Tag Archives: Group Work

Group Work

Group counseling: Neglected modality in private practice

By Kevin Doyle March 7, 2017

After approximately 25 years of working in private agencies, I started a part-time private practice a few years ago focusing on my specialty area of working with clients with substance use disorders. Having worked largely with adolescents, I was looking forward to working more frequently with adults, especially after I had the realization that I was growing older and the adolescents were not.

One of my first efforts at outreach was to my state’s monitoring program for licensed health care providers (doctors, nurses, dentists, veterinarians and so on) because I was aware that these professionals are at high risk of substance use problems for a variety of reasons. Over the past eight-plus years, I have found this area of practice to be both stimulating and professionally rewarding.

As is the case in most states, my state mandates that health care professionals must, following an issue related to a substance use or mental health disorder, participate in its monitoring program for five years to ensure professional oversight during the transition back to practice. I quickly realized that the need for individual counseling throughout the full five years, although potentially appropriate in some cases, was likely not indicated in many instances. So, I approached several nurses in the monitoring program about starting a counseling group. They were open to the idea and even enthusiastic. Eventually, I asked them about including a physician. Their response to my question was memorable: “Don’t worry. We can handle him.”

Since that time, the group has grown to include several other health professions and has ranged in size from six to eight individuals. According to the participants’ report, it is helpful to be exposed to the input and perspective of others who have been through the process of addiction (sometimes diverting medications from patients and facing criminal prosecution) as they work to put their lives back together and obtain approval to return to professional practice.

Using this experience, I have subsequently established two more recovery support groups in my practice. Both groups are for men in early recovery from substance use disorders, which constitutes a large portion of my clientele these days. In talking with other counselors in private practice, however, I have learned that very few offer group counseling, preferring to stick to the traditional model of one-on-one counseling. Why don’t more counselors offer group counseling?

Potential advantages

The ACA Code of Ethics includes standards relating to group counseling, including A.9. (Group Work) and B.4. (Groups and Families). Although these standards identify responsibilities that counselors have when choosing to provide group counseling services, none of them includes any admonition for counselors to consider offering group work.

What, then, are the potential advantages? Let’s look at three that are most commonly identified.

1) Cost to the client/payer: A ballpark calculation, based on discussions I have had with other counselors, as well as rates posted on websites, is that the per person rate for group counseling is about one-third to one-fourth of the rate that counselors tend to charge for individual sessions. Using an example on the higher end, a counselor who charges $150 for a traditional therapeutic hour (a 45- to 50-minute session) would probably charge $40-$50 per person for group counseling. Many counselors also extend group sessions to 70-90 minutes to allow adequate time for each member to participate. In this day of tightly managed insurance benefits, the cost to the payer is much less in group counseling and tends to give clients the ability to participate for longer periods of time, which is often extremely beneficial.

2) Additional revenue for the practice: Not to be overlooked is the potential that group counseling offers for a practice to enhance revenues. There are only so many hours in the week and a limit to how many clients an individual practitioner can be effective in seeing. High-end estimates tend to run to seeing clients 25 to (at most) 30 hours per week, thus still leaving time for documentation, marketing, practice management, breaks, supervision, etc. Given overhead expenses such as liability insurance, rent, phone service, office supplies and equipment, internet/web access, licensing fees and more, it is challenging for counselors to make an adequate living without following sound business practices. One of these practices can be to offer group services.

3) Enhanced therapeutic value: Finally, as the ACA Code of Ethics stresses, we should ultimately make decisions with our clients in mind, keeping whatever is best for them paramount in our thinking. Both research and anecdotal evidence support the provision of group services as an important part of addressing many clients’ needs, with substance use disorder being a clear example. The experience of hearing from other people who are both struggling with the same issues and having success addressing those issues can be life-changing for clients. Likewise, establishing a support network that people can draw on outside of sessions can also be very therapeutic and is an important outgrowth of group work.

Potential disadvantages 

What, then, might be the disadvantages, and why do so few counselors in private practice offer group services?

1) Scheduling: One of the great benefits of owning a private practice for many counselors is the flexibility it affords them in both their personal and professional lives. In my experience, the days of the client who comes in every Wednesday at 10 a.m. are no longer; in most cases, they have been replaced with a more flexible, variable style. This also gives the counselor the ability to work around a full- or part-time job, family obligations, vacations and other scheduling issues.

Groups, however, typically do meet at the same time every week, every other week or monthly. Rescheduling a group involves potentially inconveniencing eight to 10 participants, as well as the counselor, and is much more complex and problematic than rescheduling an individual client. Although I will occasionally reschedule a group in my practice, I usually hire another local practitioner to cover the group, obtaining a release of information from group members to facilitate client coordination with the other practitioner. Having a substitute counselor can supply a healthy change of pace for groups and can enhance the group process in future sessions too.

2) Lack of comfort with group modality: Group counseling classes are included in most counselor training programs, but it is possible for counselors to move quickly into a comfort zone of providing services on a one-to-one, individual basis and allow their group counseling skills to grow rusty. For many counselors, the transition to private practice begins as a part-time arrangement in combination with another full-time job. Thus, it may be many years before the counselor is fully engaged in private practice work as his or her primary activity. This may further contribute to the lengthy delay between when a counselor receives group skills training and finally implements those skills in a private practice setting. This is not the only scenario under which counselors move into working privately for themselves, but this pattern may partially explain why so few private practitioners offer groups.

3) Too much effort to establish: Finally, and related to the scheduling challenges noted earlier, there is the effort required to get a group off the ground. Persuading clients that group counseling is an option worth considering can sometimes be a formidable obstacle.

I recall one particular client of mine who was dead set against group work, indicating that he did not want to share his “personal business” with a group of strangers. After nearly two years of relatively successful individual counseling related to his problems with alcohol, he experienced a serious relapse, leading to inpatient treatment — where groups were a large part of the service delivery system. Upon returning to the community, he has engaged with his group and finds it to be an essential part of his overall recovery program.

On a more mundane level, simply finding a time that works for all potential members and the counselor can be a significant challenge. I have had some luck holding groups early in the morning, before many people start their workdays. Other options might include lunch-hour meetings, evening sessions or even weekend slots. Sometimes, however, the difficulty of establishing a regular meeting time can be so daunting that it prevents counselors in private practice from even attempting to start groups.


In summary, groups can provide a tremendous therapeutic opportunity for our clients to address their issues with the assistance of others who are confronting similar problems. Counselors should consider this modality more frequently as they look to simultaneously improve their work with clients and solidify their private practices from both a quality and financial standpoint.

Opportunities for retraining for those professionals who have not had group experience since graduate school are abundant. These opportunities include myriad continuing education options such as conferences, webinars and self-paced reading. Additionally, counselors can partner with other professionals in a co-facilitation arrangement. This may negate some of the financial upside of group work, but it can also assist in providing built-in coverage should a counselor need to miss a session.

Ultimately, as we ponder as counselors how best to meet the needs of our clients, group work should be something that we all consider as part of our ethical responsibility.




