Home » Therapies » Group Therapy: 32 Activities, Worksheets and Discussion Topics for Adults and Teens
“The best part about being with a group is that you don’t have to do everything alone.” – Anonymous
This quote may seem like a pretty obvious truth – of course you won’t do everything alone if you’re in a group!
However, it is an obvious truth that we often forget.
It can be easy to slide into isolation when we’re feeling down, especially for those suffering from an invisible illness or problem, but this is the exact opposite of the action that is most likely to help us climb out of that pit. Loneliness and isolation tend to breed more loneliness and isolation, but making the (often difficult or exhausting) effort to connect with others is just the thing we may need to start feeling better.
As uncomfortable as it may sound, sometimes sharing difficult thoughts and feelings in a group setting can be extremely effective in facilitating healing.
This quote describes how sharing can help:
“Some of the most comforting words in the universe are ‘me too.’ That moment when you find out that your struggle is also someone else’s struggle, that you’re not alone, and that others have been down the same road.” – Anonymous
Luckily, there is already an established type of therapy built on this idea. This article will define group therapy, describe typical sessions, and provide several activities and exercises you can put to use in your group therapy sessions.
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What is Group Therapy? Definitions and Theories
At the most basic level, group therapy is:
“a form of psychotherapy that involves one or more therapists working with several people at the same time” (Cherry, 2017).
It is usually a complement to individual therapy and sometimes medication as well, although it may be used as a standalone treatment for certain issues or problems.
According to one of the most renowned group therapists, Dr. Irvin D. Yalom, there are 11 key principles of group therapy:
- The instillation of hope. Since group therapy often includes clients at different stages in their treatment, some of the newer clients can find encouragement from seeing the positive impacts on clients further along in their treatment.
- Universality. Just being part of a group of people who understand what you are going through and have experienced similar problems will help clients see that they are not alone, and that suffering is universal.
- Imparting information. Group members can be a great resource of information for each other.
- Altruism. Group therapy gives members a chance to practice altruism by helping others in the group, an experience which will likely help them as well.
- The corrective recapitulation of the primary family group. This long-winded principle refers to the process of clients learning and exploring the childhood experiences, personalities, behaviors, and feelings of themselves and other group members, and learning how to identify and avoid destructive or non-helpful behaviors.
- Development of socialization techniques. The simple experience of working in a group provides excellent opportunities to socialize, practice new behaviors, and experiment in a safe environment.
- Imitative behavior. Clients can observe and imitate or model positive and helpful behaviors for others in the group, including the therapist.
- Interpersonal learning. Interacting with the therapist and other group members and receiving feedback can help a client learn more about themselves.
- Group cohesiveness. Group therapy sessions can facilitate a shared sense of belonging and acceptance of one another.
- Catharsis. This principle is based on the healing powers of sharing with others; talking through your feelings and experiences in a group can help relieve pain, guilt, and stress.
- Existential factors. Although group therapy offers guidance and support through the group, it also helps clients realize that they are responsible for their own actions and the consequences that follow (Cherry, 2017).
Going back to the first quote about the best part of being in a group, this set of principles makes it clear that there are many advantages to working with a group rather than individually. Some of these principles may apply in individual therapy, but most of them require a group setting.
Group Therapy Session Outline
The general tone and direction of the group therapy session will vary depending on the type of group. There are many different kinds of groups with different areas of focus, but they generally fall into one of two categories:
1) Psychoeducational – These groups are intended to provide members with information they need to address or cope with whatever it is that brought them to the group; they are usually structured with specific topics or modules to cover.
2) Process- Oriented – These groups are more focused on experience, sharing with one another, and making connections; discussion among the members dominates this group rather than a set agenda (Good Therapy, 2013).
Further, groups can be broken down by discussion topics and the structure of the group itself. Some of the most common therapy groups include:
- Self-Help Groups – These are generally led by someone who is not a professional group facilitator, but has struggled with a problem or successfully overcome or addressed a problem, and wishes to help others through the process.
- Medication Groups – The focus of these groups is on compliance with prescribed medication; the intent is to educate clients about their medication, ensure compliance with the doctor’s instruction, and decreasing their sense of isolation.
- Interpersonal Therapy Groups – This type of group is intended to dive deeper into the clients’ current relationships to understand current problems; the present is the focus of these groups rather than the past.
- Encounter Groups – These groups aim to immerse members in potentially uncomfortable and intense group situations in the hopes of provoking greater change than a typical therapy group.
- Psychodrama – This unique type of group therapy is based on members acting out significant portions of their life. These dramatic reenactments can provoke strong emotions, which are discussed after each “scene” (Counselling Connection, 2010).
The number of participants in a group therapy sessions also depends on the type of group, but can range from only three or four people to twelve or more (although more than twelve participants may not be as effective). Typically, group sessions are held once or twice a week for one or two hours a session. The minimum recommended number of sessions is generally six, but group therapy often continues for up to a year or more (Cherry, 2017).
There are two kinds of group therapy sessions:
1) Open groups: new participants are welcome to join sessions at any time; for example, Alcoholics Anonymous is an open session which invites new members to join in any session.
2) Closed groups: the therapy sessions are closed to a core group of participants; new participants may only be welcomed when a new group is formed (Cherry, 2017).
In terms of what will actually happen in a group therapy session, sessions can vary based on the topic, participants, and treatment progress, but these are some of the common features:
- The participants will meet in a room with chairs formed into a large circle.
- The session may begin with group members introducing themselves and explaining why they are in therapy.
- In subsequent sessions (in closed groups) or in every session (in open groups), members may also share their progress and any updates since the previous group meeting.
The flow of the session will depend on the same factors described above, but it will likely follow one of these general paths:
1) Free-form: each participant will engage with the group as much or as little as s/he wants, and participants are the main drivers of the discussion with facilitation and guidance from the therapist.
2) Planned: in other cases, the therapist may have a set agenda for the meeting with planned activities and skill building exercises for group members to engage in (Cherry, 2017).
5 Guidelines and Rules for Group Therapy
Whatever type of group therapy you attend, the general rules will likely be the same. These are the rules must be followed for the safety of the group and effectiveness of the treatment. Certain types of groups may have additional rules, but there is a core set of five rules that are essential for successful group therapy.
These five rules are:
- Maintain Confidentiality. It is essential that everything said in group therapy is kept private by all group members and leaders. Failing to adhere to this rule can undermine trust within the group and hinder members’ attempts to heal.
- Commitment to Attendance. This is another essential rule for nearly any group – it is vital that each member attend every session, arrive on time, and stay for the entire session. In addition to the absent member missing valuable information and practice, absence or late arrival/early leaving can interrupt the whole group.
- No Socializing with Group Members. Group therapy is not a social activity, it is (hopefully!) a therapeutic one. Forming close friendships or other bonds with group members can interfere with group success, especially if members become hesitant to share personal information because of another group member. Friendships should be saved for after the group has disbanded.
- Communicate with Words, Not Actions. This rule could be considered the exact opposite of the standard advice storytellers receive: “Show, don’t tell!” People have different reactions to physical contact, so expressing yourself through words instead of physical actions is an important rule to follow.
- Participate. Group therapy doesn’t have much of a therapeutic effect if the members do not participate! The potential for healing and growth rests on how much group members are able to connect, share, and learn from one another. It is essential for all group members to truly participate for this treatment to be effective.
See here, here, and here for examples of rules and guidelines for different types of group therapy.
How to Become a Group Therapist
There is no specific path to become a group therapist beyond the path to becoming a therapist in general. Most therapists who mainly offer group therapy also offer individual therapy and vice versa.
In general, the path to becoming a therapist consists of three components:
- Education: To practice as a licensed therapist in most states and countries, you must complete a Master’s program in any of the areas listed below. Many therapists choose to earn a doctoral degree as well, which qualifies them to be a licensed clinical or counseling psychologist. Visit www.cacrep.org to learn about accredited graduate level counseling programs.
