but not sufficient to maximize the positive benefits of the group and include such ill-defined concepts as cohesion, norms, group climate, role relationships and developmental stage. in all^, group practice research is hampered by the limited availability of practical and sound empirical measures. While outcome measures have been used in a variety of scientific studies to assess the relationship between clinical interventions and changes in patient functioning, group process measures are not well developed. A useful collection of outcome measures is contained in the Core Battery, a self assessment kit designed for the practitioner's use (Cochk, 1983). The kit contains self report instruments for patients, leaders, and significant others, as well as practical advice about overcoming resistance to research and to determine the significance of change. Included in the Core Battery are the following:
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Self Repor? Symptom Inventory (Derogatis, 1977) provides
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scores for nine symptoms (e.g., depression, anxiety) plus summary indices.
Social Adjustment Scale (Weissman and Bothwell, 1976) focuses on adjustment to such areas as work, family, leisure; can be completed by patients or significant others. Emotional Profile Index (Plutchik, 1980) provides scores on eight personality dimensions (e.g., trustful, timid, dcpressed) and is geared toward the normal personality. Target goals (Kiresuk and Sherman, 1968) three pre-group treatment goals arc listed and then rated on a 7 point goal attainment scale post group or at intervals during the group; can be used by patients, leaders, or significant others. Group proccss measures utilize either external or internal instruments. External raters observe the group directly or rate audiotvideo recordings of group sessions. Most external measures are cumbersome, costly, and time-consuming to implement. For this reason and because group researchers value the "phenomenological set" (Lieberman, 1983, p. 193), self report rating scales are used frequcntly in clinical research. These instruments measure a specific group construct (e.g., change mechanisms, norms) rather than the actual interaction being studied. Two examples are the Group Climate Questionnairc (GCQ) and the critical-incidents approach (MacKenzie, 1983). The short form, GCQ-S, is scored on thrcc scales (engaged, avoiding, conflict) and is administered each session. It is frequently paircd with a "critical incident" rcport in which group membcrs record their perception of helpful therapeutic events.
CURRENT FINDINGS Given the methodological problems discussed above, research in thc area of group practice in health care is in the infancy stage. The beginnings include attempts to classify descriptive and anecdotal literature into important variables that lend themselves to the development of hypotheses which can be empirically tested (Roscnberg and Neill, 1982; Northen, 1983; Schopler and Galinsky, 1984;
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Berkman et al., 1988). A further development includes descriptive studies which examine in more detail some of the relationships between identified variables. Two studies by Galkinsky and Schopler (1985, 1987) are examples. Although their work is not specific to health care, their studies of "Patterns of Entry and Exit in OpenEnded Groups" and of "Practitioners Views of Assets and Liabilities in Open-Ended Groups" are pertinent to the field and include data from practitioners in health care settings. Studies of self-help groups represent another area in which findings are of interest to social work practice. Examples include studies of leadership patterns (Yoak and Chessler, 1985), links between change mechanisms and types of benefit (Lieberman and Borman, 1979), and an examination of the relationship of member and group characteristics to the perceived value of the group (Chesney et al., in press). Finally, there are a few studies which use experimental design. Subramanian studied the effect of a multimethod group approach with chronic pain patients on physical and psychosocial dysfunction and negative mood states (Subramanian and Rose, 1985). She found that treatment subjects improved significantly on both measures. This study was part of a comprehensive research program (Rose et al., 1986; Rose, 1986), which was tailored to the rigors of experimental design. Ferlic et al. (1979) compared the effect of a structured educational and psychological support program for newly diagnosed advanced cancer patients to a control group and reported significant improvement in patient perception and self concept in the treatment group. Other studies of homogeneous disease groups (e.g., Cancer, [Spiegel et al., 1981; Spiegel and Bloom, 19831; Myocardial Infarction, [Rahe et al., 1979; Horlick et al., 1984; Stern et al., 39831 and Diabetes [White et al., 19861) measured outcome by monitoring physiologic signs and symptoms and/ or using psychosocial measures. For the most part, the use of group intervention did not yield significant results on physiologic measures but it did elicit impressive results on psychosocial indices. Research on the relationship of process to outcome is extremely limited. While some studies (Roskies, 1978; Walls and Meyers, 1984-85) did attempt to compare the effects of different types of groups (e.g., education, support, behavioral or "traditional" therapy), these groups were poorly defined and lacked process mea-
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surcmcnts. Other studies (Stcrn et al., 1984; Lieberman and Borman, 1979) have explored the relationship between outcome and mechanisms of change but these were static concepts which did not examine interactional processes. Only onc study (Lieberman, 1989) of spousal bereavement sclf hclp groups examined the linkage behvccn norms and patient outcome. Although the generalizability of the results needs to be tested, this study represents an important step in process research. While empirical research in health related group practice is limitcd, rcsearch findings, in general, support group intervention as an effective method of service delivery. Toscland and Siporin (1986) in a review of 32 classical experimental design studies comparing individual and group treatment, found that in 75 pcrcent of the studics, group treatment was as effective as individual treatment and more effective in 25 percent. What this review and other outcome studies have not addressed is the qucstion of who benefits under what conditions.