Kevin Doyle, a licensed professional counselor and licensed substance abuse treatment practitioner, is chair of the Department of Education and Special Education and an assistant professor of counselor education at Longwood University in Virginia. Contact him at doyleks@longwood.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Behind the Book: Group Work With Persons With Disabilities

By Bethany Bray March 6, 2017

Group counseling can serve as a powerful antidote to the isolation clients often feel, whether they’re going through infertility, addiction or a range of other issues. This can be especially true for clients with disabilities, say Sheri Bauman and Linda Shaw, co-authors of the American Counseling Association-published book Group Work With Persons With Disabilities.

“For persons with disabilities, being in a group with others who have the same challenges can reduce the sense of isolation that often accompanies such circumstances,” they write in the book’s introduction. “… When members encounter others at different stages of dealing with an issue, they may develop a sense of hope that they, too, can make progress and feel more satisfied and fulfilled. For those whose disability may limit their opportunities to join with others, the feeling of cohesiveness that develops in groups can provide that sense of belonging that is so essential for optional human functioning.”

Bauman and Shaw are both professors in the University of Arizona’s Department of Disability and Psychoeducational Studies. They collaborated to write Group Work With Persons With Disabilities to use in a course they co-teach on group work.


Counseling Today sent them some questions, via email, to learn more:


The group dynamic in and of itself can be a powerful counseling tool. Please talk about how this can be the case, particularly, for clients with disabilities.

The therapeutic or curative factors in groups are well known. It’s not unusual for people with disabilities, particularly newly acquired disabilities, to feel that their experience is unique and that their disability can be socially isolating. Consequently, the following curative factors may be of particular relevance for persons with disabilities: universality (realizing one is not alone in their struggles); instillation of hope (seeing other members who are living full and productive lives, despite myths and misconceptions about disability); cohesiveness (the feeling of belonging that develops within a group); interpersonal learning (discovering, through group feedback, how others see them; having the opportunity to practice new skills in a safe environment); and the imparting of information (learning practical medical management skills and information about negotiating social and physical barriers in their environments). There are others but these are particularly relevant.


What would you want counselors to know about this topic — Especially counselors who may not have encountered it in graduate school?

Regardless of a counselor’s specialty area of practice, it is highly likely that sooner or later people with disabilities — who are about 20 percent of the population — will seek services from them and just like any other clients, many will be potential group members. People with disabilities have all the same kinds of issues any other person may have, so it is likely that they will appear in groups with a variety of themes. Often when people with disabilities seek assistance from a counselor, there is a tendency on the part of the counselor to assume that the disability itself is the source of the problem. Counselors should guard against the tendency to do this, as the issue may or may not be related to the disability. Just as they would approach any other client, the counselor must see and address the needs of the whole person. Including questions that invite discussion about disabilities (some are invisible) in screening interviews will alert the counselor that some accommodations may be needed, and give the counselor the opportunity to seek out additional information if unfamiliar with the needs of individuals with this particular disability as it applies to group participation. Although people’s disabilities are an important aspect of their identity, they are more than their disability. In our book, we provide counselors with background information and specific skills that will allow them to conduct groups with this clientele successfully.


In your opinion, what makes counselors a “good fit” for leading groups with clients with disabilities?

A counselor who is sensitive to diverse groups will be able to bring that sensibility to include persons with disabilities. Counselors who are able to reflect on their own potential biases and fears will bring honesty to the experience and serve as important role models to other group members. Counselors also need to be open to learning additional information that would increase their comfort level and competency in working with diverse group members, including those with disabilities.

People with disabilities are not different from other group members. Just as in working with any diverse group, having an understanding of the particular needs of these members is an important area of cultural competence.


Do you feel that, in general, counselors might have misconceptions or gaps in knowledge about group work with clients with disabilities?

Just as in the general population, persons with disabilities are often overlooked and misconceptions are common. Generally, people without disabilities tend to believe that disabilities have a much more negative impact on quality of life than do people with disabilities themselves, and they may see “successful” people with disabilities as heroic or especially admirable. Additionally, many people assume that the most important life task of a person with a disability is to “overcome” their disability. In point of fact, many people with disabilities see their disability as part of the natural diversity of people, and that the problem is not so much the disability itself, but rather the barriers to full participation in life created by physical and attitudinal barriers. Adjustment to disability is seen as a social, rather than a personal problem.

Many counseling training programs touch on disabilities only tangentially, and thus indirectly convey the message that this is not a group that counselors will encounter in their practices, unless they specialize in disabilities. The reality is that persons with disabilities may have relationship problems, financial problems, stresses, depression and all of the same kinds of concerns that bring nondisabled people to groups.


What advice would you give to a counselor who might want to refer a client to a group? What should they keep in mind? How can they find an appropriate group in their area?

Groups provide many opportunities for growth for persons with and without disabilities, as well as for the counselor. Groups offer many advantages over individual therapy, such as the chance to learn and practice new skills in a safe environment, to receive feedback from others, to learn from others’ experience, to develop relationships, etc.

Counselors referring a person with disabilities to a group should prepare the client just as they would any client when making a referral. In our book, we discuss a number of screening considerations, such the advantages of homogeneous vs. heterogeneous groups, which may be important in finding a good match for the client’s present needs. Logistical issues may also be important to consider, such as access, availability of public transportation, etc. These issues are discussed in detail in our book.

Be careful to avoid making assumptions about what a client can and cannot do; counselors sometimes underestimate the potential of clients to benefit from the group experience. The best expert on the client’s abilities and needs is the client him or herself.


What inspired you to collaborate and write this book?

[At University of Arizona,] we have graduate counseling programs in both school and mental health and rehabilitation specializations, and we both teach sections of a group counseling course that is required of students in both programs. When planning for this course, we were unable to locate a suitable supplementary text to address this important topic – so we wrote one! Additionally, we wanted to provide a resource to practicing group counselors who may feel that they would benefit from increasing their knowledge about disability and wish to expand their capacity for cultural competency and inclusiveness.





Group Work With Persons With Disabilities is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222


Sheri Bauman and Linda Shaw will be signing books at ACA’s 2017 Conference & Expo in San Francisco on Friday, March 17 from 1 to 2 p.m. Find out more at counseling.org/conference/sanfrancisco2017


About the authors

Sheri Bauman is professor and director of the counseling graduate program in the Department of Disability and Psychoeducational Studies in the College of Education at the University of Arizona. She has a background in public school counseling.

Linda Shaw is professor and department head in the Department of Disability and Psychoeducational Studies at the University of Arizona. Her background is in rehabilitation counseling; she is a licensed mental health counselor and a certified rehabilitation counselor and was a member of ACA’s Code of Ethics Revision Task Force in 2014.






Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.





Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.



A counselor’s view of advanced breast cancer

By Cheryl Fisher February 29, 2016

Breast cancer touches all of our lives, and I am no exception. In February 1996, I went for my first mammogram. I was only 33 at the time, but I had read about the importance of having a baseline mammogram for early detection of breast cancer. Early detection meant cure, right? As a single mother of two young daughters, I was all about early detection and cures.

So, I went for a mammogram, astonished at how my 34B’s were able to squish like a schnitzel on the chilled mammography plate. The technician greeted me with a smile and warm hands, and for both I was grateful. The procedure, while uncomfortable, was not unbearable. I mean, I had given birth to Branding-Images_Canceran 8-pound baby without so much as an episiotomy. This was a simple walk in the park. The technician informed me that no news was good news, and I left feeling initiated (once again) into the sisterhood of womankind.