3) Child Psychology
5) Marriage and Family Therapy
- Clinical Experience: The requirements will vary by state and country, but expect to complete at least a couple thousand hours of supervised experience. For example, in California, you will need to complete at least 3,000 hours of supervised experience over the course of at least two full years, with at least 1,750 of those hours spent in direct counseling (www.counselor-license.com).
- Licensing Exams: Once you have completed your degree and your clinical experience, you can apply for a license and take the licensing exams. In the United States, this will likely be the National Clinical Mental Health Counselor Examination or the National Counselor Examination for Licensure and Certification. Again, requirements will vary by state and country, but in most cases you will need to pass a rigorous examination to qualify for your license.
Depending on where you are located, you may also want to pursue membership as a Certified Group Psychotherapist (CGP) with the International Board for Certification of Group Psychotherapists. Becoming a CGP requires all of the same steps as becoming a therapist in addition to 12 hours of coursework in group psychotherapy theory and practice, 300 hours of clinical experience working with groups, 75 supervised hours of group psychotherapy, and references from a supervisor and colleague.
For more information on becoming a CGP, click here.
So what courses will you take on your journey to becoming a group therapist?
As noted earlier, that will depend on where you are pursuing a license to practice group therapy, but in general your coursework will include:
- Psychological Theories
- Research Methods
- Clinical Best Practices
- Ethics in Therapy
- Interpersonal Psychology
- Group Psychology
- Family Psychology
- Child Psychology
- Specialty courses in your area of choice (www.goodtherapy.org)
In addition to these courses, you may take courses in diversity and social justice in counseling, career and life development, couples therapy and marriage counseling, courses on addiction and substance abuse, and human development.
It is important for therapists to be well-educated and knowledgeable about several different arenas of human psychology, even if they plan on specializing, because you can never be sure about the problems that will arise when your client opens up. Cases that seem relatively straightforward may surprise you with layered complexity, while another client may present with a myriad of problems that can be addressed with a simple solution.
Therapists must be ready for anything, which is why a good foundation in all areas of clinical and counseling psychology is so important to build.
Benefits of Group Therapy
For participants, there are many reasons why group therapy is a treatment worth considering.
The main advantages include:
- It allows participants to receive support and encouragement from other members of the group, helping them to feel less alone or isolated.
- Group therapy provides an opportunity for group members to act as role models for other members, especially when the group is composed of participants at different stages of treatment. Even if all participants are at the same stage, some participants will naturally be more successful at managing certain types of problems than others, and group members can share their experiences and learn from each other.
- It is usually more affordable than individual treatment, since the therapist’s time is shared with other clients.
- Group therapy provides a safe environment for group members to practice new behaviors without fear of judgment.
- Interacting with others in group therapy will help the therapist to see first-hand how a client interacts with others and behaves in a social situation, allowing the therapist to provide targeted feedback and suggestions to each client (Cherry, 2017).
The American Psychological Association notes another important benefit of group therapy: diversity. We all have different experiences, backgrounds, and personalities, which leads us to our own unique perspective on the world. Working with a group can help clients see things from a new perspective, which may illuminate new ways to take on old problems and new strategies to overcome obstacles that seem insurmountable (APA, 2017).
To make sure you are taking advantage of these benefits of group therapy, follow these suggestions from Dr. Patti Cox, the president of the Eastern Group Psychotherapy Society and experienced group therapist:
- Take a pledge. Signing a contract that outlines what is expected of each participant can encourage participants to engage and contribute to group discussions, and provide incentive to engage even when it is difficult.
- Participate. Some days are more difficult than others when it comes to socializing and sharing with others, and that’s okay. However, the more a client pushes him- or herself to engage, the more likely they are to benefit from the session.
- Share. Even if a client feels that nobody cares about their problems or they have nothing useful to share with the group, chances are this is not consistent with reality. Everybody has something to share with others, and helping others has a funny way of helping you as well (Cherry, 2017).
You can download the printable version of the infographic here.
Common Discussion Topics in Group Therapy
The topics discussed in group therapy will depend on the focus of the group. Some groups are formed for specific reasons, like dealing with addiction or grief, or specific diagnoses, like depressionor anxiety, while others are formed for broader purposes, such as anyone struggling with stress in college or LGBTQ individuals who could benefit from general social support.
The long list of reasons that a therapy group may be formed includes:
- Death of a loved one
- Marriage problems
- Family problems
- Loss of a job
- Social anxiety
- Substance abuse
- Major life transitions
- Breakup or divorce
- Child behavior problems
- And many, many more
In groups formed around substance abuse, discussion topics may include:
- Stay-busy activities (to cope with cravings)
- Preparing a speech for students (whether the speech will occur or not)
- Challenging perceptions
- Role models and behaviors to emulate
- A history lesson and planning for the future (history of substances and future of substance use and legality in the group’s country)
- Self-care (SimplePractice, 2017)
Blake Flannery (2014) outlines seven major categories of discussion topics and provides suggestions for each category. These topics include:
- Health and Wellness
Recognizing warning signs
- Personal Control
Cognitive Behavioral Therapy (CBT) or Rational Behavioral Therapy (RBT)
Grief, loss, and forgiveness
- Values and Beliefs
- Safety Planning
Warning signs for recidivism
- Mental Health Systems
How to talk to your doctor
How to get the support you need
- Chemical Dependency
12 steps / Alcoholics Anonymous or Narcotics Anonymous
Dual diagnosis (co-morbidity of multiple mental health conditions)
As this list of suggested topics demonstrates, there are dozens, if not hundreds, of topics for discussion in group therapy. Some of them will only be appropriate or effective in specific groups or situations, but some will be useful in all types of groups. The best discussion topics will depend on the focus of the group, the stage of treatment, and the type of session.
7 Group Therapy Ice Breakers and Activities for Adults
In addition to specific topics for discussion in group therapy, there are many other activities and exercises that can be conducted effectively in groups. A few of these activities are described below.
Session Planning PDF
While this PDF is not an exercise or activity per say, it does provide an excellent resource for planning your first group session. You will find session objectives, procedures, planning tips, discussion questions, and more in this PDF.
The activities and procedures are geared towards addiction or substance abuse groups, many of the suggestions and planning materials can be applied to any therapy groups.
For example, the PDF includes a set of group rules and a guide on discussing the rules with group members. These rules can be extended to many other groups, including:
- Maintain confidentiality
- Attending group on time and calling if you cannot make it
- Not discussing absent members in the group
- Completing any homework assignments and bringing them to the group
- All members need to participate in all sessions
In addition, there are excellent suggestions for questions the therapist can ask to facilitate discussion on goal setting and goal striving, including:
1) How realistic is your goal?
2) What obstacles, if any, are you experiencing in trying to achieve your goal?
3) You made some very major changes in your alcohol or drug use (or anger management, negative automatic thoughts, etc.). How were you able to do that and how do you feel about these changes?
This PDF provides tons of other information and suggestions for positive group interaction. To see what else it has to offer, follow this or this link.
Relationship Growth Activity
This activity can be an excellent icebreaker for couples therapy groups. These questions don’t probe too deeply, but can be a good reminder of the couple’s emotional connection and relationship history. In addition, it can help them learn more about themselves and their partner.
The instructions are for the couple to simply take turns asking each other a question from each section below, or ask them all if they want a challenge or believe they have the right answers.
The questions are divided into six categories:
- The Fun Things (example question: What song is your partner into right now?)
- About Us (example question: When did your partner realize they were interested in you? Was there a specific moment?)
- Hopes & Dreams (example question: What is the happiest life your partner can imagine?)
- Work Life (example question: What is the most challenging task your partner has to do at their job?)
- Emotions (example question: When in your partner’s life did they feel the most scared?)
- Other Relationships (example question: Who does your partner feel closest to in their family?)
Asking and answering these questions can help couples feel closer, learn about each other, and reminisce or dream for the future together. If the couples are comfortable with this idea, they can share out to the group on something they learned about their partner or a fun memory they recalled together.