FUTURE DIRECTIONS While we are a long way from applying rigorous experimental research to the investigation of basic qucstions that lead to a sophisticated understanding of group practice, it is incumbent upon both researchers and clinicians to begin bridging the gap that exists between research and practice. With greater and greater mandates for accountability from policy-makers, third party payors and consumers, we need to be systematic in our efforts to pull together the rich body of dcscriptive clinical data into empirical documentation. One way to begin building this bridge is to standardize definitions and dcscriptions of key group practice concepts which will make comparisons of reports possible. The recent efforts to classify the body of descriptive group literature need further refinement as well as definitions that arc agrccd upon by both researchers and practitioners. A model for defining practice was created for the Hospital Social Work Information System in a monograph (Coulton et al., 1988) which describes standard terminology, definitions and data elements for hospital social work practice. The major purpose for the development of this common language was to enhance pro-
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fessional accountability by enabling social workers to define, understand and compare practice. Another area that is receiving increased attention is the use of the single subject design for evaluative research. This type of research is particularly suited for use with the repeated, short-term groups that often characterizes practice in health settings because it provides clinicians with practical feedback which is both immediate and generalizeable to similar groups. This method makes use of systematic observation and instrumentation to study a group pre, post, and during treatment for possible relationships between process variables and outcome. A number of instruments described in the CORE battery provide useful process and outcome measures and are easy to integrate into practice. Such research methodology follows the practice model of hypothesis formulation, intervention, and validation which should make its application acceptable to clinicians. In addition, as clinicians gain experience with instrumentation and learn that it does not have to be burdensome or intrusive, and can in fact be helpful, they could become more open to formal scientific research. While clinicians need to be more open to integrating research methodology into their practice, researchers, in turn, need to expend efforts in areas of concern to clinicians and those to whom clinicians are accountable. They must focus on implications for practice, spend time understanding issues of clinicians, and help clinicians learn to exolain instrumentation to oatients and imolement the research. ~ i i a l l there ~ , is the need td publish such c h i cally relevant research articles in clinical journals. REFERENCES Berkman, B., Bonander, E., Kemler, B., Marcus, L., Rubinger, M., Rutchick, I. and Silverman, P. Social Work in Health Care: A Review of the Literature, Chicago: American Hospital Association, 1988, 21-32. Bogdanofi, M. and Elbaum, P.L. Role lock: Dealing with monopolizers, mistrusters, isolates, helpful Hannahs, and other assorted characters in group psychotherapy. International Journal of Group Psychotherapy, 1978,28 ( 2 ) : 247-
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Cabot, R. Social Work: Essays on rhe Meeting-Ground of Docror and Social Worker. Boston: Houghton Mifflin Co., 1919. Caplan, G . Principles of Preventive Psychiatry. New York: Basic Books, 1964. Carlton, T.O. Group process and group work in health social work practice. Social Work wirh Groups, 1986, 9 (2), 5-20. Chesney, B.K., Rounds, K.A., and Cheder, M.A. Support for parents of children with cancer: the value of self-help groups. Social Work wirh Groups, in press. Cochi, E. Changc mcasurcs in clinical practice in group psychotherapy. In R.R. Dies and K.R. MacKenzie (Eds.) Advances in Group Psychotherapy: Integrating Research and Practice, New York: International Universities Press, 