Facilitating Occupational Therapy Groups in Mental Health and Other Practice Settings

Introduction

Bill: Thank you, everyone, for tuning in and wanting to know more about occupational therapy groups in mental health and other practice settings. I have a lot of clinical experience, inpatient and outpatient, in running groups, and I hope you will find this talk informative.

Groups in Occupational Therapy

Although they share commonalities with other types of groups, occupational therapy groups are unique.

​The activities or occupations that we choose for groups are the means by which we meet our goals and patients meet their goals. Our use of occupations naturally sets us apart from other types of groups such as traditional group therapy, and client outcomes result in improved occupational performance and function for the individual. As I said, there are some unique groups in OT in general

Definitions of Groups in OT

• Activity
• Task (Fidler)
• Developmental (Mosey)

An activity group is one in which members engage in a common task directed towards occupational performance in areas of occupation. The task group was developed by Gail Fidler, and it provides an end product or service; however, the end product is not the important part. It is the process of shared experiences along the way, and at the end, you learn something about yourself. Developmental groups by Anne Mosey are quite famous. They involve group interaction skills, and as she believes, are developmental in nature. Those groups are parallel, project, egocentric, cooperative, and mature. In the Mosey's developmental groups, the leader has a strong role at the beginning running parallel task groups, and a minimal role once the group becomes a mature group.

• Directive (Kaplan)
• Sensory Intervention Using Sensory Modulation Approaches (Champagne)

Directive groups were developed by Kaplan. They are designed to meet the needs of seriously mentally ill clients and lower functioning clients. They are highly structured and consistent in their format. Each time you run this group it is done in exactly the same way with an orientation, introduction, warm-up, selected activities, and wrap-up. The next group is sensory intervention using sensory modulation approaches. This has been made famous by Tina Champagne who has written extensively about the use of sensory stimulation, sensorimotor activities, environmental modification, sensory diets, and calming rooms. The calming rooms have been mandated to be in all the psych facilities in Massachusetts I believe. When we show people what our occupational therapy approaches can accomplish, we make headway and especially in the way of mental health. However, until people know what we do, we have to sell ourselves.

• Psychoeducational
• Community and Self-Help
• Thematic
• Expressive/projective
• Vocational
• Education
• Leisure

(Cara, 2013, pp. 292-296)

A psychoeducational group teaches specific information or techniques. Generally, this is used with shorter lengths of stay on inpatient units. These stays getting shorter all the time approximately three to five days. There are other kinds of groups that we can run. Community and self-help are popular. Thematic groups are organized around a topic or a theme. Expressive or projective groups use creative media to facilitate and project our thoughts and feelings onto either a collage, for example. If you were Fidler, you would believe that a craft project was also something that you could use that revealed things about you. You could then acknowledge your intrapsychic issues and then deal with them because now they are now out in the open. There are also vocational groups, educational groups, and leisure groups. Leisure groups will be coming into play oftentimes in 12-step programs. While there is a need for a balance in life, that is not always found by people that have active addictions. They are in recovery and need to replace all those activities that revolve around drinking as an example.

Examples

Let's now look at some examples of those groups.

Activity Cooking Group

• Cooking group for teenagers age 17-19 with an autism spectrum disorder. 
• Emphasis on the activity of cooking easy and healthy recipes in a kitchen environment similar to the group home the teenagers will be transitioning to in the next year. 
• Through the participation in the cooking group, the teenagers will learn healthy recipes, cooking and cooking skills needed for the successful completion of future IADL (i.e. home management and meal preparation).  Through participation in the group environment, teenagers will also gain important social interaction skills needed for work and leisure occupations.
• Activity example: baked ziti

Here is an example of an activity cooking group. This is a cooking group for teenagers aged 17 to 19 with ASD. The emphasis is going to be on the activity, and learning how to cook easy and healthy recipes in a kitchen environment will help these teenagers transition to living in the community. By participating in the group, teenagers will learn about healthy recipes and cooking skills. They will also gain important social interaction skills needed for work and leisure occupations. A suggested activity for this might be baked ziti.

Thematic Cooking Group

• Cooking and nutrition group for women with eating disorders, with a focus on a discussion about healthy eating habits. 
• Each week the facilitator will provide a theme of a particular habit or recipe, the group members will journal their thoughts on the topic, and then the group members will actively participate in a collective discussion while completing the recipe.
• Activity example: Making a salad with grilled chicken and fruit

This is a cooking and nutrition group for women with eating disorders. There is a focus on a discussion about healthy eating habits. Each week the facilitator will provide a theme of a particular habit or recipe. The group members might journal their thoughts, and then the group members would have active participation in an activity like completing the recipe and discussing the issues at the same time. The activity example here is making a salad with grilled chicken and fruit. People I have known with that condition have typically eaten salads without dressing and have relatively little balance in their lives. They need to learn more about nutrition and balance, and supplying all the things the body needs.

Task Cooking Group

• Cooking group for children with social anxiety. The group will focus on the interaction between group members within the group atmosphere while carrying out cooking tasks such as baking and cooking snacks. 
• Group members will have to work together to complete recipes and will be encouraged to problem solve with other group members when planning and executing recipe steps (e.g. which toppings to add). 
• Activity example: Making pizza for the group to share

This is a cooking group for children with social anxiety. The group will focus on the interaction between the group members while carrying out the cooking tasks such as baking and cooking snacks. The group members will have to work together to complete the recipes and be encouraged to problem solve with other group members when planning and executing the recipe steps. Here our example is making pizza for the group to share. I have used making pizza as an activity in many settings with also every age group, from children and adolescents through adults. It is very adaptable. The thing about cooking groups, which I will be speaking about a lot today, is they make an end product with which everyone is satisfied. It is also is easy to get people to participate in a group where they are going to have something that they choose, hopefully, to eat at the end.