You can find this worksheet here or here.
Two Truths and a Lie
This activity is a great icebreaker, but is also fun to do with group members that are already familiar with one another. It allows participants to share something about themselves, use their creativity and imagination to come up with a convincing lie, and learn interesting things about the other group members.
To lead a group through this activity, instruct all group members to take a few minutes to think about interesting aspects of their life. Give them five minutes or so to write down three “facts” about them, two of which are true and one of which is a lie.
Then, have the group members take turns reading their two truths and a lie, and let the other group members guess which ones are true and which one is a lie.
This activity can spark some great discussion and encourage positive social interaction between group members, so make sure not to cut it off too early.
Addiction Discussion Questions Handout
This handout provides six discussion questions for therapy groups focused on substance abuse and addiction. These questions can spark enlightening discussions between group members and promote the sharing of experiences, strategies, and techniques.
These questions cover a few different topics and will provide excellent fodder for deep and meaningful discussion about coping with and overcoming addiction.
The first question is written as follows:
“Oftentimes, a person’s relationship with drugs and alcohol will change over time. For example, drugs might start out as a fun ‘every now-and-then’ activity, but eventually become an everyday habit. How has your relationship with drugs changed from the time that you first used to now? Do you still use for the same reasons, or have those reasons changed?”
To see the other questions or print this handout for use in your group sessions, click here or here.
Engaging group members in an activity that requires both busy hands and concentration is a great way to help anxious members get comfortable with one another and open up.
Cooking is perfect for this type of activity, since it gets members working together, doing something fun, and it requires interaction with the other members of the group.
Further, the idea that food is a universal language is a common one, because it is one of the few things that brings everyone together! Everyone eats, and virtually everyone likes to talk about their favorite foods.
Gather the ingredients necessary for group members to work together to create a meal or snack that everyone can enjoy. Salads, sushi, and smoothies are recommended options for this activity since they don’t require a full kitchen to make.
If you want to capitalize on the atmosphere facilitated by group cooking, you can come up with discussion questions to guide the group afterwards.
To read more about this activity and other activities that can act as icebreakers or therapeutic group exercises, click here.
This activity is a great way to encourage teamwork and warm group members up for discussion.
You will need a different colored marker, crayon, or colored pencil for each group member and a large sheet of paper.
Give each group member a different colored market, crayon, or pencil and instruct them that this is the only color they can use throughout the project.
Next, show the group a picture and tell them they will need to work as a group, each using only their assigned color, to draw and color in this picture.
Once participants have finished drawing and coloring the picture, guide the group through a discussion using these questions:
- Was this a difficult task for the group? Why or why not?
- How did you work as a group to complete the picture?
- Was teamwork needed or could everyone work on their own. Is everyone in the group happy with the picture that was created? Why or why not?
- Is it easier to do things by yourself or with others?
- Why is it important to be able to work with others as a member of a team?
This activity and the following discussion will give group members a chance to work together, to think about why teamwork is important, and consider what they can do to be a better teammate.
To learn more about this activity, click here.
As noted earlier, most therapy groups begin with each member “checking in,” providing any progress updates, and perhaps sharing something interesting about their week or something they have learned since the last session. If you are working with members that don’t jump at the chance to speak in front of the group, having a specific set of questions to guide the check-in process can be helpful.
Group therapist Amanda Fenton provides an excellent set of guidelines and suggestions for check-in questions.
Fenton (2014) encourages therapists to ask themselves these questions when considering an effective check-in question:
- How much time do you have for the check-in? Two sentences? Two minutes? Five minutes?
- How can the check-in connect and support the rest of the agenda and the overall purpose of the gathering?
- What kind of tone do you want to create through the check-in? Playful? Serious? Connecting?
- Is this a group that is familiar with check-ins and has been meeting together regularly?
The most appropriate check-in question will depend on your answers to these questions.
For example, if you have time for a longer check-in from each member, a phrase like “Tell us the story of…” can be a good prompt for members to share more than a few words. If you’re short on time and just want a quick update, using “Say a few words on…” may be the better option.
To see these tips and check out Fenton’s long list of potential check-in questions, click here.
10 Group Therapy Techniques, Ideas, and Games for Youth and Teens
Many of the exercises and activities described above can be applied to group therapy with younger members, but some are more appropriate than others. Several exercises and techniques that work well in younger groups are listed below.
Icebreakers and Trust-Building
This section is actually a sort of bonus section – it includes over two dozen different ideas!
There are many icebreakers that are appropriate for both teens and adults in group therapy.
Some examples include:
In this icebreaker, participants are asked to organize themselves into smaller groups based on a category, such as favorite color, favorite food, number of siblings, etc. It will help teens to get more comfortable interacting with each other and learn something new about the other members.
This activity requires group members to physically interact with each other, so it may not be appropriate for all groups. All members get in a circle and take the hand of someone who is not right next to them, then try to unravel the knot they have created without letting go of anyone’s hand.
Fear in a Hat
This icebreaker is best applied in a setting where everyone is at least somewhat familiar with the other members of the group. Everyone writes down their deepest, darkest fear on a piece of paper. These pieces of paper are gathered and placed in a hat. Each member will draw one fear each, read it aloud, and try to identify who wrote it.
Trust-building activities are also great ways to get group members comfortable with one another and encourage a safe and secure place to share.
Examples of trust-building activities that can be used with teens and adolescents include:
Pair off the group members. If there is an odd number of members, the therapist can pair with a member to make it even. Instruct each pair to blindfold one member and tell the other member to guide them around the room in search of a particular object or objects. If there is enough time, the partners can switch when the object(s) has been found.
This extremely simple exercise simply divides members into pairs and requires them to look into each other’s eyes for 60 seconds. Maintaining prolonged eye contact will help group members get comfortable with each other, practice an important part of social interaction, and connect with each other on a deeper level.
This classic trust exercise is still a great way to build trust within a group. Have each member take their turn climbing onto a table and falling backwards into the other members of the group without looking behind them. This one is a classic for a reason – it works!
To see more icebreakers and trust-building activities, visit this page.
This engaging activity is a great opportunity for teens and adolescents to exercise their creativity and express themselves.
Instruct each member to bring to mind their most joyful memory. Once each group member has settled on a happy memory, have them prepare a scene based on this memory.
They will need to cast other group members in whatever roles are necessary, write lines or suggest ideas for lines, and direct the scene.
The other group members are encouraged to watch the scenes and share the feelings and memories that each scene brings to the surface.
You can read about this activity here.
This activity is great for children and young adults, with a perfect mixture of creativity, imagination, silliness, and active engagement in a task.
Instruct the group members to come up with their three favorite animals, in order. For each animal, the members are to write down the name of the animal and write three qualities you like about the animal.
Once each group member has identified and described their three favorite animals, ask them to consider that each animal represents you, in different ways. The first animal and its three qualities represent how you want others to see you, the second represents how people actually see you, and the third represents who you really are. This can be a great discussion for group members, helping them to explore their thoughts and feelings in a fun and easy way. It can also generate a lot of laughs!
Finally, have each member combine their three favorite animals into one, and draw or paint a picture of this animal in its habitat. Tell the members to share these creations with the rest of the group, and prepare for a silly discussion!
You can read more about this activity and others like it here.
Thoughts, Feelings, and Behaviors Worksheet
This worksheet can be a great tool for families with young children in therapy. It is intended for a child to complete, and the results can be discussed as a family to facilitate understanding and come up with solutions for family problems.
This worksheet includes an outline of a person or child with six boxes to fill in, three on each side.
The directions instruct the child to fill in this blank “When I am…” with a specific emotion.
Thinking about this emotion in a specific situation, the child is instructed to fill in the three boxes on the left side of the worksheet:
- I think… (box pointing to the head)
- I feel like this in my body… (box pointing to the midsection)
- I behave this way… (box underneath the feet)
Once the child has filled in these three boxes, their next step is to imagine that their thoughts change. Maybe this is a natural change, or maybe they are instructed to imagine their reaction if they purposefully change their thinking to something more positive.