You can imagine my shock when I received a call mid-March that something unusual had been detected in my mammogram and that I needed to return for an amplification. The previously chipper technician met me with a solemn face and greeted me in almost a whisper. She did not make eye contact. The amplification was done in silence. Again I was told that I would be contacted if something was detected.

A week later, I was scheduled for a needle biopsy. As I lay facedown, my left breast dangling through the hole in the hospital table, thoughts raced through my head: “What if it is cancer? I can’t stop working. How will I take care of the girls?”

“No,” I told myself. “This is not cancer. I’m only 33 after all, and who gets cancer this young? I am a vegetarian. I am an aerobics instructor, for heaven’s sake! I don’t feel sick!”

I was provided with a bag of ice to place over the area of my breast that had been biopsied. They had found three suspicious areas and removed them, leaving a marker just in case … In case of what? I wondered. I left with my bag of ice and a fearful heart.

I started noticing articles in newspapers and magazines about young women with breast cancer. Had these always been there? Was I just now seeing them? I went home, hugged my daughters and cried. I cried the entire weekend as I waited for Monday’s pathology report.

I went alone to the hospital. I didn’t want to feel like I had to take care of another human being if my news was grim. I wasn’t sure I could take care of myself, let alone another person.

I went to the desk and announced my arrival. Again, the quiet whispered reception. I was immediately whisked away to a back office. Alone. Alone with a running video titled Living With Breast Cancer. Oh, my God! It’s true! I must have breast cancer. They’re preparing me by showing this video.

I began rehearsing how I would tell my family … my parents … my brothers … my daughters. The pathologist arrived and sat in a chair across from me. I took a deep breath. I don’t think I exhaled until I had been home for several days.

The pathologist began. “Well, we found three suspicious nodules and we removed them.” OK, buddy, so what are they?

“I’m curious,” he continued. “Have you ever experienced a trauma to the left breast?”

A trauma? You mean other than the needle biopsy that occurred the previous week? “No,” I replied in a small voice while still holding my breath. “Not that I am aware of. Why?”

“These are calcifications that appear to be from a traumatic blow to the breast,” he answered.

Let me get this right. I have been poked, prodded and petrified because of benign calcifications that possibly occurred during a Thanksgiving round of family football?

“So, I do not have cancer?” I whispered.

He shook his head and finally made eye contact. I was flooded with relief. I would live. I would raise my daughters. I would endure their teenage antics, their graduations, their weddings perhaps. I might even experience grandchildren!

What I wasn’t prepared for was the second wave of emotion that I experienced — anger. Anger at the time wasted, waiting and worrying for four excruciating days before I had to return to the hospital, find parking and sit in a room for 20 minutes watching a video about breast cancer. Anger at waiting for a doctor to hand over my fate. To me, this seemed so insensitive and cruel. What is wrong with health care that we treat the disease without treating the person?

However, I was 33 years old, a single mother, and I had just been told that I did not have cancer. I left that hospital, lived my young life and put breast cancer aside — until recently.

The call

I am a licensed clinical professional counselor. I had been in private practice for a few years when I received an email from METAvivor (metavivor.org), a local nonprofit group whose mission includes providing emotional support to individuals living with stage 4 metastatic breast cancer and promoting funding for research projects. The organization was looking for a therapist to facilitate a support group focused on meaning construction and stage 4 metastatic breast cancer.

Author and psychiatrist Viktor Frankl provided us with a foundational understanding of the importance of meaning construction in his classic book Man’s Search for Meaning. He proposed that the search for meaning was universal to the human experience and that it was a prerequisite for mental and physical well-being. Furthermore, an inability to make sense of our situation has been found to be associated with poor health. Therefore, a cancer support group that promoted meaning-making could provide patients with the necessary tools to experience a sense of well-being, even in light of their diagnoses.

My clinical practice had included counseling for bereavement and hospice care, but I had been spending more time working with survivors of trauma and had focused my advanced training in the area of trauma and spirituality. So, I wasn’t certain that I was going to be the best person to facilitate a support group for stage 4 metastatic breast cancer. Regardless, I agreed to co-facilitate the pilot group with a colleague from a local hospice.

The pilot group lasted eight weeks. During that time, I became acutely aware that the youngest member of the group was experiencing her diagnosis in a much different way than her older counterparts were. She was a 30-year-old married woman who had been diagnosed with stage 4 metastatic breast cancer eight months prior to the launch of the group. She had a beautiful 6-month-old baby boy who provided all of us such joy when he visited our group. Her disease appeared to be relentless, however, resulting in a complete bilateral mastectomy and oophorectomy and causing her days of nausea and fatigue. She would come to group pale and weak, convinced that the last round of treatment had to be curative because of its great potency. She died two months after our group ended.

According to the Metastatic Breast Cancer Network, approximately 162,000 women in the United States are living with stage 4 metastatic breast cancer, and only 27 percent will survive as long as five years. This translates to one death from metastatic breast cancer every 14 minutes. Of this population, 5 percent are women younger than 45. Metastatic breast cancer is more aggressive the younger the person is at onset; only 2 percent of premenopausal women with metastatic breast cancer survive longer than five years following their diagnosis of advanced cancer. Most women living with breast cancer may share similar experiences regarding self-image, relationships and support issues, but unique needs appear to exist among young women living with advanced breast cancer.

As a result of meeting the young woman in our pilot support group, I conducted my dissertation research on spirituality and meaning-making in premenopausal women diagnosed with stage 4 metastatic breast cancer. I dedicated my dissertation to her and to all of the young women living with advanced breast cancer, and I committed my work to serve as the voice of those who can no longer speak. What follows is some of the wisdom provided to me by the women in my pilot group and research study.

I am woman?

The treatment for advanced breast cancer involves invasive surgeries that remove not only what many women described as their femininity (breast tissue and nipples) but also their fertility (ovaries and uterus). As a result of treatment, women were catapulted into early menopause and became subject to the physical and psychological manifestations of estrogen depletion.  These manifestations included weight gain related to decreased metabolism, hot sweats, dry skin, decrease in vaginal lubrication and decline in libido.

According to the women in my study, the experience of metastatic breast cancer had stripped them of their bodies, their fertility, their youth and their sexuality. Extensive research demonstrates that physical alterations of the body related to the treatment of breast cancer may have negative effects on identity, confidence, mood, esteem, sexuality, self-satisfaction and quality of life. Treatment may involve not only the removal of breast tissue and nipples, surrounding lymph nodes and ovaries, but also the insertion of an external port to receive chemotherapy. This may be followed by radiation therapy. The body is left scarred and burned with an existing portal that emerges from the upper trunk.

Many of the women in my study described feeling like a “freak,” a “mess” or a “patchwork quilt.” All of the women described feeling detached from their bodies following their treatments. The body that remained was described as lifeless and clinical, almost corpselike.

BFFs and other strangers

The struggle to cultivate authentic relationships was a common theme in this study. The women spoke of their desire to be able to discuss the genuinely harsh reality of their diagnoses with family members and friends. However, the women felt that a substantial portion of their circles of support were unable (or unwilling) to assimilate adequately and comprehend the grave world of living with advanced cancer. The women were asked (directly and indirectly) by family and friends to compartmentalize their experience with cancer and to act as if they were not ill. Such requests led at times to feelings of anger, resentment and, eventually, rejection and isolation.


