In Brief
Groups are a useful and common method for helping people with diabetes. Well-designed, functional groups require thoughtfulness about the institutional setting, purpose of the group, role of the leader, and recruitment of members. This article provides basic guidelines and techniques for running a successful group.
Group methods in diabetes care have often been defined in the broadest terms, encompassing many kinds of groups with goals that range from behavioral change to educational exchange. Groups are very diverse, extending from brief to long-term, meeting daily or monthly, with specific or open agendas, with a rigid membership or members coming and going, with a fee or free. With such a large variety of groups in the field, it was with some hesitation that I ventured to write guidelines that would have relevance for all groups. I focus here on groups that have a professional leader and describe broad principles and techniques adapted from group psychotherapy that would have general value for all group leaders.
Groups are part of the natural process of living, like breathing, and groups for people with medical concerns have a long tradition. Phys-icians at the Asklepieion (an early version of the spa/health center) in ancient Greece and Turkey used group relationships as a treatment strategy.1 Then, the use of groups in medical settings faded until 1905, when Dr. Joseph Pratt, a Boston, Mass., physician, brought his tuberculosis patients together for weekly discussion groups and found that these meetings provided mutual support, alleviated depression, and decreased isolation.2 Groups have become a primary technique in most health care settings today because of the need for practical management of large numbers of patients, clinical efficacy, and the changes driven by insurance reimbursement.2
Advantages and Disadvantages of Groups
All groups for people with diabetes hope to alleviate illness or distress with the help of group interaction and provide the following benefits:
Diabetes is a chronic illness that is often invisible and leaves people feeling isolated or uncertain about whether anyone else faces the same problems. One of the primary advantages of a group is that people feel less alone. Group members find that their feelings, fears, fantasies, and hopes are shared by others.
Groups support adherence with diabetes self-care regimens and help members make changes in lifestyle, including diet and exercise. Groups also encourage members to find support from family and friends and to relate more effectively to health care professionals.
Group members learn from the insight and experience of others. This learning can be educational and behavioral as group members learn information about diabetes, therapeutic alternatives, or new coping strategies from each other.
Accepting information, advice, or constructive criticism from others dealing with the same problem may be easier than accepting the same advice from health care professionals.
A group makes expressing and dealing with intense emotions more possible because, by their nature, groups offer emotional support based on a common bond with a common disease.
Group interactions quickly recreate and expose characteristic patterns of behavior (despite what everyone says about “not being this way outside of this group”). Groups are social and family microcosms that reflect the way one behaves in the outside world. This general principle of group interaction can be invaluable to group leaders seeking to understand how patients function in their lives. Leaders can then use this knowledge and experience to help their group support individual patients’ coping styles or address barriers to learning and self-care.3
There are three distinct disadvantages to group methods:
The primary disadvantage is that confidentiality has limitations. Group leaders cannot guarantee that members will respect confidences.
Patients in group interventions get less exclusive time and attention than they would during individual appointments.
Groups can create a feeling of being lost in the crowd or not being appreciated for one’s uniqueness.
First Steps
A successful group requires thoughtful planning:
First, clarify your own values about why you believe a group is effective and useful. Your level of enthusiasm and belief in groups will show through even if you try to keep them hidden.
Second, assess the institution in which you work and determine whether it values group methods. Will the institution and your colleagues aid or undermine your attempts to start a group program? Who in your institution values or devalues groups? Who has the authority to help you start a group? What kinds of groups already exist? What kinds of patients need a group? What kind of group do they need? How will you select group members? How much competition is there among professionals for these patients?
Third, be crystal-clear about the type of group you are offering. This is very important. For example, the group may be educational, supportive, therapeutic, or some combination of the three. This level of specificity will help explain the purpose of the group to potential patients and referral sources and will help define your role as the group leader. For example, in a class about insulin-to-carbohydrate ratios, the leader’s primary role would be as a teacher; whereas in an insulin pump support group, the leader’s role would be to help members talk to one another.
Selecting Group Members
Groups are not random collections of strangers thrown together because the clinic has too few clinicians and too many patients. Hopefully, each group has a specific purpose and fulfills a specific need. Ideally, if you can match group goals with members’ needs, the chances are greater for a successful group. In practice, members often select themselves based on a brochure or program description, but ideally, some screening of potential group members will reduce future group problems.
In general, it is important to select patients who will benefit from a group and to place them in a group from which they will benefit. Group members who see themselves as “one of a kind” in the group are at high risk of dropping out, e.g., an older woman with type 2 diabetes who finds herself in a group with young men who have type 1 diabetes.
There are three reasons why patients drop out of groups:
The right group at the wrong time, that is, a patient is not ready for a group
The wrong group at the right time, for example, a newly diagnosed patient in a group focused on complications from diabetes
The wrong group all the time, that is, a patient who is not suited for a group and needs individual consultation
In general, most patients can work effectively in some type of group. If patients are willing to learn, listen to others, and talk about themselves, then they are appropriate group candidates. Exclusionary criteria include refusing to abide by group guidelines and demonstrating serious problems with interpersonal relationships. Contrary to popular opinion, people who do poorly in groups are not candidates for groups. Difficult patients who are self-centered and demanding can create difficult groups and become hated group members.
Volumes have been written about managing difficult patients, but it is worth mentioning one particularly constructive approach to controlling prickly situations. In essence, the leader focuses on other group members’ reactions to the disruptive patient rather than singling out and attacking the disruptive patient.