When the child has this new thought in mind, they fill in the same three boxes, except these are on the right side.
This exercise can help the child compare how they think, feel, and behave when they are struggling with an emotion to how they might think, feel, and behave if their thinking changed. It can help children to understand the value of modifying their thinking to make it more positive, in addition to helping parents and other family members understand what the child is going through.
You can find this worksheet at this or this link.
Know Me More
This activity is most effective with a group of five or more members.
Come to the group session with a list of questions prepared. These questions should be fun and interesting questions that will help the members get more comfortable talking about themselves.
Potential questions could include:
- Where would you be now if you were not in this group?
- What motivates you to come here?
- What is one thing about yourself that makes you proud and happy?
- What is one thing about yourself that you are not proud of?
Nominate one member to be the questioner, or the therapist can act as the questioner.
Ask each member one of these questions, or all of these questions if time permits, and encourage them to give it some thought and answer it honestly and in a meaningful way.
These questions will help group members to become more comfortable talking and sharing with others, as well as helping members learn about one another. They can be found at this link along with other ideas for teen therapy group activities.
4 Group Therapy Exercises and Worksheets for Depression and Anxiety
Group therapy is commonly used in the treatment of people with depression and anxiety. A group setting is a perfect place for people suffering from depression or anxiety to connect with others, practice important social skills, and learn healthy coping strategies from each other.
While many of the activities and exercises mentioned above can be applied to individuals with any diagnosis or issue that brings them to therapy, there are some that can be especially effective for those with depression or anxiety. A few of these exercises and worksheets are listed below.
Coping with Stress
While the experience of stress is not exclusive to those with a diagnosis of depression or anxiety, those suffering from these disorders often have the most trouble coping with stress. Many of those struggling with depression or anxiety will turn to unhealthy, unhelpful, or even harmful ways to cope. This activity can help them find new, healthy ways to cope.
This exercise requires only a poster board and a marker, as well as enough group members to split into smaller groups of two to four members each.
Instruct the group to nominate one person to write and another to present to the larger group.
Tell the group that they will be discussing healthy ways to cope with stress, and encourage them to come up with at least 10 ways to cope in a healthy manner. For groups of teens or children, it is helpful to provide a few examples to get them going. Providing two examples of ways you personally cope should be enough to get the ball rolling.
Give the groups a set amount of time to brainstorm and discuss. Once each group has come up with a list of at least 10 coping mechanisms, have the presenter in each group share the group’s mechanisms out to the larger group.
This activity can spark a great discussion about coping, what is healthy and what is not, and identify new strategies for coping.
To extend this discussion, you can instruct members to identify a situation in which they would use each technique.
For more information on this activity, click here.
Setting and striving towards goals can be tough for us all, but for those struggling with depression, even setting a realistic goal can seem like a monumental task. To help group members set and work towards their goals, this activity can help.
This activity can be applied in each group meeting and discussed in the next group meeting.
The therapist should preface the first practice of this activity with a discussion on the importance of setting small, realistic, and measurable goals.
Once each group member has an understanding of how to set good goals, end the session by giving each group member a piece of paper and a pen and instructing them to set one small, measurable goal for that week (or until the next session). Collect the papers once the members are done.At the beginning of the next session, hand out the papers and tell members to think about what they have done to achieve those goals since the last session. This can be done individually or in a group, although it may be best to save the group version for later sessions to allow members to get comfortable with one another.
This activity will help group members learn how to set small, realistic goals and, hopefully, give them the experience of meeting these small, realistic goals.
Click here to read about this activity.
Schema Activation Formulation
This cognitive therapy worksheet can help clients trace the development of a particular schema and understand the subsequent reactions, sensations, and choices he or she makes.
On the left side of the worksheet is a box labeled “Event.” The clients should think hard about when they first developed a particular schema and trace it back to the event that created it. For example, if a client feels they will never be good enough, perhaps this schema came from a parent who gave no praise for a big accomplishment or told the child they didn’t do well enough.
Next, this box leads to a triangle labeled “Schema.” This is where the clients should write down the schema they hold, such as “I am not good enough.”
This schema leads to a set of four interrelated and interacting consequences of the schema: bodily sensations, emotions, thoughts, and behaviors. The clients should fill in each box with the corresponding descriptions of how this schema makes them feel, think, and behave.
Completing this worksheet in a group setting can help clients connect with each other and realize that they are not alone in their negative thoughts and beliefs. It can be far too easy to believe that we are the only ones struggling and suffering with mental health or emotional problems, but this is far from the truth. Working in a group will help relieve clients of this false belief and encourage them to share and connect with others.
This worksheet will be available for download soon.
Cracking the NUTS and Eliminating the ANTS
This fun activity is based on the work of renowned psychologists Elisha Goldstein, Aaron Beck, and David Burns.
NUTS refers to Negative Unconscious Thoughts, an acronym created by Goldstein and described in his book Uncovering Happiness. He believed that identifying and bringing awareness to these thoughts was the first and most important step in ridding ourselves of our negative, unhelpful, or harmful beliefs.
ANTS refers to Automatic Negative Thoughts, an acronym coined by David Burns in his groundbreaking book Feeling Good. Burns finds that these ANTS can cause depression and anxiety and lead to low self-esteem, self-doubt, and a host of other problems.
For this activity, the therapist should lead the group through a discussion of NUTS and ANTS, terms which can be used interchangeably when talking about the self-sabotaging habits we have.
To begin, have each group member write down five phrases that put the NUTS and ANTS into words, such as “I’m not good enough,” “There’s something wrong with me,” or “I don’t deserve to be loved.” Have group members reflect on these NUTS and ANTS, and identify any themes or patterns that connect them. Encourage members to discuss them as a group or in mini-groups.
Next, tell group members to think about how certain they are that their ANTS and NUTS are true. Have they ever challenged these thoughts? Can they find evidence for or against the ANTS and NUTS? Considering the evidence, which possibility is more likely: that they are true, or that they are false? Help them think of more factual ways to reframe these beliefs, such as “I am not perfect, but I don’t need to be,” or “I am a good person who sometimes makes mistakes.”
Finally, help group members see how much these NUTS and ANTS infiltrate their thoughts. Give group member s a few minutes to identify their NUTS and ANTS and count how many they can identify within a certain period of time. When they are done, they can share their counts and their NUTS and ANTS with the group, if they are comfortable doing so.
To learn more about this exercise and to see a companion worksheet to go with it, click here or here. This activity is a sample from Judith Belmont’s book 150 More Group Therapy Activities & TIPS, which will be described in more detail below.
Best Books, YouTube Videos, and Podcasts on Group Therapy
The following books, videos, and podcasts are packed full of information on group therapy. Whether you’re a therapist who already facilitates group therapy, a mental health professional who is looking to incorporate group sessions, or simply curious about group therapy, you will find value in these resources.
Theory and Practice of Group Psychotherapy by Irvin D. Yalom and Molyn Leszcz
This book is an excellent book for those who wish to learn about Yalom’s signature group psychotherapy model. It can also be used as a textbook for therapy students or a resource for practicing therapists who wish to add group therapy to their practice.
Not only does this book cover the basics and the foundational assumptions and theories behind this group therapy model, it was also recently updated to include new developments in the field. Added topics include online therapy, specialized groups, ethnocultural diversity, trauma, managed care, and more.
This book enjoys a very positive 4.4 rating on Amazon, and boasts a litany of appreciative reviews. Click here to check out some of these reviews or purchase the book for yourself.
150 More Group Activities and TIPS (Treatment Ideas & Practical Strategies) by Judith Belmont
This book is a valuable addition to the therapist’s toolbox. It includes 150 activities, handouts, and strategies that can be used in group therapy. For each exercise or handout, the author breaks it down into the theory behind it, how to implement it, and how to understand and apply the results.
The author draws upon Dialectical Behavior Therapy, Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and positive psychology to provide effective and engaging activities that will have a positive impact on clients’ treatment experience.