In addition, there appears to be an absence of sensuality as it relates to the body that remains. This, combined with decreased libido, proved to be a common issue for all the participants in my study. The women expressed a desire to resume an active, healthy sex life with their partners, but they struggled with experiencing a lack of sex drive and feeling unattractive.

Research indicates that women younger than 45 who are diagnosed with breast cancer have more difficulty adjusting than do older women. These younger women have lowered overall quality-of-life ratings linked to concerns about body image, partner relationships and sexual functioning, and they also exhibit less adaptive coping styles.

It also appears that having casual sexual encounters becomes less attractive when living with advanced cancer. One of the women described the need to feel emotionally safe before allowing a stranger into the scarred world of breast cancer. She noted, “I will need to trust the person to tell my whole story.”

Legendary living

Engaging in honest dialogue regarding the fears experienced by a person living with a life-threatening illness seems to provide some degree of anxiety relief for the person. This appears to be the result of directly identifying and addressing that which concerns the individual.

For example, many of the women in this study spoke of their fear of being forgotten and not having a part in the rearing of their children. This discussion provided opportunities to identify ways that might allow their values and beliefs to continue to exist even after their lives ceased. Among the ways these women attempted to provide continuity of their presence in the lives of their families was through writing letters, keeping journals and signing cards for future events.

In addition to memory-making projects, all of the women in the study were involved in using their stories to promote education and awareness of the specific needs of young women living with stage 4 metastatic breast cancer.

Pink isn’t my color

In addition to feeling isolated from family and friends, these young women living with advanced breast cancer described feeling alienated from the breast cancer community as a whole. The “pink” model of breast cancer awareness strives to inspire hope of survival and a cure. However, these women live with a diagnosis that mandates that they are not in remission and that the cancer has spread to other organs. For them, there is no cure at this time. One woman in the study described the pink ribbon as “a noose that is killing me.”

Faith and peace

Psychiatrist and author Irvin Yalom proposed, “If we must die, if we constitute our own world, if each is ultimately alone in an indifferent universe, then what meaning does life have?”

As one of the study participants said, life-threatening illness can “suck the meaning out of life, making the person feel already lifeless.” In facing death, we are faced with making sense of life, and it would appear that we make choices about how to live our lives until death. Therefore, anything that affirms life force, meaning and importance to others can counter the sense that death has made its claim.

Frankl reminds us that we have the ability to choose how we respond regardless of our circumstance. This can be empowering even when facing death. The women in my study discussed the role of choice. One woman described using humor to help her cope with the chemotherapy. Another described an attitude of gratitude: “I show gratitude more often. … It is liberating to know I can choose happiness.”

The women spoke of feeling a sense of being part of a bigger, universal plan. In particular, they described feeling that a divine presence was actively participating in their illness. Some women in the study felt that their diagnosis was a wake-up call to be more present in their lives and to be closer to the transcendent. Each described a restoration process of reclaiming and redefining her life.

Other women in the study believed that their spiritual faith gave them the strength to endure the changes brought about by their illness and its subsequent treatment. Interestingly, all of the women described experiencing a richer, more authentic life that a “loving presence” had transformed from the ashes of advanced cancer.


As counselors, we have an incredible opportunity to help support young women living with advanced breast cancer in the following ways.

Body talk: We can help these women (and their partners) reconnect with their bodies in a healthy and empowering manner. We can talk about sexuality and recognize the role that it plays in our emotional, spiritual and physical well-being. To support premenopausal women who are living with advanced breast cancer, we need a greater understanding of their fears around rejection and increased recognition of the role that sexual intimacy plays in their lives. This is a focus of my current research.

Bittersweet friendships: We can validate the changes that occur in these women’s friendships and offer grief work around these losses. We can help clients establish healthy boundaries in relationships that feel authentic and protective. In addition, we can promote the strengthening of those relationships that are nurturing and empowering.

Legacy work: We can help clients cultivate strategies for legacy. Lillie Shockney, administrative director of the Johns Hopkins Breast Center, has written an exceptional book titled 100 Questions & Answers About Advanced and Metastatic Breast Cancer that helps clients and families navigate the challenges of advanced breast cancer. It also provides excellent ideas for being present and remembered beyond the cancer. In addition to her book, Shockney hosts exceptional retreats for families living with advanced breast cancer and provides a forum for discussion, connection and community to these patients and families.

Beyond the pink ribbon: We can connect young women who have advanced breast cancer to communities that are validating and supportive. Wonderful online communities include Young Survivors Coalition (youngsurvival.org) and the Pink Daisy Project (pinkdaisyproject.com).

Faith and justice: Facing death directly can be strangely comforting and empowering. However, counselors may be uncomfortable facilitating a candid dialogue that might be painful for their clients. Furthermore, counselors need to be open to their own discomfort in discussing death and dying. Counselors are encouraged to work from a conviction that they are helping rather than hurting clients by asking them to lean into the discomfort that comes from confronting one’s death. These clients are faced with family members and friends who are reluctant or unable to join them on this journey of facing death. Counselors have the opportunity to embody the existential experience and join the client on this difficult journey. The essence of relational, embodied theology is not captured simply by the empathic presence of the counselor, nor the rites and rituals that inspire spiritual and psychological nourishment. The essence of embodying suffering is to give voice to marginalized persons and to tell their stories. Better still, counselors can be instrumental in nurturing the intrinsic divine wisdom that is present in all of us and empowering clients to tell their own stories.




Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. Additionally, she is a visiting full-time faculty member in the pastoral counseling program at Loyola University Maryland. Her current research is titled “Sex, spirituality and stage 3 breast cancer.” Contact her at cyfisherphd@gmail.com

Letters to the editor: ct@counseling.org




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Behind the Book: Group Counseling With LGBTQI Persons

By Bethany Bray August 10, 2015

The group dynamic can be a counselor’s ally — a powerful setting that induces growth and change for clients.

It is no different for counselors who lead groups with lesbian, gay, bisexual, transgender, questioning and intersex (LGBTQI) clients. However, there is a void of literature and counselor training on group work with this population, according to Kristopher Goodrich and Melissa Luke. This prompted the two counselors to write Group Counseling With LGBTQI Persons, published by the American Counseling Association earlier this year.

From relationships and developmental issues to grief or career readiness, counselors need to keep specific needs and considerations in mind when working either with LGBTQI groups or groups that Branding-Box_LGBTQI_groupfeature a mix of LGBTQI and non-LGBTQI clients.

“Not only is it probable that a group leader will work with LGBTQI group members, but the group leader is also likely to encounter a larger number of group members who live with and love LGBTQI persons,” the duo write in the book’s introduction. “Thus, we approach this book with a belief that without more knowledge, awareness and skills in working with LGBTQI persons, group leaders are at risk of stereotyping and perpetuating societal misattributions, which both can be harmful to individuals and groups. [This] book is also predicated on the belief that with increased knowledge, awareness and skills, group leaders can utilize the unique properties and growth-promoting experiences for all group members, specifically LGBTQI members.”

Goodrich and Luke’s book contains chapters focusing on a range of issues, from groups that focus on addictions or coming out/disclosure to school and residential settings.


