Social Group Work with Adults having Intellectual Disabilities

Abstract

Social group work is considered as a viable treatment modality for adults with intellectual developmental disabilities. This paper demonstrates the usefulness of conducting social group work for adults having developmental disabilities. The authors share their experience of conducting group work with them at psychiatric rehabilitation center in a tertiary care hospital. This article gives a brief description of group work which used to aid adults with intellectual disabilities in their activities of daily living, working, and learning situations.

Introduction

Though professional social work was dominant by casework method since its inception, but later it was realized that focusing on individuals alone without considering the cognizance of social milieu would be futile for all purposes. This gave birth to social group work as the second method being more important than social casework.

Group Work pioneer, Trecker [16] who defined social group work is a method through which individuals in groups and social settings are helped by a worker who guides their interaction in group activities, so that they can relate among themselves with other people and experience growth opportunities in accordance with their needs and capacities to the end of the individual, group and community development.

Douglas [8] assumes that group experience provides an opportunity for change of static individual attitudes and behaviors; develops a sense belongingness to grow together and become an instrument to help others in difficult circumstances.

Individuals with adjustment problems, when exposed in a group, would have more chances of getting better compared to treating them in isolation or individually. Taking cue from social work literature and practice, the mental health and allied professionals started adapting group work practice; giving more emphasis on the individual’s inner problems and called this method as ‘group psychotherapy’. This process was more suitable and efficacious than just group work in the management of persons with intellectual disabilities. Objective of which was to promote self-care skills, enhancing communication abilities, interpersonal relationship, develop work habits in day care service programs and promoting social and vocational skills.

This article focuses on guidelines for conducting group psychotherapy with adults having intellectual developmental disabilities (IDD) in a day care psychiatric rehabilitation setting, demonstrates the usefulness of it and sharing the group work experience with these underserved populations.

Overview of Group Psychotherapy

Group psychotherapy is a form of psychotherapy in which a small number of people meet together to discuss common problems under the guidance of a professionally trained therapist to help themselves and one another [1].

Group psychotherapy with adults having IDD has been limited owing to their cognitive ability and attributed to variety of reasons. Very few practitioners have tried group psychotherapy with them. It was assumed individuals with IDD do not require counselling because to undergo counselling one needs verbal skills and these individuals lack them, it is time consuming, outcome would be slow and minimal, seldom gain insight into their problems [6]. Individuals with IDD have similar needs as normal. Owing to their limitations, they are unable to meet their needs. Therefore, they face more emotional problems such as failure, rejection, low self-esteem, lack of motivation, anger, frustration and adjustment problems [17]. Hence, group psychotherapy may be more suitable for them.

Adults with IDD lack adequate group treatment opportunities. Earlier these individuals faced institutionalization, sterilization, and isolation [18]. Wagner [18] has described in detail the process of group psychotherapy and its usefulness with eight individuals attending vocational day care program. Its goals varies from improving their behaviour, reduce socially unacceptable behavior, realization of their potentials, gaining knowledge, reinforcement of coping [4]. Fisher [9] is the first one to document in the literature about group therapy with mentally retarded in the year 1953. Borenzweig [5] found that most group work with them was primarily recreational, helped to socialize with their peers, their parents, and siblings as well-received group therapy services. He reported that the domain of group work should be more on improving their social functioning than recreational.

Group psychotherapy is indirect treatment modality to treat secondary consequences of intellectual deficits [7]. Many failed to view mentally retarded as a source of knowledge. Individuals with mild retardation respond better to group treatment. Kahn [12] reported interesting finding that these individuals respond better in emergency situations such as bus break down, change of schedule as normals. Similar responses were observed in our setting as well in crisis situations when the group member gets seizure at workplace or while climbing stair case.

Group psychotherapy for people with intellectual disabilities has been most effective when a directive style with structured session is used. Additionally the use of active / interactive techniques stimulates more sensory and affective modals of learning than the verbal modality alone [10].