150 More Group Activities and TIPS builds off of the author’s previous book, 103 Group Activities and TIPS (Treatment Ideas & Practical Strategies). You can find the original book here and the new book here.
YouTube Video: Essential Skills for Effective Interpersonal Group Facilitation
In this YouTube video, psychologist June Lake discusses the Yalom model of group psychotherapy. You will learn about the foundations of this model, the necessary skills required to facilitate this type of therapy, and a brief overview of the approach. In addition, June discusses some of the most common mistakes new group therapy facilitators make and how to avoid them.
YouTube Video: Leading Therapy Groups with Adolescents
If you’re curious to see an actual group therapy session unfold, this video can sate that curiosity! In the video, two group therapists facilitate a group therapy session with high schoolers. You will get an idea of the atmosphere of a group therapy session with adolescents and a model of effective facilitation from the two therapists. In the video description, there is a link to the full video if you’re hungry for more.
Podcast: Using Groups to Fill Your Private Practice
This podcast from Jennifer Sneeden and Katie K. May is a great resource for therapists who are considering the addition of group therapy sessions or workshops into their practice. Katie is a counselor in Philadelphia who runs a successful private practice, and in this podcast she shares some of the keys to her success.
Click here to check out the podcast.
Podcast: Benefits of Group Therapy
In this podcast, Krstine Hitchens, the Director of Family Programs at the Father Martin’s Ashley addiction treatment center, discusses the importance of group therapy in the treatment of addiction and outlines the many potential benefits.
You will find this podcast here.
You can download the printable version of the infographic here.
Group Therapy and Group Counseling Near Me
If you are interested in taking advantage of group therapy or counseling, the options available will depend on your location. A quick Google search for “group therapy near me” should turn up some helpful information.
However, if Google isn’t delivering on this search, there are a few helpful websites you may want to check out:
- The Mental Health America website can help Americans struggling with mental illness find groups to support or supplement their treatment.
- NAMI (National Alliance on Mental Illness) is another great resource for people in America.
- MeetUp is usually used for finding like-minded friends to share a hobby with, but it can also be used to find an informal support group.
- This website can also help match you with informal support groups for anxiety, depression, and related issues. Its results are generally within the United States, but there are some listings for groups in Australia, South Africa, and remote support groups.
A Take Home Message
This article is chock full of activities, exercises, worksheets, and techniques that can be put to effective use in group therapy. Most of these activities and exercises can be applied in a wide range of group therapy situations.
I hope you have found this article as informative and useful as I found researching it. Whether you’re a therapist or other mental health professional, or just curious about how group therapy can benefit you, you should find at least a few things in this piece that add to your knowledge or set of tools for group facilitation.
Let us know what you learned or found especially interesting in the comments below. Would you use any of these activities in your practice? Do you have any tips or advice on how to implement these activities and techniques?
As always, thank you for reading!
- APA. (2017). Psychotherapy: Understanding group therapy. American Psychological Association. Retrieved from http://www.apa.org/helpcenter/group-therapy.aspx http://www.belmontwellness.com/
- Cherry, K. (2017, May 20). What is group therapy and how does it work? Very Well. Retrieved from https://www.verywell.com/what-is-group-therapy-2795760 Counselling Connection. (2010, September 8). Types of therapuetic groups. Counselling Connection. Retrieved from http://www.counsellingconnection.com/index.php/2010/09/08/types-of-therapeutic-groups/
- Fenton, A. (2014, April 12). Check-in question ideas. Amanda Fenton. Retrieved from http://amandafenton.com/2014/04/check-in-question-ideas/
- Flannery, B. (2014, August 11). Group therapy topics: Mental health educational activities. Hub Pages. Retrieved from https://hubpages.com/health/Group-Topics-for-the-Mentally-Ill
- Good Therapy. (2013, December 18). Group therapy. GoodTherapy. Retrieved from http://www.goodtherapy.org/learn-about-therapy/modes/group-therapy
- Orenstein, B. W. (2014, November 25). 6 benefits of group therapy for mental health treatment. Everyday Health. Retrieved from http://www.everydayhealth.com/news/benefits-group-therapy-mental-health-treatment/
- SimplePractice. (2017, January 11). 8 substance abuse group topics for addiction treatment counselors. SimplePractice. Retrieved from https://www.simplepractice.com/blog/substance-abuse-group-topics-addiction-treatment-counselors/
About the AuthorCourtney Ackerman is a graduate of the positive organizational psychology and evaluation program at Claremont Graduate University. She is currently working as a researcher for the State of California and her professional interests include survey research, well-being in the workplace, and compassion. When she’s not gleefully crafting survey reminders, she loves spending time with her dogs, visiting wine country, and curling up in front of the fireplace with a good book or video game.
Broder, M. Making Optimal Use Of Homework To Enhance Your Therapeutic Effectiveness. Journal of Rational– Emotive & Cognitive-Behavior Therapy, Volume 17, Number 1, Spring 2000.
MAKING OPTIMAL USE OF HOMEWORK TO ENHANCE YOUR THERAPEUTIC EFFECTIVENESS
Michael S. Broder
Homework is a well-established yet extremely under-emphasized aspect of the Rational-Emotive/cognitive behavioral orientation. This article recognizes homework as being a very powerful tool that needs to be incorporated into treatment in order to make it more efficient and effective. The author presents numerous techniques that can be used with virtually any therapeutic approach to maximize the impact of therapy between sessions. They include audio and bibliotherapy, goal setting, SUD Scale, mood management, disputation, affirmations, mood diary, list making, guided imagery, visualization, relaxation and meditation techniques, exposure, and thought stopping techniques. The article concludes with a discussion of why clients display resistance to homework along with some approaches that can be taken to address this resistance.
The use of homework in psychotherapy is a well-established protocol of the Rational-Emotive/Cognitive Behavioral orientation and one of Albert Ellis’ many great contributions to the field. Trademark homework assignments include reading, forms of exposure to an anxious situation, making a decision, and taking a risk such as confronting someone or something more easily avoided (Ellis, 1962; 1996).
Homework empowers our clients to make and see progress on their own. To a great degree, homework can enable your client to become your collaborator in their treatment. Homework can also help you to assess your client’s motivation. After all, if you get an agreement to do a certain type of homework and at the next session it is not done, that can tell you much about a client’s motivation. And one area where most therapists agree is that a client’s level of motivation is one of the greatest predictors of whether treatment will be successful. Yet in most REBT and Cognitive Behavioral literature, homework remains quite underemphasized.
Homework can also be a great focusing tool. But only if it is clear, specific, measurable and doable. “Clear” means that you and your client are on the same page as to what the homework assignment involves; for example, what reading to do or whom to confront. “Specific” means that the homework assignment zeros in on your client’s problem in such a way that its relevancy is obvious to both of you. For example, if you were to assign as homework a relaxation exercise, there would be, hopefully, no question about the relationship between that assignment and the issues you are working on in therapy. “Measurable” means that both you and your client can objectively evaluate the extent to which the assignment was completed so there is no question as to what you mean when you ask if the reading was done or if the list was made. An assignment that is “doable” is one that can be completed by the client. In other words, its outcome depends only on the actions taken by the client and not necessarily on the agreement and! or cooperation of others. An example of a bad homework assignment would be to have the client agree to get a job or to get a date. Instead, you might encourage your client to send out a certain number of resumes or to approach an agreed upon number of people for a date. In these examples of homework, no one else’s agreement is necessary for your client to complete the assignment successfully. On the other hand, getting a job or a date requires the compliance of someone other than the client.
The main premise of homework is a recognition that real changes occur outside your office, not inside your office. In that spirit, I believe that work done by clients between therapy sessions is often as or more important as what is done in the session itself. The main challenge is to make homework as relevant and user-friendly as possible. Homework assignments need to be designed using the principle of successive approximation making sure that the step or steps assigned to be taken are not too large or too small, especially when you are dealing with difficult clients or AXIS II cases.