Q+A with Kristopher Goodrich and Melissa Luke, co-authors of Group Counseling With LGBTQI Persons


What about the group setting works well for fostering growth and change for LGBTIQ clients?

Melissa Luke: Group work has been supported by research as an effective modality of treatment for most presenting issues and a particularly effective treatment modality for clients who struggle with core issues that manifest with interpersonal and relational challenges. Accordingly, most LGBTQI+* persons have grown up and live in cultures and societies that are rooted in heterosexist, transphobic and gender normative assumptions and, further, many are part of families and educational or work institutions wherein ongoing discrimination, bias and harassment exist. It is therefore not surprising that these experiences can contribute to not only intrapersonal risk factors but also can generate interpersonal challenges as well.

While individual counseling offers a means to address the former, group work is distinctive in its ability to offer an in vivo space to explore, develop and try out new ways of being with and relating to others in a therapeutic setting.


*The + in LGBTQI+ is used to encompass all the identities that are part of the LGBT community; for instance, the Q can mean queer or questioning.


In what ways does group work meet the unique needs of LGBTQI clients?

Kris Goodrich: Group work can uniquely meet the needs of LGBTQI+ clients in a variety of ways. In regard to LGBTQI persons, it allows for the individual to learn they are not isolated or alone, [and] the presenting concerns they may have can be identified and felt by others. In addition, it allows the individual to role-play and practice new ways of interacting with others, as well as practice revealing additional aspects of themselves with feedback from others.

Interventions at the couples and family level allow group members to come together and process what it is like to be part of a system and have the helpful feedback from others in similar situations as well as the group leader; to note processes that may be occurring without their awareness; and to learn new ways [of] responding as a couple/family system. Finally, group work for non-LGBTQI+ persons allows [them] to understand new ways of understanding and interacting with LGBTQI+ persons and also helps to teach the group leader/counselor ways to use systems interventions to advocate with, and act as allies for, LGBTQI persons. Pulling from ecological counseling theory, we know that systemic interventions can be extremely powerful and, in many ways, more influential for long-term change processes. Group interventions are one way to address LGBTQI concerns at a larger systemic level than traditional individual counseling.


What inspired you to collaborate and write this book?

ML: First of all, Kris Goodrich is not only my academic partner but also one of my dearest friends, and that enriches our work together. We have also discovered that both our interests and work styles have proven to be productive complements to one another. In my mind, these aspects are foundational to good and enduring collaboration.

That said, Kris and I have worked together now for over a decade on many different projects, and through that work, we became aware of a number of gaps in the literature. One gap being the ways in which group work could uniquely meet the needs of LGBTQI+ persons, and another gap being the lack of training and resources for group counselors to develop their skills to more effectively respond to the unique needs that LGBTQI persons bring to group work. Given that Kris and I both thrive from challenging ourselves, we decided to endeavor to fill that gap. That was the genesis of the book.


What do you hope readers take away from the book?

KG: Melissa and I hope that readers take away the fact that there are many different presenting issues and concerns that LGBTQI+ clients bring with them to group counseling situations, and that group leaders are uniquely trained to address these issues using the power of group dynamics to allow for corrective experiences of LGBTQI+ clients and those close to them. Our book has a number of new group interventions, most not published elsewhere, using group dynamics to address a variety of presenting issues or concerns not often discussed in the group or LGBTQI+ counseling literature. We hope that readers will be able to take away that LGBTQI persons have more presenting concerns beyond identity development, coming out and relational concerns, and that systemic interventions can be more powerful than interventions at the individual level.


In the book’s introduction, you write that counselors who do not have enough skills or awareness about working with LGBTQI persons are at risk of “stereotyping and perpetuating societal misattributions” in group settings. Can you elaborate?

ML: Just as most LGBTQI+ clients grow up and live in cultures, societies, families and work environments that reflect institutionalized heterosexist, transphobic and gender normative beliefs and practices, so do most counselors. As such, no counselor is immune to the arguably insidious effects of such. It is our belief that without ongoing and intentional efforts, we are all at risk of stereotyping and misunderstanding others, including LGBTQI+ persons.

Recently, there has been increased media attention on LGBTQI+ persons and a number of well-publicized and historic events relating to LGBTQI+ concerns. However, when we refer to LGBTQI+ persons, this encompasses many different communities and identities, not all of whom have the same circumstances and needs.

In addition, the field is continually evolving in our knowledge about LGBTQI+ identity, as well as the ways in which we as counselors can more effectively work with LGBTQI+ clients across the life span. As such, we believe [that] to ethically and effectively meet the needs of our clients and to fully enact our multicultural, social justice and advocacy competencies, we counselors must commit to lifelong reflective practice, including supervision, lest we risk inadvertently reifying the same oppressive beliefs and practices that have historically marginalized LGBTQI+ persons.


What do you want counselors to know about this?

KG: Melissa did a very good job addressing this issue in the previous question. The only thing I might add is that within the fields of counseling and psychology, there is a focus on issues relating to microaggressions. This comes from the work of Derald Wing Sue and his colleagues in regard to race but has also been applied to sexual/affectual orientation by Kevin Nadal and others. Just as we as counselors are vulnerable to unconsciously perpetuating racial microaggressions, the same can be said for affectual orientation or gender concerns.

Understanding the nuances about LGBTQI identities is the first step toward self-awareness and affirmative practice on this journey. However, it does not end there. Group leaders and counselors need to interact with the material, which often means interacting with LGBTQI+ persons, to better understand LGBTQI persons’ needs and concerns, as well as any unconscious processes that might influence how that counselor may interact with clients (in individual or group counseling settings) in the future.

Counselors must know that regardless of our identities or background, we are all vulnerable to uninformed or misaffirming beliefs or behaviors due to the heterosexist, transphobic and gender normative culture we have grown up and lived in. This isn’t said to disparage counselors or question their ability to effectively work with LGBTQI+ clients but to form awareness that for each of us, there is always more to be aware of [and] to learn [so we can] continue honing our skills with others.


Who is your target audience for the book? What type of counselors?

ML: The primary audience for this book is practicing counselors, counselors-in-training and those who educate and supervise counselors. The book includes chapters that address specific counseling contexts (e.g., school, community), as well as varied types of group work (e.g., gay-straight alliances, coming out groups, family groups, grief and loss). While the book is clearly focused on group work with LGBTQI+ clients, we are very careful to remind readers that whether or not they recognize it, it is likely that all group work involves some LGBTQI+ clients.

Also, we have been told that much of the content in the book — each chapter begins with a literature review, includes sample interventions and then concludes with a case vignette illustrating application of an intervention — is easily adaptable to work with all clients across a variety of treatment modalities, not solely group work. We are also very pleased to learn that the book has been well-received by other human service practitioners who work with LGBTQIA (the A stands for ally/asexual) persons in group contexts, such as educators and community organization workers.


How might the book be helpful for counselors who primarily work individually and do not practice group work?

KG: When we wrote the book, we really tried to address many issues that LGBTQI+ persons might interact with over their life course. This information is helpful for both individual as well as group counselors. The interventions, although written for a group counseling setting, can easily be applied in individual counseling, with the group leader acting as the “chorus” of group members, pushing individual clients to see insight in their beliefs and actions.


