Using the five Stage Group
By Mildred Ross
In the early '70s, a physical therapist and I coordinated an exercise group in a state hospital for patients with chronic neurological diseases such as stroke, TBI and Parkinson's disease.
At one session a new patient came into the group and sat down. Then she looked around, jumped up and fled from the room in tears, exclaiming, "I don't want to be with a bunch of cripples!" A silence followed the outburst. Then one of the group members spoke up and said, "Now I know how far I've come. That was me three months ago."
The intrinsic value of presenting treatment in a group impressed itself upon me at that moment. Starting first in physical disability settings, I moved on to a psychiatric setting. Similar needs exist in both settings, as physical stress exposes emotional issues, and emotional distress has repercussions in the body.
As I persisted in working with people who were sometimes quite difficult to reach, I developed a particular approach, the Five Stage Group, that would result in more consistent and satisfying outcomes.
Group treatment is included in the new PPS payment schedule--an encouraging sign, because the group setting lends itself to the psychosocial side of treatment.
In groups clients find out they are unique enough to be appreciated by other people, and that others have similar fears to their own. Clients learn by watching others perform; they gain hope from seeing others' successes, and within that time spent together, they know they are not alone.
Occupational therapy brings a richness of activities to the delivery of group treatment. Many kinds of OT groups exist. They may be oriented to verbalization, self-expression, tasks, skill-building or physical exercise, to name a few. But I experimented with a structure that presented each of these activities in accordance with a hierarchical level of demand and in different ways to different populations. Therefore, when an activity should be presented and how it should be presented were more major considerations than what the activity should be.
The Five Stage Group is best suited to those people whose chronic illnesses have whittled down their coping skills. These individuals need extra time to feel safe, comfortable, energized, and stimulated to participate and learn in a group setting. This systematic, sequential method for presenting selected activities to encourage adaptive responses can incorporate many strategies within its different stages for improving daily life.
A spirit of fun accompanies the flow of the stages and helps to ease the anxieties that may exist in group members.
In the first stage, orientation, each member is welcomed individually and learns the purpose of the occupational therapy group.
The explanation varies:
* When working with adults with developmental disabilities, I state that we meet to exercise together and to learn how to help ourselves and each other do what we need and want to do.
* When working with adults with mental illness or substance abuse, I explain how occupational therapy can help members regain old skills or find new interests that can be used in strategies to keep one functioning independently.
* For a group whose membership has neurological dysfunctions, I explain that OT can help individuals overcome the problems that limit their independence and performance of daily activities.
Then it's time to relax and stimulate each person's interest. We pass around an object that might evoke memories or invite group members to share a singular fact about themselves. Or, each person might state a favorite fruit, possession, place, animal, proverb, etc.
Individuals readily enjoy handling items they may have known in the past but have not handled for years, such as a kaleidoscope, music box, or hand exerciser. Many of my items come from fairs and museums. Group members feel secure in expressing a favorite detail about themselves. This stage prepares them to become participants in the group.
Stage 2 uses movement to increase energy and a sense of self-direction, as members perform in any manner they choose. The therapist can initiate stretching and ranging of all joints, offer weights to move with, or design aerobic movements suitable for the specific group. These, hopefully, may carry over into a daily personal regimen. Placing items such as batons, theraband or scarves in the hands of group members provides additionally creative ways for them to move and feel in the present.
In stage 3, the perceptual-motor stage, responses need to become more specifically adaptive. Activities in this group promote function and well being. Depending on the population, the group may make a large floor puzzle, perform small hand tasks using only one hand, or explore aromatherapy by creating sachets with potpourri and different scented oils. One also might learn to tie a tie or sew a button on, or fill out worksheets on topics of nutrition, stress, insomnia or friendship, to name a few.
Reading poetry and writing it are creative ways to encourage imagination, expression of feelings and explorations of desires. Talking about animals in personal ways, using pictures and animal puppets, calms individuals greatly and reminds them of a time when they were in control. Tasks are adapted to be completed within 10 to 15 minutes of the time allotted for the group session.
It is in stage 4, the cognitive stage, when group members and therapist become more verbally engaged in understanding how what one has learned may be applied to oneself. By this stage, members are listening better to each other and nurturing one another.
Stage 5, closure, depends on what has gone before. An essential outcome of the group is to help members feel calm, alert and ready to move on to the next activity of the day. To achieve this, a clean-up may be in order. Sometimes standing and holding hands with eyes closed will help toward further calming. Sometimes a volunteer can repeat what members reported in stage 1 as their favorite items, as this is an alerting activity. Or someone may wish to go around and shake every member's hand in leave-taking.
The Five Stage Group is meant to offer compelling opportunities for response. Therefore it may not satisfy a group of adults who wish chiefly to vent feelings. Or the acutely ill patient who needs a lower-key approach.
Occupational therapy groups , with their emphasis on the use of purposeful activities, can be a powerful modality to use for physical improvement, healing and behavioral changes. *
Mildred Ross, OTR/L, is the author of Integrative Group Therapy: Mobilizing Coping Abilities with the Five Stage Group, published by AOTA in 1997. She lives in New Britain, CT.