My personal preference is to have clients spend at least as much time doing homework as they spend in therapy. This is not an absolute or even an optimal amount, but a minimum guideline that I will generally discuss with each client. Another guideline is for you, the therapist, not to work harder than your client. All of us who have done therapy for any length of time know that this can be easier said than done, especially with some of Your more difficult cases. However, this is still a worthy goal.
In this article I offer a smorgasbord of ideas designed to help you do what you do more effectively by making maximum use of the 167 hours in between sessions as well as the therapy hour itself.
Here are a variety of techniques that you can use to engage your clients in between sessions. I will give a flavor for how they can be used as homework assignments with the understanding that they need to be tailored and fine-tuned to suit the Particular needs they are designed to address.
TECHNIQUES THAT CAN BE USED IN BETWEEN SESSIONS
Bibliotherapy and Audiotherapy
Bibliotherapy is assigned reading that is specific to the issue that you are working on in treatment. Few would dispute that the right reading is a great tool; provided, of course, the client does the reading. There are many sources of good and relevant reading information that is available to address virtually any issue (Ellis, 1993). The main problem with bibliotherapy is that clients are not as likely to read as they are to use approaches that require less effort. In addition, different people read and comprehend their reading with considerable variation. Another consideration is that most self-help material is oriented toward women. This is because publishers have long recognized that women out-buy men by a margin of more than four-to-one in the category of bibliotherapy_ type (self, help) materials (Holm, 1998).
One of the best ways to address these bibliotherapy problems is by using audiotherapy or assigning clients to listen to appropriate audiotapes that reinforce the material covered in your session in between sessions_ I have found that audiotherapy is more effective than its bibliotherapy counterpart simply because people are way more likely to listen than to read. If a tape is one-hour long, it will take everyone regardless of his Or her skill level one hour to listen to it_ Also, self-help audiotape publishers. have found that men are as likely some cases more likely) to listen, as are women. In addition, both men and women can listen to audiotherapy assignments while driving cars, exercising or walking, and at other times when they mao the mood to take on one more activity-such as listening not distract them from what they are doing. Proper listening as reading) provides the repetition of information that can h malize the issue(s) they are working on, as well as a reinforce of what is being said and worked on in treatment. When us assigned correctly, audio therapy goes a long way to free the hour so that you may concentrate on resistance and other issue5 more unique to your client.
Repetition is an important aspect of teaching difficult info In my experience, an overwhelming number of clients are more to listen again and again to get that needed repetition than the~ read and reread bibliotherapy material.
For example, if self-evaluation is the issue, they need to learn in the session and by virtue of the homework they are assign whenever they engage in global rating as “I am no good,” an generalization is taking place (Broder, 1995). Then your client disputation and other cognitive restructuring techniques as mo vant.
Clients who are going through major changes need to learn t. and doubt is quite normal, while generally not desirable. Client are working on relationships and sexual issues need to unde~_ that many myths can cause dysfunction. For example, the m in a good relationship orgasms are simultaneous and automatic very dysfunction-causing (Broder, 1996). Where better can a learn that these myths could explain why they may negate sex doing reading or listening to material that makes these points to force what they have learned in their therapy sessions.
Sometimes the easiest part of therapy is communicating info and misinformation about an issue, but at the same time it can one of the most time-consuming parts of treatment. Many thera have trained and supervised over the years have confided that th . tired of going over the same points with client after client after and, therefore, find that they develop a tendency to avoid doing remember the function of biblio- and audio therapy is to give that mation that you the therapist may take for granted, to encourage tition of it, and to reinforce what you are teaching and working the session. Thus, audio- and bibliotherapy can be considered a e ine form of mentoring.
There are several other audiotherapy approaches you can employ.
Many therapists make up relaxation tapes for their clients as well as tapes on other topics. Another fine technique is to encourage your clients to tape their therapy sessions for re-listening. This can be done by bringing their own tape and tape recorder to therapy sessions. They keep the tapes to listen to, perhaps, several times in between sessions. This is a practice that can be quite helpful in getting clients to hear much of the things they “know intellectually” but need to learn on an emotional level. Repetition of this type is one excellent way to achieve a breakthrough with hard-to-integrate material. An often helpful follow-up to this approach is to give your client a short (but expected) “quiz” on things that were said during the previous session, based on the tape they produced in therapy and, hopefully, listened to in between sessions. Finally, there are many audiocassette programs that can be used for audiotherapy purposes. Over the past few years I developed a series of audiotherapy programs that incorporate numerous techniques into a series of self-contained homework assignments with reproducible exercise worksheets which I call The Therapist’s Assistant (Broder, 1995; 1996). This series was edited by Albert Ellis and is one of many resources at your disposal.
Covering all the steps and ramifications of goal setting and goal prioritizing is often impossible to do within the time constraints of a therapy session. Yet, it is an extremely important step in the therapeutic process. So having your client work on goals-whether or not they were goals established during your session-is a great use of homework time. This includes identifying all the important aspects of the goals-all of the Who, What, When, Where and Why questions. A basic goal-setting homework assignment exercise will have the client come into the next session with answers to all of these questions: What is the goal? What do you want to accomplish by reaching it? Who is it that can be involved in this besides you? That is, who, if anyone, can help you achieve it? When do you want it accomplished by? Where is it to take place? And most importantly, why do you want to achieve this goal anyway? Once your client’s issue or reason for being in therapy is defined and fine-tuned, then the goal (what the situation would be if that issue were resolved) needs to be just as finely tuned.
The next step in goal setting is to think about and write out a strategy or plan which is defined as the shortest route between Point A (the issue) and Point B (the goal); and then, lining up whatever support is needed to achieve the goal becomes the next homework step. This can be done at home; and is also excellent material for your next session.
When there are many goals, prioritizing them is important; and goal prioritizing is also an excellent homework assignment. For example, consider a client who has lost his job and presents with a multitude of therapeutic issues. He may be depressed, feel a lack of direction, be experiencing a low level of self-confidence, and be nervous about a job interview. You have a litany of presenting problems: depression, the self-evaluation problem, you may have to help him deal with what his choices are with respect to which career moves are next. There might also be performance anxiety about taking the job interviews, anger at the boss who let him go, and marital problems at home as a result of all those things all triggered by this crisis. So finding out where the most energy is by having your client prioritize those issues and goals is a very important step. Doing this as homework can afford your client the quiet introspection this task deserves.
As a part of goal setting, it is also helpful to have your client break each defined goal into manageable steps or sub-goals. For example, there may be several smaller goals that are necessary to reach before taking that first job interview. After all, pushing your client to go right for something that may be perceived as extremely anxiety-producing such as (in this case) a job interview could be quite an approximation error that results in avoidance or a setup for failure. So the sub-goals are smaller steps that can be defined and attempted between sessions. They are ripe for discussion at your next session.
The SUD Scale (Wolpe, 1991) is an excellent way of teaching your client to quantify his or her feelings. SUD is an acronym that stands for Subjective Units of Distress (discomfort or disturbance). It measures the degree of intensity of a particular feeling or reaction on a scale of zero to ten. If you were measuring anxiety, for instance, “zero” would be no anxiety at all. A SUD of “one” would be a very small degree of anxiety whereas a “ten” would be an extreme amount of anxiety.