Do you feel this topic is adequately covered in today’s graduate school programs and counselor training?

ML: Said simply, absolutely not. Recent research has identified that although the identities and needs of some LGBTQI+ persons are more included in counselor preparation than in the past, bisexual, transgender and intersex identities are much less discussed.

In addition, though counselor educators increasingly report including LGBTQI+ content in their course work, [we, together with] Janna Scarborough (2011) found that this was typically attempted in a single, three-hour class session and that the focus of this work was on counselor knowledge and awareness, not counselor skills. Todd Jennings (2014), a teacher educator who conducted a replication study with a different sample, found similar results. Further, participants in this study identified the importance of personal engagement, well-developed training resources, as well as experiential and iterative learning. Sadly, research has demonstrated that these opportunities are lacking in counselor preparation and supervision with respect to LGBTQI+ persons and related topics.


What would you want recent grads and new counselors to know about working with LGBTQI clients in group settings?

KG: As these concerns are typically not covered in a comprehensive fashion in counselor training, we would like recent graduates to know about this material and introduce new ways of interacting with LGBTQI clients. We also would love to instill the idea and passion for continuing education, as there is never a time when one [can] know everything about how to work with clients, especially from multicultural groups.

As Melissa noted above, many identities addressed within this book (e.g., bisexual, transgender, intersex, etc.) are not covered or receive very little attention within counselor training programs. That is problematic because if we do not know about these identities, we are likely to perpetuate stereotypical or biased behavior against these clients or unconsciously commit microaggressions against them. That could influence both our relationship with our client [and any future potential relationship that those clients might have with counselors. It can steer whole groups of people away from counseling.

This is most pronounced in the transgender community, as so little information is known by counselors, and counselors can be seen as gatekeepers by those individuals who have interest in pursuing gender conforming treatments. Of course, gender confirmation procedures are not pursued by all trans* clients, as addressed in our book, but it is one example of when a client might present to counseling and feel mandated to do so. Having an awareness of the history, the concerns and affirmative ways to interact with clients not [only] allows one better relationships with one’s own clients, it also opens that client to future counseling experiences if needed in the future.

Overall, we want new counselors to know that their training and education are not done, and there is always more to know. We also would like them to recognize the differences between affectual orientation and gender identity and how these two concepts interact with one another. And, finally, we would like to provide them some tips and tricks to add to their toolbox, as there are some very creative interventions in the book that could be utilized by anyone with an interest in creativity in counseling.


*trans* (with an asterisk) has become more commonly used than “transgender,” as it stands for the different variations of the transgender identity, according to Goodrich.




Group Counseling With LGBTQI Persons is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222.





About the authors

Kristopher Goodrich is the program coordinator and assistant professor of counselor education at the University of New Mexico. A licensed mental health counselor (LMHC) and an approved clinical supervisor (ACS), he is president of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling and president-elect of the Rocky Mountain Association for Counselor Education.

Melissa Luke is an associate professor of counseling and human services and the coordinator of school counseling at Syracuse University. An LMHC and ACS, she is the president of the North Atlantic Region of the Association for Counselor Education and Supervision.





Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Group effort

By Laurie Meyers May 25, 2015

When a client seeks help, often the focused, tailored nature of individual counseling is exactly what he or she needs. But sometimes there is a particular alchemy in a group.

Many clients benefit from group counseling, either in addition to or instead of individual treatment. Why is that? The counselors to whom we spoke pointed to one element in particular: peer power.

Jonathan J. Orr, president of the Association for Specialists in Group Work (ASGW), a division of the American Counseling Association, thinks that group counseling is always a better alternative than individual counseling. “If you think about it,” he says, “groups are the natural setting for us as Group_Brandinghumans. We are social beings by nature, interactive by nature, and group counseling most closely approximates how we live our lives.”

From Orr’s perspective, it is the intense individual counseling setting — in which clients share everything with a single person — that is more artificial, demanding a kind of forced intimacy. People are not naturally inclined to reveal all of themselves to just one person, he contends. But in a group, clients can choose what to reveal and can also listen and learn from what others share. It also tends to be easier to discuss problems with people who have experienced similar difficulties, Orr concludes.

The groups described in this article focus on specific client populations that counselors determined would benefit most from the group process. These group leaders emphasize that although proper facilitation skills are crucial to the success of the group, many of the most important contributions — and changes — are the result of the participants’ interactions.

Ex-offenders in need of job assistance

When people are released from prison in North Carolina, they are offered services such as substance abuse counseling, help finding affordable housing and money management courses. But one type of service is not offered to these individuals trying to reintegrate into society — a service that ACA member Mark B. Scholl believes is absolutely essential: career development.

Scholl began offering group counseling in career development to ex-offenders this past fall. At the time, he was a counselor educator at East Carolina University in Greenville, and the impetus for forming the groups came from a graduate student who was also a probation officer. The student explained that ex-offenders were not receiving any career guidance and asked Scholl if he could work with them on career development and related career entry skills.

“It just seemed like such a glaring omission when you think about becoming reintegrated into society,” says Scholl, who is also a member of the National Career Development Association, a division of ACA. “What individuals need to feel like they are reintegrated … is a purpose, and work fulfills that purpose for many of us. One of the most important indicators of desistance” — or not repeating the criminal behavior — “is having employment.”

Given those circumstances, Scholl and his student set up a career program for ex-offenders in Beaufort County. The program, designed by Scholl, is promoted by the North Carolina Department of Public Safety, which oversees the state’s probation and parole officers. Scholl also sends fliers to local mental health agencies. The program is open to both men and women, and the length of the participants’ criminal histories varies, he says. Typically, group members have been convicted of substance-related offenses, such as possessing or selling drugs, or other nonviolent offenses. But a few applicants have convictions for weapons charges or other violent offenses. Although this will limit their employment choices, it does not disqualify them from joining the group, Scholl says. However, the group does require that participants be clean and sober, take any mandated psychotropic medications, speak and write English fluently and be either unemployed or underemployed.

Scholl set up a second program in Forsyth County after moving from East Carolina to Wake Forest University. He and his co-facilitators, all of whom do the work pro bono, work with one group of ex-offenders at a time in each program. The groups are small, typically having four to six members apiece. Depending on the group members’ progress, there are six to eight sessions, each of which lasts for two hours. The group meets every three to four weeks and spends one to two sessions on each of the four topic areas: assessment, résumé writing, interviewing skills and job search strategies.

The program starts with a skills assessment. Facilitators and group members work together to identify experiences that can be translated into viable job skills. Scholl and the facilitators emphasize that skills are anything a group member is good at and may even include abilities that the person used in his or her criminal activities.

“You might be really good with numbers, or you might be really good at selling things,” he explains to participants. “You might have been selling things that were against the law, like drugs or stolen merchandise, but you still have those transferable skills and … those are valuable.”

Everyone in the group gets a transferable skills list, Scholl says. “[It] is very comprehensive. It includes different categories of skills like communicating, influencing and organizing, and under each of those categories, there are about 20 transferable skills,” he explains. “Because they’re transferable skills, [it doesn’t] require formal training or education to have them or to claim them.”

For instance, “communication” can include skills such as being a good listener, being good at explaining things or giving directions, being good at persuading and selling or even, in certain contexts, arguing or debating, Scholl says.