1983. Coulton, C., Friedrnan, A., and Keller, S. A Minimum Data Set for Hospiral Social Work. HSWIS monograph series, report no. 1. Society for Hospital Social Work Directors, American Hospital Association, Chicago, IL, 1988. Dies, R.R. Bridging the gap between research and practice in group psychotherapy. In R.R. Dies and K.R. MacKenzie (Eds)Advancesin Group Psychotherapy: lntegraring Research arld Practice, New York: International Universities Prcss, 1983. Derogatis. L.R. The SCL-90-R: Administration, Scoring and Procedures Manual, I. Baltimore: Clinical Psychometric Research, 1977. Feldman, R.A. Group work knowledge and research: a two-decade comparison. Social Work witl~Groups, 1986, 9 (3): 7-14. Ferlic, M., Goldman, A. and Kennedy. B.J. Group counselling in adult patients with advanced cancer. Cancer, 1979, 43: 760-76. Galinsky, M.J. and Schopler, J.H. Patterns of entry and exit in open-ended groups. Social Work wirh Groups, 1985, 67-79. Galinsky, M.J. and Schopler, J.H. Practitioners' views of assets and liabilities of open-ended groups. In J. Lassner, K. Powell, and E. Finnegan (Eds.) Social Group Work: Competence and Values in Practice, Ncw York: The Haworth Press, 1987, 83-98. Garland, J.A., Jones, H.A. and Kolodny, R. A model for stages of development in social work groups. In S. Bernstein, (Ed.) Explorations in Croup Work: Essaw in Theory and Practice. Boston: Milford House, Inc., 1965, 17-71, Gittcrman, A. Thc usc of groups in health settings. In A. Lurie, G. Rosenberg and S. Pinsky (Eds.) Sociol Work Wirh Groups in Healrh Setting, New York: Prodist, 1982, 6-24. Horlick, L., Cameron, R., Firor, W., Bhalcrao, U. and Balkan. The cffecrs of education and group discussion in the post myocardial infarction patient. Journal of Psychosontatic Research, 1984. 28 ( 6 ) :485-492. Karasu, T.B. Psychotherapy of the medically ill. American Journal oJPsychiatry, 1979, 136 (I): 1-11. Kiresuk, T.J. and Sherman, R.E. Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Contnruniry Mental Heolrk Journal, 1968, 4 , 443-453.
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Lieberman, M.A. Group properties and outcomes: A study of group norms on self help groups for widows and widowers. International Journal of Croup Psychotherapy, l989,39 (2): 191-208. Lieberman, M.A. Comparative analyses of change mechanisms in groups. In R.R. Dies and K.R. MacKenzie (Eds.) Advances in Group Psychotherapy: Integrating Research and Practice, New York: International Universities Press, Inc., 1983. Lieberman, M.A. and Borman, L.D. Self-Help Croups for Coping with Crisis. San Francisco: Jossey-Bass, 1979. Lonergan, E.C. Group intervention for medical patient- a treatment for damaged self-esteem. Group, 1980a, 4 (2):36-45. Lonergan, E.C. Humanizing the hospital experience: Report of a group program for medical patients. Health and Social Work, 1980b, 5 (4): 53-63. Lonergan, E.C. Croup Intervention: How to Begin and Maintain Groups in Medical and Psychiatric Settings. New York: Jason Aronson, Inc., 1982. Lubin, Bernard and Lubin, Alice W. Comprehensive Indev of Croup Psychotherapy Writings. Madison: International Universities Press, Inc., 1987. Lurie, A. and Shulman, L. The professional connection with self help groups in health care settings. Social Work in Health Care, 1983, 8 (4):69-78. MacKenzie, K.R. The clinical application of the group climate measure. In R.R. Dies and K.R. MacKenzie (Eds.) Advances in Croup Psychotherapy: Integrating Reseanh and Practice, New York: lnternational Universities Press, Inc., 1983. Northen, H. Social work with groups in health settings: Promises and problems. Social Work in Health Care, 1983, 8 (3): 107-121. Plutchik, R. Emotions: A Psychoevoluntionay Synthesis. New York: Harper and Row, 1980. Pratt, J.H. The class method of treating consumption in the homes of the poor. Journal of the American Medical Association, 1907, 49: 755-759. Rahe, R.H., Ward, H.W., and Hayes, V. Brief group therapy in myocardial infarction rehabilitation: Three to four year follow-up of a controlled trial. Psychosomatic Medicine, 1979, 41 (3): 229-242. Rice, C.A. and Rutan, J.S. Boundary maintenance in inpatient