This can certainly be used for a variety of applications during your session. But an effective homework assignment is to haveyour clients create a customized anxiety barometer by having them identify on the scale of zero to ten something that would help trigger each level of anxiety they could feel. For example, a SUD barometer for anxiety could look like this:
Level One. While sunbathing a rain cloud appears
Level Two. Being a little bit late for dinner reservations Level Three. Having to send food back to a restaurant Level Four. Getting caught in traffic jam
Level Five. Having a flat tire while in a rush
Level Six. Asking someone you find attractive out for date while there is a real chance of being turned down
Level Seven. Waiting outside the boss’ office when there is a possibility of being fired
Level Eight. Speaking to a large and intimidating audience
Level Nine. Waiting to hear a medical report that is potentially life-threatening
Level Ten. Driving a car that is swerving out of control toward an embankment
This is just one example of an anxiety barometer. As a homework assignment, I routinely have clients who talk about anger, depression, anxiety or guilt start keeping track of just how angry, anxious, depressed or guilty they feel during the week by identifying what their potential range of the emotion is. You will find this particularly helpful, for instance, with depressed clients who negate their progress whenever the slightest twinge of depression appears, even though they may have been depressed at an eight or nine when they first started to see you and are now down to perhaps a three or four. This is quite a significant change, but if they have the tendency to negate their progress, it may be difficult for them to keep their own perspective on how far they have come without using something like a SUD Scale to keep track of their depression at home.
You can also determine together at which SUD level it might be most appropriate for your client to approach a threatening situation. For example, in the case of the client who has lost his job and is in the process of readying himself for another job interview, you may be able to collaborate and establish a target level for anxiety on the SUD Scale as the optimal point at which he would be ready to commit to actually start taking job interviews. This approach is especially indicated for someone who has demonstrated a tendency to be characteristically avoidant. It can also be used in conjunction with several of the homework techniques to be discussed later in this article.
Mood management is teaching a client how to anticipate and then master a mood-when it occurs-instead of becoming overwhelmed by it. This can be used for feelings of anxiety, depression or virtually any other kind of mood situation. The first step with mood management is to have clients identify their internal triggers to the mood and then learn to see beyond them. In other words, clients need to ask themselves “What would be my situation if I could truly master this mood?” Next, clients can learn to work both during the session and at home to develop some strategies that can be employed when finding themselves in circumstances that will predictably trigger the mood. Then, by using mood-changing techniques at the appropriate moment such as certain breathing and posture exercises, they can learn a degree of empowerment over their moods.
One of my favorite mood management exercises that employs numerous techniques you can use as homework is called the “emotional fire drill” (Broder, 1992), where I have clients anticipate-that is, identify and visualize a dreaded situation (e.g., a job interview, asking someone out for a date, or giving a talk to a large intimidating audience). I ask them to imagine the situation going first the best possible way; and then to imagine it going the worst possible way. In so doing, clients can come to anticipate that in between the two extremes generally lay the reality. An emotional fire drill can be done several times a day as a way of rehearsing for an adverse situation and learning how to handle the emotion or emotions so that they in and of themselves don’t become the dreaded situation. Thus, the emotional fire drill technique helps clients to acknowledge and learn at the crucial time they need to know it, the fact that quite often it is their emotional reaction-often the discomfort anxiety-that is dreaded way more than the trigger itself.
Disputation is perhaps the most well-known and widely used classic staple of REBT (Ellis, 1962). Disputations are generally questions that you can ask clients or, in the case of homework, clients can ask themselves. The task here both in therapy sessions and as homework is to teach clients to challenge their own irrational beliefs identified both in and out of the session.
I often have clients come up with and make lists at home of new disputations for material discussed at the last session. These client created disputations can be used whenever the situation calls for it. An example of a disputational question is “How does falling off the wagon mean that I can’t stay sober?” If a client believes “People who divorce are losers,” a disputation question might be: “If I heard that for the first time today, would I believe it?” For clients who believe that their childhood has doomed them to a life of unhappiness, they need to learn to ask themselves-between sessions-“If I had perfect parents and the best childhood of anyone I know, how would I handle (fill in the blank) differently?” This gets them into the habit of first examining and then cross-examining their own errant thinking. A client who believes “My situation won’t improve,” needs to ask, “How do I know that?” “Is that what I would tell someone I really care about who is in the same predicament?” “If not, what would I advise?” The answer to these disputation questions might prompt you to assign the client as homework to make a list of things they would advise their children to do in that situation; and you will often see an entirely different level of wisdom come out.
Effective affirmations are both coping statements and rational beliefs. Something that I have clients do on a routine basis at home is to make lists of their affirmations or coping statements and then look at them several times a day, even when they are not especially feeling the need to. Learning an affirmation on a deep emotional level involves not only looking at it when they are troubled by the issue, but also when they are in a more neutral or positive frame of mind. Coping statements reinforce the notion that poor self-evaluation and low frustration tolerance, and so forth are merely thinking habits. One big advantage to clients of seeing problems as thinking habits is simply that most people acknowledge that habits can be changed. This notion is a much harder sell when clients believe they are dealing with traits instead of habits.
Any time your client says something like “I never thought of it that way” as an answer to a disputation, whatever it is that they have just thought about differently is an excellent addition to their list of affirmations to be studied and reviewed at home. Some other examples of affirmations include, “I don’t have to lose my temper when I’m angry,” “I can handle this,” “I can stand it” (whatever one’s unique “it” may be), “Failing at a task does not make me a failure,” “I don’t have to give into my cravings for (fill in the blanks),” and “These cravings will pass.” It can be very helpful for your clients to put their affirmations on index cards and keep them handy for those times during the week when they are in the mood or simply ready to learn and re-learn this information.
A mood diary is a written record of moods kept by the client between sessions. It can be quite helpful in identifying triggers for anxiety, anger and depression. For example, a well-kept mood diary used for anger management might contain the following information:
What triggered the angry feelings?
What am I telling myself about the trigger?
A rating of the feeling on that SUD Scale of 0 to lO?
Was my angry response to the situation helpful or harmful?
Was it really worth all the attention or energy that I expended to become enraged?
Was there anything I really could have done to make those things that triggered my anger different?
If I had it to do all over again, how would I react now?
How would I advise someone else I really cared about to react or respond in this or another similarly upsetting situation?
What could have been a response that would have disarmed me if I had acted the way my opponent did?
I generally instruct clients that we do not have to spend a great deal of session time with the details of their mood diary, since it is the triggers and patterns that are most important for us to focus on in their sessions. Still, some clients will have a need to go over their entire diary in great detail during the sessions. This is all quite negotiable, but once they begin and continue to keep their mood diary at home, a lot of the dynamics of their moods will become obvious to them.
Making lists is really a way of self-brainstorming. As homework, you can have clients make any number of lists such as “All the people who care about me,” “Things I am proud of,” “Things I can do to feel better when I’m tense,” or “A list of everything that is bothering me” (including every problem, then rank them in order as though they were totally independent of each other), then a “List of solutions.” They can refer to these lists when they are feeling isolated, lonely or depressed. If you work with single clients who believe that they can only be happy if they are in a relationship, have them make a list entitled “Twenty things I now avoid that I would be doing if I were in an ideal relationship.” They will be surprised to see that most of them can be done in one form or another either alone or with a member of their support group right now. I like long lists better than short lists because long lists challenge clients to really think. Using the analogy of exercise, I explain that the pushups one does at the very end of the set are the most beneficial ones. Encouraging clients to get beyond the things they normally think of makes the lists most helpful. And in between sessions is when they have the time to do this activity the most justice.
Another favorite list of mine to assign is “If I could do it all over again go back to age 18 or high school or when single or when married, and so on, (or whatever the hindsight-driven case may be)-what would I now do differently?” (and list twenty or more things). They will find once again that most of the entries on their list can be done in some form now. This particular exercise often helps clients to rediscover their passion while reducing their need to obsess about the past.
Guided imagery techniques such as Rational Emotive Imagery (Ellis, 1962) can be extremely powerful tools for you to teach clients to do at home. They stimulate client’s affectivity through suggestions that create imagined situations rich in therapeutic material.
You can make an imagery tape during the session of your voice that is tailored especially to clients’ issues for them to hear in the session and then re-listen to at home during the week. For example, you can have them imagine a very safe place, or becoming some other person in an interaction where they are having difficulties. If you use behavioral contingencies, you can use imagery to help them produce a list of pleasant images, such as touch or lying on a beach or a warm water effect; or unpleasant images such as loud noise, pain, rodents, or something they identify as being more specifically unpleasant. After awhile, they will begin to use these skills with very little difficulty.