Astrachan [2] documented that the use of group psychotherapy with 31 female patients in terms of change brought out reduction in the patients’ feelings of isolation, shame and fear after attending group psychotherapy. He described role of therapist, type of communication, number of group interactions, content, ratio of patients to therapist and group composition. Other role of the therapist were supportive, being comfortable in dealing with them, formulating questions, bridging the comments, finishing fragmented statements, summarizing the discussions, being role model, and therapeutic use of self.

Nezu [13] reported that lack of literature in respect of effective treatment approaches for adults with IDD and emphasized on psychodynamic, behavioral, and group psychotherapy approaches with mentally retarded adults. Many professionals have favoured the use of social skills training in group psychotherapy, because the therapeutic value of group psychotherapy has a powerful, generalized effect, promoting self-confidence and improvements in mental health [11].

However, the effectiveness of group psychotherapy needs empirical validation [3] with reference to this population who have cognitive problems. By way of observation, a technique which is mostly used by social work professionals; it was felt necessary that group psychotherapy with individuals with IDD minimizes their process of adjustment and others. Hence, it was planned to observe the effect of group psychotherapy being used at the psychiatric rehabilitation centre, NIMHANS, Bangalore.

Concentrating on the Indian situation, the NIMHANS experience in respect of psychiatric rehabilitation is noteworthy. The rehabilitation centre at NIMHANS was initiated in 1954 in the form of occupational therapy for the purposes of providing occupational engagement for patients who are in the process of recovery in which even adults with IDD were included. This centre has various occupational training in different sections namely, bamboo, candle making, bakery, printing, mat weaving, tailoring, computer, plastic moulding, weaving, leather, craft, horticulture, domestic skills, recreation, arts and recreation activities.

Multidisciplinary team is involved in providing rehabilitation services. Team consists of a psychiatrist, clinical psychologist, psychiatric social workers, and psychiatric nursing with vocational instructors. Following rehabilitation services such as maintaining a regular and active life style, activities of daily living and instrumental activities, dealing with problem behaviours, socializing with others, regaining self-confidence, and taking initiative, vocational training, resuming work, availing disability benefits were provided to them. A sizeable number of adults with intellectual disabilities avail vocational day care services at psychiatric rehabilitation Centre. They get engaged in vocational sections for four to six hours during the daytime.

Group Structure

Most often group members consist of persons with mild to moderate level of intellectual disabilities as they are educable and trainable were included in group psychotherapy. The group happens to be a mixed group (heterogeneous) with both male and female persons. Frequency of the group sessions: four times in a week mostly in the afternoons with duration of 45–60 min. On an average 8–12 members attended the group sessions. Group was developmental and interactive in nature. Though the group happens to be open, the frequency of new members joining the group has been rare. Group members’ age ranged from 20 to 45 years. Majority were belonging to 25–35 years of age. Group members were usually seated in circle shape. Particular member chair would be left vacant if he/she is absent for the group. Group worker and group members have similar chairs. Majority of the adults with IDD attendance in the group was ranging from four to 10 years.

Group Process

Group process refers to what happens in the group, particularly in terms of the development and patterns of relationships among group members [19]. These processes occur at both observable and inferred levels. Group work starts with initial greeting and randomly asking everyone to introduce them, day and date, name of the vocational section where they placed and nature of work they were involved. Followed by brief review of previous week session for 10–15 min; each member would be asked to contribute one point which was discussed in the previous group session. General rules such as everyone has to participate and one at a time to talk, are reminded. Then the group members would be asked about the topic, what they would like to discuss for the day. Each member’s opinion would be asked; but the majority of the members’ opinion would prevail.