Directive Cooking Group

• Cooking group for adults with schizophrenia with clearly defined roles for each participant contingent upon participant skills (i.e. Mark is chopping vegetables, George is putting cheese on top, Kim is washing the dishes, etc.).
• There will be clearly defined structure to each group section including an orientation to the group, introduction to the recipe, assignment of roles, completion of the recipe, and a wrap up for group processing. 
• Activity example:  Making chocolate chip cookies

The directive cooking group has a specific order that has to be followed each time you run a group with these particular group members. As we talked about, this is for those with more severe and persistent mental illnesses and are generally low-functioning. There are clearly defined roles for each participant is contingent upon their skills. Someone might be good at chopping, someone better at putting cheese on top, and so on. We have the clearly defined structure to each group so they will have an orientation, an introduction to the recipe, and an assignment of their roles. They will complete the activity, and then they will wrap up for group processing. This is a simple activity that you could make here is the activity of making chocolate chip cookies.

Psychoeducational Cooking Group

• Cooking group for adults with diabetes and their families with a focus on learning healthy recipes and how to utilize nutrition and diet to help manage diabetes.
• Group members will learn ways to substitute healthier options for preferred meals and then practice healthy recipes within the group setting.
• Activity example: Making oatmeal muffins, substituting applesauce for part of the sugar and oil

As we say with psychoeducational groups, the participants are learning, and we are teaching some skill or information that they need to manage their problems or their lives in general. This particular group is going to be a cooking group for adults with diabetes and their families. It is important to always include the family in treatment because people are going to carry out largely their treatment without you in the community with their family. A supportive family that is familiar with the diagnosis and the things that that person finds difficult and need to master really is going to make the prognosis much better. With this group, the group members will learn ways to substitute healthier options for preferred meals and then practice healthy recipes within the group setting. In this example, we are making oatmeal muffins and substituting applesauce for part of the sugar and oil.

Starting a Group

Steps

Here are the steps for starting a group.

• Conduct a needs assessment
• Groups begin with evaluation and assessment of the individual or population to receive services
• Environment/location for group
• Purpose of the group
• Selection criteria
• Source of referrals
• Specific activities
• Outcome measure  

We begin a group by conducting a needs assignment. We find out through evaluation and assessment of either the individual, the population, or both. We look for the appropriate environment or location for the group. If we want to run cooking groups at a senior center, for example, it needs to be equipped with a kitchen. Can we use hot plates or other things? What kind of materials will we need? Is it accessible to the people that you want to serve? The purpose of the group needs to be established. You also need to have selection criteria like who is appropriate for the group and who is not. Importantly, you need to know a source for referrals. In a hospital setting or a mental health hospital setting, typically you are going to get a referral from the psychiatrist. Oftentimes, everyone is referred to occupational therapy. In the outpatient world, you may get referrals from a psychiatrist or any doctor that will enable you to provide OT services. Other times, when we are not working with a medical model and clients in the community, we are going to have to look for other ways of getting referrals naturally. There is word of mouth. You could advertise and post things electronically. You could also put something old-fashioned like a notice on a bulletin board at the senior center we were just talking about to inform people of the upcoming group and the things that it can do for them. You will plan your specific activities once you have all of that groundwork laid.

Lastly, it is important to have an outcome measure. We might believe that a group is meeting peoples' needs and we think they are achieving their goals, but they may not think so. They may not be satisfied with what the outcome has been so far. You can use the processing of the group. This is one outcome measure that is not necessarily measurable. However, it is important to process every group. You could also use a questionnaire at the end of your group. This is great to do so that you know if you are on the right track for helping meet those specific clients' needs. A pretest and a post-test measure might be helpful as well.

What Are the Groups Interests and Goals?

Ultimately, we want to know what are the group members' interests and goals. It is another thing that makes OT unique is that it is client-driven and client-centered. What do they want to accomplish? What are they interested in? You might accomplish that, obviously, through an occupational profile. You are going to want to consider the functional and developmental level of the individual and grade the activity for success. For example, when I worked on the children's unit, a six-year-old is very different in every way from a 12-year-old. I would group the children according to developmental level. We had a playgroup for the younger children who needed to master play and basic social skills. It also provided a projective outlet for them to let us know what was going on in their lives. Then, with the older kids, say 10, 11, 12 years old, we would run groups that we called skill development groups to work on their problems. One example is the use of board games to facilitate talking about their problems.

I ran a very successful cooking group for a number of years on a 20-bed adult inpatient unit. I worked there each Thursday and Friday. When I got there on Thursday, I would get a rundown from the nurse on who was there. With short lengths of stay, the clients were all different from the people I had met the week before. I would attend their community meeting that they had at the beginning of the day. This is where they would identify goals and so on. I did a quick assessment of what their function levels were like and what their goals were. Following the community meeting, I would then explain what OT was and that we were going to have a cooking group. I would ask them what they wanted to make. In inpatient settings, people have very little control over what they eat. Thus, what is really appealing about a cooking group is that the clients are able to choose their own recipe and carry it out. I would ask them to plan a meal and make a grocery list. If they are able to go into the community, that would be ideal. But in this case, they were not, so I would run out after the community meeting group, and I would purchase all the stuff that they needed. They then were able to cook a meal.

With this group, I was able to meet almost every person's need.