Everyone in the group picks three skills and then shares them with the facilitators and group members. These transferable skills will help the participants craft their résumés and also come into play as they learn about the interviewing process.

Scholl and the other facilitators give the group members sample résumés and a list of action verbs to use — for example, coordinate, sell, order, supervise, facilitate, interview — when writing their own résumé lines.

The group facilitators discourage ex-offenders from listing jobs that they held in prison on their résumés but stress that in addition to past paid work, participants can include volunteer work in churches and in the community. Skills that group members gained in prison or while engaged in criminal activity can be listed under the “professional skills” section of the résumé, Scholl says. The facilitators then edit and provide feedback on the group members’ résumés.

The next step in the group program is perhaps the most delicate and difficult: interviewing. Scholl describes the group’s counseling approach as postmodern, and that approach especially comes into play at this point.

“We emphasize that [they] are active meaning-makers,” he says. “Part of the postmodern tradition is that we all have that capacity to construct meaning for ourselves. So, for example, one thing we practice is self-disclosing your criminal record in a way that’s as positive as possible. You make the part where you talk about your mistake and your bad choice brief and concise, and you own that you are fully responsible. But you quickly move on to emphasizing that you’re not letting it [the mistake] define you as a person.”

Group members can then delineate the steps they have taken to improve themselves. By presenting their pasts in this way, they become the authors of their past experiences, Scholl explains.

Group members also prepare for interviews by constructing narratives around their strengths and what they can contribute to a company. Facilitators teach participants to use the acronym STAR (situation, task, action, result) to build these narratives, Scholl says.

For example, if wanting to demonstrate a strength such as sales or planning skills, the group member might tell a story about a time in high school when he or she was asked to sell magazine subscriptions door to door (situation and task) and made a plan to go to 10 houses each day after school for a week (action). As a result, the group member sold 35 magazine subscriptions and raised X number of dollars toward the purchase of uniforms for the high school band (result).

Another application of STAR could be a story about when the group member worked in a laundry setting (without emphasizing that it was the prison laundry) with a co-worker who wasn’t pulling his or her weight. The group member reasoned with the co-worker and, as a result, the team member’s work improved, Scholl says.

Group members write their STAR narratives and break up into pairs to role-play, taking turns being the interviewer and the interviewee, Scholl explains. They then give each other feedback on how to make their stories more compelling or clearer, asking questions such as “Why was this a strength?” or “What was the outcome?” Participants then reassemble to get feedback from the facilitators and other members of the group.

Scholl and his facilitators emphasize the importance of the STAR narratives to the group members. “We talk about … when you are interviewing for a job, things like your GPA or how much money you made in your last position, that’s not the kind of thing that makes you a memorable applicant,” Scholl says. “It’s the stories you tell. If 150 people apply [for a job], the one or ones with the most compelling stories are going to be unforgettable.”

The last stage of the group program involves job search strategies, which includes information about the importance of the informational interview, how to conduct an informational interview and how to approach someone for such an interview, Scholl says. But the strongest emphasis during this portion of the group is on self-presentation, including grooming and hygiene, he says. The facilitators also stress to group members the importance of being polite and friendly to everyone they encounter, because they never know when they might re-encounter someone in the job search, Scholl says.

Scholl acknowledges that he doesn’t possess much hard data on the overall efficacy of the group. But he says he can point to tangible products such as résumés — many group participants now have one for the first time. He and his facilitators also have anecdotal evidence, such as hearing that “Doug” got a job last week or “Mike” is going back to get his two-year degree so he can acquire the training necessary to work in a field in which he has a strong interest. Former group members also come back to sessions to share what they got out of the program.

“We recently had a woman come back to say that she was going to get her four-year degree,” Scholl recounts. Although the woman had been sober for several years prior to participating in the career group, she also credited the group with helping her maintain her sobriety.

For Scholl, this demonstrates why the value of group counseling goes beyond its curriculum or resources. The true value is in group members experiencing mutual support. “I think there is so much power in the ability to role-play with a peer and to view the group as an alliance of peers that can bring information, ideas and support,” he says.

When the caregivers need care

Laura Kestemberg is the director and associate dean of the newly established clinical mental health counseling master’s program at Molloy College in Rockville Centre, New York. For the past few years, she has been researching stress in parents of children with autism. Along with fellow ACA member Laura DeGennaro, Kestemberg joined Molloy’s initiative to launch an interdisciplinary autism center.

As Kestemberg and DeGennaro, the clinical director and clinical coordinator, respectively, of the proposed autism center, worked with these children, they identified another group that needed help — the children’s parents. The social and behavioral impairments that accompany autism cause challenges that permeate almost every aspect of a family’s life, Kestemberg notes. “Parents [of children with autism] feel very isolated and ashamed and that it’s just them,” she explains. “Sometimes it’s been them [alone] battling with the school system or battling with providers.”

Parents of children with autism often experience a lack of social support, Kestemberg says. It’s not uncommon for friends and family members to pull away, and even if they don’t, it’s difficult for them to truly understand what the family is going through. But parents of other children with autism do understand, Kestemberg says, which makes a group counseling approach particularly helpful for them. In addition, group counseling has been shown to be very powerful for populations experiencing high levels of stress.

Both Kestemberg and DeGennaro had previously worked with parents of children with disabilities. “So we decided to put our heads together and try to have a clinical intervention for the parents,” Kestemberg says. They approached John Carpente, executive director of the proposed autism center and director of the Rebecca Center for Music Therapy at Molloy College, about providing this clinical resource for parents and collecting data on parenting stress.

As they were developing the group, Kestemberg and DeGennaro assumed they would run across other groups that focused on supporting the parents of children with autism, but that wasn’t the case. “We found that there were a lot of advocacy groups and a lot of parent training groups,” Kestemberg says. In training groups, counselors help parents learn to manage the child’s acting-out behaviors or show parents how to help the child manage in the school setting. “But it’s always about the child,” Kestemberg stresses. “We wanted … to do something where they could come to a group and [we could] say, ‘We’re going to talk about you — the parents, not your child. And we’re going to provide you with the strategies to help reduce your stressors.’”

Kestemberg and DeGennaro struggled with determining when to hold the group. They finally decided on the summer, when most children were still in summer camps, during the middle of the day. Evening groups were too difficult to coordinate because many of the parents didn’t have good child care options, and Kestemberg and DeGennaro didn’t yet possess the resources to offer child care while the group met.

Participants were recruited from the Rebecca Center and other local organizations that provide services to children with autism. Kestemberg and DeGennaro conducted a telephone intake interview with each parent. Although they wanted the group to include fathers, the mothers had greater availability. They ended up with a group of five women who met for 90-minute sessions 10 times throughout the summer of 2014.

Kestemberg and DeGennaro started each session by going around the circle and asking each woman to update the group on the most important things that had happened during the past week. At first, the women were more likely to bring up problems their children were having. “We tried to steer them toward what was going on with them or how what was going on with their child affected them,” Kestemberg says.

At first, it was difficult for some of the group members to open up. “The mindset was, ‘If I let a little bit out, I just won’t stop crying,’ or … ‘I’ll have so much anger that I’ll blow people away,’” Kestemberg recalls.