Content of the Group Sessions

Problems of activities of daily living, difficulties in work place, asking for destination and route when they travel in a bus, seeking help when they miss their way to home, emergency contact numbers, things to remember when they go for shopping (money management and indulging transaction), managing epilepsy in times by alerting the bystanders when they sense the occurrence of epilepsy, discussion about their incentives that they received for their work in the occupational therapy units, deviant behaviours, anger management, absenteeism in work and day care programme, difficulties in fulfilling quality and quantity of the work output, interpersonal difficulties such as accommodating others, poor drug compliance, interpersonal difficulties with family members (critical comments, hostility), dealing with stigma in neighborhood, issues in transportation, common issues faced by the group members were considered for the discussion in the group. During group process members were allowed to narrate their experiences in the neighborhood and about vocational instructions. Others learn to share similar experience by mutual learning in the group. The initiation of group discussion sometimes used to be by the group members, but at times the group worker prompt them to start disclosing their grievances, complaints and the like.

Group sessions are facilitated by asking the members to share their views and opinions about the theme. Everyone would be encouraged to participate, and share their views. Each member would be often instructed to wait for their turn. After that other members are asked to summarize what the previous speaker has said. Group discussions are facilitated through democratic decision-making, guided group interaction, prompting, enabling, providing opportunities, giving enough time to share their views. Techniques such as reflecting or rewarding comments of individual group members, asking for group members response to member’s statement, pointing out any shared feelings within the group, asking pertinent questions, summarizing at various points within the session were used to facilitate the group interaction. Skills were imparted through role-plays, positive feedback.

It was very difficult to prompt them at every level for quality participation and discussion. Often, very few members were geared to understand and comprehend discussions. For some, attending the weekly group meeting was considered monotonous; waiting to express their problems to find solutions, and for some, wanting to express their new skills and its application at home and at neighbourhood.

Before concluding the group session, members would be randomly asked to highlight important issues discussed on that day on voluntary basis followed by summarization of key points. Each group member would be asked to share his/her feelings at the end of the session. Group activity would conclude by thanking its members, appreciating everyone for their contribution and participation in the discussion. Next week topic would be introduced at the end of group session and informing them to remember the topic and to come prepared for the same.

Group Work Skills

Group worker roles are prompting, making everyone to participate, being supportive, flexible, accommodative, using directive approach, simple communication, friendly, non-threatening nature, summarizing the group session. Group workers need to have qualities such as being humanistic, accepting them as they are and their cognitive limitation, understanding their strengths, treating them equal, with dignity, respect as humans without looking at their deficits, without discrimination or criticizing their behavior. Group worker is expected to have cognizance of behavior patterns of mentally retarded adults such as not waiting for the one’s turn to talk, answering before the other person finish talking. The group worker must be skillful in gaining the acceptance of the group, analyzing the group situation, participating, dealing with group feeling, programme development, using agency and community resources, recording, and evaluating the group [15]. Siddique [14] identified a set of core skills for conducting group such as communication, listening, observation, analytical thinking, empathy, self-control, and leadership skills.

The following parameters were used in assessing the development of group members. They were; regular attendance of the group members, sense of belonging towards other group members, willingness to take-up responsibility, feeling of dependence in the group, group cohesiveness, motivation among the members to attend the group sessions, engaging in meaningful discussion, talking about individual concerns and resolving their conflicts, expressing their desire to have more programs.

Observed Outcomes

By this way adults with IDD started feeling s/he is not the only person having the problem but there are many persons having such problems. S/he feels s/he is not only the lonely sufferer and s/he can share his/her problems in the group. In the group work, members themselves help each other in expressing the problem, and in finding out effective ways of solving them. Adults with IDD in the group begin to feel that they are not only here to get help but they can also to help others. There are fewer chances for them to develop transference, dependency on the therapist as the group worker is not the only person involved in the development process. Their own suggestions and guidelines are considered good and accepted by others as well as by the group worker.

Group worker helps the individuals to express their burning problems so that it motivates others as well to communicate their problems easily. It was observed that when persons with IDD integrated in Ramana Maharishi Academy for visually disabled, Bangalore for availing job opportunities, the skills imparted in group work programme such as developing communication, maintaining interpersonal relations, accepting the work culture, adjusting to work with visually disabled, such outcomes in attitudinal changes were possible because of their attendance over a longer period of four to 10 years.