One great advantage you have with audiotherapy is that the tape can actually become the therapist. Additionally, on the tape you can change the entire approach from a didactic to an experiential one. This is ideal for guided imagery between sessions. With guided imagery, you can introduce a trigger or create any situation you would as previously described with the emotional fire drill. For example, clients can create situations that may depress them on the O-to-10-SUD Scale at a nine or ten. You can then teach them how to use various mood-changing techniques to quickly reduce their feelings of depression down to a one or two. And this can be practiced over and over again at home.
A sister technique to imagery is visualization where clients visualize going to some desirable or undesirable endpoint and in their mind’s eye and then work backwards to the present. You can help your clients create a situation that would exist on the other side of the obstacles they are now facing. For example, a client feeling a great deal of anxiety about giving a talk can visualize getting a standing ovation after a superb speech.
If you are working with someone who is ending a love relationship, you can have him or her imagine themselves five years from the present with all of the emotional and practical issues now on the table, having been resolved. You can then help them to come up with a vision of what their situation might be at that blissful time five years hence. From that endpoint, you can work backwards to where they are now. If done well, the result can be a very viable set of goals and plans to get to that visualized endpoint. That is a time projection technique that combines visualization with goal setting and can be done in your office or completed at home with the exercise on tape.
Yet another variation of this technique that can be assigned as homework is to have your clients look ahead and ask “What would I do differently in my life if I had an unlimited amount of self-confidence?” Once completed, clients would then make a list of every possible answer to that question after thoroughly seeing themselves in that much improved state. If any of these visions get too difficult to do in between sessions, chances are they bring up a lot of material that is worth revisiting in the next therapy session with your help in getting through the obstacles encountered.
Relaxation and Meditation Techniques
There are many relaxation and meditation approaches clients can use in between sessions when they are anxious or stressed (Broder, 1993). Many are even available on tape. One very simple meditation technique you can teach your clients without any external props is for them to get into a comfortable posture, and with their eyes closed to think of the word “calm” while inhaling and the phrase let go on the exhale. The purpose of this is to teach clients to bring their relaxation response under their own control. This can be done for any length of time.
A more direct relaxation homework technique is (again with eyes used) for clients to count backwards from ten to one, telling themselves that at the count of one they will feel completely at peace, totally relaxed and that this relaxed state can be maintained for as long – they choose. For clients to return to an alert state, they can be instructed to count forward from one to five. At the count of five, they will be back to the present bringing the relaxation exercise to an end.
This is practiced on a daily basis-once, twice or three times a day they will soon master their relaxation response and will be able to use – practically any time as an on-the-spot technique at the first signs of stress or anxiety.
Exposure is a well-tested procedure of choice to help clients confront an anxiety-provoking situation. By using exposure properly, clients earn to hold their own feet to the fire. To avoid an approximation error (taking steps that are too big resulting in failure), it is often wise ~o use imagery, visualization and other types of rehearsal before clients actually confront in-vivo the “dreaded” situation. Getting to this step is usually an advanced goal of therapy. By this stage, clients are ready to attempt the job interview or get into the elevator (if that is ~hat the anxiety is about) or, perhaps, to face another situation which has been long-feared. For example, if you are dealing with single clients with loneliness issues who are dreading Christmas, New Year’s eve, Valentine’s Day, their birthdays, or even a Saturday night, you can teach them to face that situation head-on with the goal of finding the formula to turn it into a positive situation, or at the very least to prove to themselves that they need not fear those occasions because they can stand (though may not like) them. Clients can benefit from assignments such as going alone to a nice restaurant, to the ballet, to a wedding or to someplace where they have repeatedly felt they could not bear to be unless they were with some special person. A good attitude to teach them is the realization that if the exposure exercise goes better than they thought, that progress has obviously been made. But if older fears are realized, it is still a no-lose situation since they have taught themselves the valuable lesson that they can handle themselves even if they did not particularly enjoy themselves. This insight greatly lessens their fear in performing the behavior again.
Thought-stopping techniques are very effective ways of reinforcing the notion that certain negative emotions may merely be unwanted thoughts that you can learn to control (Beck et aI., 1979). A thought stopping technique is anything that interrupts the pattern or intensity of an unwanted thought. Physical activity such as exercise is often effective. The old rubber band technique where whenever clients begin to experience an unwanted thought a rubber band around their wrist is snapped, giving them a very small amount of quite harmless pain. Thinking about yelling aloud to oneself the word “stop” at the right moment can also interrupt irrational thinking. As well, clients can make a list of things that can be distracters, such as music or anything that will interrupt their negative thought process.
HOMEWORK RESISTANCE: CAUSES, CURES
What can you do with clients who do not complete agreed-upon homework assignments? The answer often lies in the very resistance to change that could be behind practically all of their therapeutic issues. Consider some of these possibilities: Perhaps, some of your homework assignments are too difficult and need to be more carefully fine-tuned. Have your “overly compliant” clients agreed to do more than they were able? Do your clients fully understand the benefits of doing homework? For example, it is possible that the rationale and importance of working on their issues between sessions has not been fully communicated. Are your clients’ non-compliance merely examples of some of the biggest reasons they are in treatment in the first place? For instance, extreme discomfort anxiety-where the issue is short-versus long-term gain-could be the saboteur in many areas. In the short-term, it may be much easier for some of your clients to avoid the immediate pain of change than to challenge themselves with the promise of reward. Likewise, for many discomfort dodgers, it is much easier in the short run to avoid doing the homework, even though in the long run the changes they are seeking in therapy may not be forthcoming. Chances are once you have identified this strand of resistance it will be related to the cause of the presenting problem itself as well as to the resistance to doing whatever it takes to resolve it.
Extremely poor self-evaluation is another possibility for clients failing to complete homework assignments. These clients may be saying to themselves that they are so ineffectual and hopeless that no matter what they do their feelings, circumstances and life will not change anyway. The issue here is hopelessness and helplessness and all the Pandora Boxes to which those issues lead. In these cases, smaller steps resulting in some success are usually called for.
Another factor that can undermine homework compliance is that of a higher order disturbance. Some clients resist solving the presenting problem because they unconsciously anticipate that the solution of one problem will trigger even more serious problems. For example, clients who resist assignments that will help them to become emotionally free of an ended love relationship, may already be fearing and thus avoiding what they have identified as the next logical step the fear of rejection in developing a new relationship. In other words, the presenting problem could merely represent what I have long called a comfortable state of, discomfort.”
With that in mind, here are some simple strategies you can employ immediately to make homework more of a staple in your treatment protocol:
Communicate the importance of homework as early in treatment as possible with emphasis on its benefits to your client.
If your sessions are limited, space them out in such a way as to make treatment as effective as possible by giving ample time to complete homework assignments and exercises. If you do that, make it clear that if your client runs into difficulty additional sessions can be scheduled. Make sure your client understands that sessions are precious commodities.
Give lots of feedback and positive reinforcement when it becomes apparent that homework was completed.
Help your client see how therapy supplements what is being done in between sessions as well as the reverse.
Use both positive and negative contingencies to shape the completion of homework assignments.
Begin sessions by following up on homework assignments. I have found this strategy to be quite helpful in staying focused on one issue at a time. By not following up, homework may be perceived by clients as not being very important. In addition, following up gives you a built-in opportunity to reinforce whatever progress has been made in between sessions.
When you teach clients to do homework you are also teaching them relapse prevention. Those same skills they have mastered in doing homework assignments are the very skills they will need to call upon when the process of life tests them, as it will, over and over again.
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Broder, M. (1995). The Therapist’s Assistant, Volume I. Philadelphia, PA: Media Psychology Associates (available through www.therapistsassistant.com).
Broder, M. (1996). The Therapist’s Assistant, Volume II (Relationship Series).
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Broder, M. (1992). Positive Attitude Training: The Power of Cognitive-Behavioral Psychology (on cassette). Chicago, IL: Nightingale/Conant.
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