Little by little, as Kestemberg and DeGennaro reassured the members that the group represented a safe place with others who were going through the same challenges, the women began to share. They talked about very painful topics, such as deciding whether to have another child, feeling alone in their marriages or yelling at their offspring and how ashamed they felt about doing that in the face of the child’s disability. “And other women in the group would say, ‘You know, I’ve done that too,’ or ‘I also think my marriage isn’t going so well,’” Kestemberg says.

As the women shared, an important concept became evident to each group member: “You are not alone.” In turn, this helped the group work toward the goals that Kestemberg and DeGennaro had set for the parents, which included:

  • Feeling more empowered
  • Decreasing their feelings of guilt
  • Decreasing their stress levels
  • Becoming more aware of their own needs
  • Learning to use more positive coping strategies

The experiences the women shared weren’t just helpful emotionally but practically as well, Kestemberg says. For example, one mother expressed concern about going in front of a school district special education committee to talk about her child. These meetings involve educators, service providers and parents getting together to decide how best to meet the needs of the child. However, the gatherings can be emotionally charged because these parents often feel like it is a struggle to obtain the proper services for their children. Going in front of the committees, they feel the burden of having their facts straight and presenting a compelling case concerning why their requests for their children are valid.

In the case of this mother, the other group members suggested role-playing to help her prepare. Several of the other mothers had already gone through similar hearings, Kestemberg explains.

Another common experience the women reported was feeling like they had to gird themselves before entering the house upon returning home. “A lot of our moms … said, ‘I’m so stressed that I can’t go right into my house. I sit in my car, have a cup of coffee, listen to the radio or do what I have to do before I have to face the chaos of what’s going on in the house,’” Kestemberg reports.

To help them cope with these overwhelming moments, DeGennaro and Kestemberg taught the mothers mindfulness techniques such as meditation, deep breathing, observing thoughts, mindful eating and walking, body scans and guided imagery. They also closed each session with a GROUP THERAPYmeditation or relaxation exercise and asked group members to practice the mindfulness techniques themselves as homework. Kestemberg and DeGennaro also informed the mothers about mobile apps for relaxation such as Stress Tracker, Breathe2Relax, MindShift and Take a Break! Guided Meditations for Stress Relief.

But so much of the benefit from the group came from what its members gave to each other, like offering to role-play, Kestemberg says. “[The group] was much more powerful than meeting with a therapist or mental health care provider one-on-one because they were with other moms who had gone through it,” she emphasizes.

The group ended up being a mix of mothers with children who were very young and newly diagnosed with autism and mothers whose children were as old as 18. Kestemberg and DeGennaro initially thought it would be best to separate participants by age or level of severity of diagnosis, but because the total number of recruits ended up being so small, there was a need to combine them. This was a serendipitous necessity because it allowed the mothers with children who were newly diagnosed to see that there were other mothers who had “survived” and flourished throughout the school years.

These shared experiences resulted in a strong bond forming among the group members. The mothers would email each other between sessions to trade resources or just to offer support.

Kestemberg and DeGennaro conducted both pre-group and post-group parental stress assessments but did not find a significant decrease. However, they think that the mothers’ experience of opening up and actually acknowledging what they were going through may partly account for the results. Acknowledging the strain may have changed the way they reported their stress levels, DeGennaro explains.

This was only a pilot study, but DeGennaro and Kestemberg already have a waiting list for this summer’s groups. They intend to increase the number of sessions and plan to measure participants’ coping styles and levels of loneliness, anxiety, depression, subjective well-being and hope.

Helping kids at risk of dropping out

How can schools help students who are struggling academically and at risk of falling behind or even dropping out? When ACA and ASGW member Jonathan Ohrt was an assistant professor in the counseling and higher education department at the University of North Texas (UNT) in the Dallas-Fort Worth area, he worked with groups of students to teach them skills that could help them succeed. UNT had an agreement with two area middle schools to work with students the schools deemed to be at risk for dropping out. Students qualified as at risk using a combination of teacher recommendations and items from the Texas Education Agency’s at-risk factors, which include not maintaining an average of 70 in two or more subjects in the previous or current school year and having multiple suspensions.

Ohrt and his team had researched which elements were most predictive of students’ academic success or failure. Although GPAs and test scores typically receive the lion’s share of attention, Ohrt found that social and emotional factors played larger roles. Armed with these findings, Ohrt decided to use the Student Success Skills (SSS) curriculum (designed by counselor educators, researchers and ACA members Greg Brigman and Linda Webb) because it has shown success with factors such as goal setting, self-regulation, academic self-efficacy and engagement. The curriculum also focuses on factors such as social skills, overall health and well-being, and physical activity. Although the curriculum features elements of psychoeducation, Ohrt believes the practical elements of goal setting and peer support are most crucial to group members’ success.

Ohrt and his co-facilitators led three different groups, each containing six to eight students, at the two middle schools. The groups ran for eight weeks with one 40-minute session per week.

The first session was spent on introductions, with the students getting to know one another and the facilitators. The second session was psychoeducational in nature, with the leaders talking about the life skills that are related to being successful, such as goal setting, progress monitoring, memory skills, managing attention and managing anger. The SSS curriculum includes worksheets that explain the life skills areas, and the facilitators went over these with the students to help them identify areas they needed to work on.

After that, the students set goals and worked on maintaining them, which provided the focus for sessions three through seven. The group leaders helped the students visualize setting and achieving goals. “Talk to the students about what their goal might look like and what the concrete steps are,” Ohrt advises. “As a group leader, you need to be able to visualize what would help them succeed [and] what is going on that is causing them not to succeed.”

Ohrt likes to use solution-focused counseling during this process, prompting group members with questions such as, “Did you have a time when you were doing well in school? What was going well? What changed?” He adds, however, that implementing solution-focused counseling isn’t a requirement for leading such a group. Counselors can use their preferred theoretical orientation to help group members visualize their goals.

Generally, Ohrt says, each group member chooses just one goal on which to focus because making small, specific adjustments over time tends to be the most sustainable path to success. Typical goals include:

  • I’m going to complete my homework on time more often
  • I’m going to spend X number of hours preparing for my math tests
  • I’m going to focus on paying more attention in class
  • I’m going to work on controlling my anger

The students paired off at the beginning of each session and talked about the progress they had made with their goals. Then the entire group convened again, with each student again sharing his or her progress. If certain group members were having difficulties with their particular goals, the other students often shared what had worked — or what hadn’t worked — for them. If no one offered a possible solution, Ohrt or the other facilitators spurred discussion by asking questions such as “Has anyone struggled with that?” or “Have any of you heard something else that another student did that you might want to try?”

Session eight, the final session, served as a general wrapup of the group, with students talking about what they had learned and how they had progressed.

Ohrt and his team tested for three elements both before and after the groups: self-regulation, perceived academic efficacy and self-esteem. The results showed that although the students’ self-esteem had not improved, they had made strides in both their self-efficacy and self-regulation. When the team repeated the testing two months after the groups concluded, however, it found that the students had gone backward a bit on their improvements. Ohrt thinks that holding brief booster sessions every few months after a group ends might help to maintain the students’ gains.

Ohrt is now working as an assistant professor of educational studies at the University of South Carolina, where he is supervising graduate students leading similar groups in several area schools.



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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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