In the process of finding solutions to their day to day problems and discussion make few of the group members emerge as leaders in terms of leading the group with suggestions, remedial measures for the problems faced, and when they gain knowledge over a problematic situation, they feel empowered to cope with it. Members tend to monitor other members’ interaction and behaviours and decision making abilities during the group process and discussion facilitates action plans. Group work enhances to take collective responsibilities in helping the group members (for e.g. climbing staircase and when other person having seizures), improvement in communication, interaction skills thereby improving their social skills. Developing strong sense of “we-feeling” among them and helping each other and organizing recreation group activities such as anthaakshari, jokes, and singing. This would help to identify their latent potentials and they continue to look forward for further growth.

Adults with IDD who are selected for vocational training are bestowed with abilities to develop work habits, acquiring work skills, maintaining quality and quantity of the work output with the incentives, which adequately motivate them for vocational rehabilitation. This facilitates the group worker to explore resources for employability inside the campus and community as well. The weekly group sessions being organized under the supervision of group worker indulging in discussion related to day to day activities of day care services, programmes, primarily focusing, its attention on learning mutually on the experiences of others, undergoing attitudinal changes from negative to positive though verbalization of problem situation being confronted, developing ‘we-feeling’, discussing the issues in detail, finding the solutions, despite cognitive limitations.

Group members who can’t be helped for the livelihood earning in the community, they were asked to attend the day care service for 4–6 h every day, according to their work performance they would get monthly incentives ranging Rs. 750–Rs. 1500 which is a great boon for the families and their siblings. For family members, the day care programme for the mentally retarded is relief from the caregiver burden. Group work compliments every other intervention measures in process of habilitation of mentally retarded.

Issues and Challenges

One of the greatest obstacles in carrying out group intervention with mentally retarded is scientific validation of the process and outcome of the group intervention. The challenges are kept before us is lack of assessment tools for evaluating the effectiveness of group intervention with mentally retarded adults. Pre-post evaluation can be done with work behavior assessment. Group intervention is possible with mentally retarded adults but is important to know that this group would show slow progress. It is time consuming process.

How the Challenges are Handled?

The intellectual limitation creates hindrances, many a times the group worker develop pessimistic outlook with reference to the overall outcome. The consistency of group sessions, efforts, patience, perseverance, optimistic outlook and waiting for optimum period for producing desirable change were determinants to overcome the challenges. Individuals with mild and moderate intellectual disabilities were given different activities to acquire the needed skills.

Future Directions

Day care service is considered to be important means to address the global requirement of persons with IDD with comprehensive therapeutic interventions like occupational therapy, behaviour modification, vocational training, recreational therapy, family intervention when needed, social skills training, sheltered employment and self-help groups. Such programmes are expected to bring forth the needed changes and enabling them to become productive and less burden to the family members. Often, it is observed that individuals of this category when they were not engaged with above said programmes either in the community or in the respective home settings found to be qualitatively burden and unproductive. Hence, there is a need emphasized on the part of the policy makers and mental health professionals to induct group work in day care service an important adjunctive programme for psychosocial rehabilitation of adults with IDD.

Conclusion

It is observed that over a period of 4–10 years the group work programmes in a day care setting qualitatively make adults with IDD to undergo significant changes in the area of acquiring self-care, social skills, communication skills, improved interaction with other group members and improved work behaviour in a day care. The group worker being the qualified mental health professional using the process of group work method during every session with recording the outcome, considering the progress made, periodical evaluation of the same, becoming a prerequisite for any changes to be brought with these individuals which results in achieving the goal set for them in the course of rehabilitation.

By experience, one will become not only competent in applying these guidelines and techniques of group work practice with adults having IDD in rehabilitation setting but also become innovative in handling their problems in a group setting.