therapy groups. lnternational Journal of Group Psychotherapy, 1981, 31 (3): 3 11-328. Rioch, M.J.The work of Wilfred Bion on groups. Psychiatry, 1970, 33: 56-66. Roback, H.B. (Ed.) Helping Patients and Their Families Cope Wirh Medical Problem. San Francisco: Jossey-Bass, Inc., 1984. Rose, S.D., Tallant, S.H., Tolman, R. and Subramanian, K. A multimelhod group approach: Program development research. Social Work With Croups, 1986, 9 (3): 71-88. Rose, S.D. Fourteen practice research dissertafions and how they grew. Presented at the Annual conference of the Group for Advancemenl of Doctoral Education in Social Work, New York, October 10, 1986. Rosenberg, G. and Neill, G. Group services and medical illness a review of the
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literature- 1964-1978. In A. Lurie, G. Rosenberg, and S. Pinsky (Eds.) Social Work With Groups in Healrh Serrings, New York: Prodist, 1982, 39-53. Roskics, E., Spevack, M.,Surkis, A,, Cohen, C. and Gilman, S. Changing the coronary-prone (Type A) behavior pattern in a nonclinical population. Journal of Behavioral Medicine, 1978, 1 (2): 201-216. Rutchick, I. The Single Session Group in Medical Settings: Group Development, Curative Factors and Leadership Tasks. Presented at the Northeastern Society for Group Psychotherapy Annual Conference, Wellesley, Massachusetts, June 1984. Schopler, J.H. and Galinsky, M.J. Meeting practice needs: conceptualizing the open-ended group. Social Work Wilh Groups, 1984, 7 (2): 3-21. Schwark, W. On the use of groups in social work practice. In W . Schwartz and S.R. Zalba (Eds.) The Practice of Group Work, New York: Columbia University Press, 1971, 13-18. Singer, D.L.,Astrachan, B.L., Gould, L.J. and Klein, E.B. Boundary managcment in psychological work with groups. The Journal of Applied Behavioral Science, 1973, 11 (2): 137-176. Spiegel, D., Bloom, J.R. and Yalom, I. Group support for patients with metastatic cancer: A randomized prospective outcome study. Archives of General Psychiarr)., 1981, 38, 527-533. Spiegel, D. and Bloom, J.R. Group therapy and hypnosis rcducc metastatic breast carcinoma pain. Psycltosomaric Medicine, 1983, 45 (4): 333-339. Stcrn, M.J., Gorman, P.A. and Kaslow, L. The group counselling v. exercise therapy study: a controlled intervention with subjects following myocardial infarction. Archives of I n t m a l Medicine, 1983, 143: 1719-1725. Stern, M.J., Flionis, E., Kaslow, L. Group process expectations and outcome with post myocardial infarction patients. General Hospifal Psychiafry, 1984,6 (2): 101-108. Subramanian, K. and Rose, S.D. Group treatment for the management of chronic pain. Social Work Research and Abstracrs, Research Note 21, Fall 1985, 2930. Toseland, R.W. and Siporin, M.When to recommend group Ireatment: a review of the clinical and the research literature. ln~ernationalJournal of Group Psychorherapy, 1986, 36 (2): 171-202. Tuckman, B.W. Developmental sequence of small groups. Psychological Bullefin, 1965, 63 (6): 384-399. Von Bertalanffy, L. General System Theory, New York: Braziller, 1968. Walls, N. and Meyers, A.W. Outcome in group treatments for bereavement: Experimental results and recommendations for clinical practice. Infernational Journal of Mental Healfh, 1984-85, 13 (3-4): 126-127. Weissman, M.M. and Bothwell, S. Assessment of social adjustment by patient self report. Archives of General Psychiarry, 1976, 33: 11 11-1115. Whitaker, D.S. Connections between group analytic and group focal conflict per-
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spective. International Journal of Group Psychotherap, 1987, 37 (2): 20121 R White, N., Carnahan, J., Nugent, C.A.. Iwaoka, T.and Dodson, M.A. Management o f obese patients with diabetes mellitus: Comparison o f advice education with group management. Diabetes Care, 1986,9 (5): 490-496. Yalom, I.D.The Theoty and Practice of Group Psychotherapy. New York: Basic Books, 1975. Yoak, M. and Cheder, M. Alternative professional roles in health care delivery: Leadership patterns in self-help groups. Journal of Applied Behavioral Science, 1985,ZI: 427-444.
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