Basic Ground Rules
Some groups meet daily and even several times daily; others meet weekly or monthly. Some groups have only one meeting; others may reoccur at regular intervals. Some groups meet for only 30 minutes; others may meet for up to several hours at a time. Some groups have a predetermined and fixed number of members; others have fluctuating membership. The important point for patient benefit, regardless of time, intensity, membership, and frequency, is that patients have enough time to get their fair share of attention and do not lose contact with the purpose and process of the meeting. The important point for leaders is that the meeting not last so long that it exhausts both leader and group members.
Ideally, groups should have at least four members. Smaller groups fail to provide a “hall of mirrors” effect (that is, the opportunity to see multiple aspects of yourself reflected in other people) and tempt their leaders to focus on individuals rather than on the group as a whole. How large the group becomes depends on its purpose, the leader’s level of comfort with larger groups, and the point at which it becomes unmanageable and less productive. Group leaders are always responsible for arranging a comfortable, private space with enough chairs and/or tables for everyone.
Scheduling and marketing are two basic but often neglected aspects of planning a group. When selecting group meeting times, leaders must be careful to avoid major religious days or civil holidays. You must also be aware of the availability of public transportation, convenient parking, and handicapped access on potential meeting days.
A common experience in launching a group is that “if you build it, they will not come.” Leaders must advertise group programs aggressively to colleagues (the best referral sources), local diabetes educators, clinics and hospitals, local American Diabetes Association chapters, and, of course, to potential group members. One of the most common mistakes novices make in starting a group is to expect that people will be drawn to it because of the exciting topic or the unending requests for a group. A principle that leaders must never forget is that ambivalence (especially anxiety about revealing oneself in a group) will rear its ugly head, and two-thirds of the people who said they couldn’t wait to come to a group will suddenly discover that the group conflicts with their bowling night or the time they absolutely must spend reorganizing their recipes.4
Tips for Group Leaders
The next challenge, after overcoming the hurdles of deciding the purpose of your group and recruiting members, is to show up and decide how you can best help the group. Leaders must be prepared to face several decisions:
How to impart education and information without ignoring feelings and relationships?
How much to concentrate on the current agenda while welcoming reports of past experiences and future hopes?
How much attention to give to individuals while still observing the interactions between members or among the entire group?
How to integrate discussions among group members with discussions about people outside the group?
How much to respond to group demands or wishes?
How much personal information to share?
What to say, how much to say, and when to say it?
All these leadership decisions are influenced by theoretical orientation, personality, and the context of the group. Moreover, all are a matter of degree, not all-or-nothing, and each will have consequences for the group. All of these variables may seem overwhelming, so here are 10 rules to live by so that you will not feel lost at sea in the middle of a group:
Begin and end the group on time. This will help members understand the importance of arriving promptly. It also helps them realize that, if they have important things to say, they need to bring them up while there is plenty of time for discussion, because meetings will not be extended.
Help group members feel welcome, relaxed, and comfortable. It is reasonable to assume that no matter how anxious you may be as the leader, the group members are more nervous. The less nervous group members feel, the more open they are likely to be to learning and talking. Spare no effort to prevent or stop group members from saying or doing something that would embarrass themselves or others in the group. Do not allow patients to act inappropriately.
Group members’ opening remarks are not random and often have some important significance for what they are expecting to happen during the group. For example, “looks like we’re in for a storm today” is more than a comment on the weather but reflects anxiety about potential group conflict. Pay special attention to these beginning words that might predict the upcoming group theme.
Each meeting is in a context (time, place, purpose). Pay attention to what is happening in the group at that very moment—the here-and-now focus. Ask yourself: What is happening, and why is it happening now?
Each group member has a context. Try to keep in mind each member’s reason for coming to the group and personal history, if you happen to know it.
Each group has a primary theme, topic, or connecting thread. Keeping the connecting thread in mind will help a leader make sense of what may seem like disconnected threads in an evolving conversation. Deciphering the connecting thread will also help to reduce the leader’s anxiety by providing a tool with which to understand the predictably bewildering moments that occur in groups.
Remember that everything that happens in the group has something to do with the group. This is helpful to keep in mind during those times when you feel panicky because you do not know what is happening in the group. This is a common experience, and remembering this point can help you keep group events connected to the primary theme. For example, in a diabetes support group, the members were talking about the Red Sox game. At first glance, the discussion may have appeared to have nothing to do with the purpose of the group, but in fact, it was intimately related to how the members thought about their own physical condition compared to the healthy athletes out on the field.
Try to be careful about answering personal questions before you understand the purpose behind them. Typically, questions are not an attempt to get details about your personal life, but are related to patients’ need to feel confident in your care. For example, a patient who asks if you are married is more interested in whether you understand what it is like to be married rather than in the details of your personal life.
Avoid premature reassurance that can undermine your credibility. For example, don’t say to a distraught renal patient, “Don’t worry, we have a top-notch renal team” without first fully exploring the patient’s concerns. Make sure you thoroughly understand the situation and its meaning for the patient. Ask lots of questions before leaping in with advice or direction. Group leaders usually gain more respect when they base careful comments on what they hear and see in the group rather than when they offer premature conjecture. The biggest mistake novice group leaders make is trying to do too much, too soon.
Use your own emotional responses to the group as a barometer of what is happening in the meeting. Your own feelings most likely reflect those of the group.5
Groups are empowering vehicles and can play an important role in education and behavioral change in diabetes care. For many patients, a group format is the method of choice. For well-prepared group leaders, group interventions can be personally and professionally rewarding experiences.
John Zrebiec, MSW, CDE, is a lecturer on group psychotherapy at Harvard Medical School and associate director of the Behavioral and Mental Health Unit at the Joslin Diabetes Center in Boston, Mass.
