Post a comparison of the termination process between treatment groups and family sessions. Explain how you would evaluate readiness to terminate group and family treatment, identifying similarities and differences between the evaluation of the two types of treatment. Describe the techniques you would use to terminate a treatment group and how these may be the same or different than the techniques you would use to terminate a family intervention.
London, M. (2007). Performance appraisal for groups: Models and methods for assessing group processes and outcomes for development and evaluation. Consulting Psychology Journal: Practice and Research, 59(3), 175–188. https://doi-org.ezp.waldenulibrary.org/10.1037/106…
Toseland, R. W., & Rivas, R. F. (2017). An introduction to group work practice (8th ed.). Boston, MA: Pearson.Chapter 13, “Ending the Group’s Work” (pp. 395-416)The ending stage, a critical part of group work practice, has been given little attention in the literature since a special issue of the International Journal of Group Psychotherapy was published in 1996. The skills workers use in the ending stage determine, in part, the success of the entire group experience. In this stage, workers and members form their lasting impressions of the group. An otherwise satisfying and effective group can be ruined by a worker who is not skillful at ending the group’s work.During the ending stage, the group’s work is consolidated. In task groups, the decisions, reports, recommendations, and other products of the group as a whole are completed, and consideration is given to how the results of the work can best be implemented. In treatment groups, the changes made by individual group members are stabilized, and plans are made for maintaining these gains after the group ends. In groups in which members’ self-disclosure has been high, it is necessary to help members work through their feelings about terminating their relationships with the worker and with each other. It is also a time when workers confront their own feelings regarding ending their work with a particular group. This chapter examines the tasks and skills involved in ending individual group meetings and ending the work of the group as a whole.Factors That Influence Group EndingsEndings vary depending on whether a group has an open or closed membership policy. In closed groups, unless there are unplanned terminations, all members end at the same time. In these groups, the worker can help all members to deal with common issues and feelings that arise as the group draws to a close. Open groups present a more difficult challenge for the worker. Some members may be experiencing reactions to termination, but others may experience reactions common to the beginning stage of the group. In open groups, the worker should individualize work with each member. However, because each member will eventually experience disengagement from the group, the worker can use the reactions of members who are terminating to help members who will experience similar reactions in the future.Endings also vary according to the attraction of the group for its members. In groups that members find attractive, endings may not be viewed as a positive event. Conversely, if group meetings are viewed as something to be endured, news of the last meeting may be received with relief.In addition, endings vary depending on whether the group is a treatment group or a task group. In many therapy groups and support groups, for example, members reveal intimate details of their personal lives. They let down their defenses and become vulnerable as they share concerns and issues that are important to them. In these types of groups, mutual aid and support develop as members deepen relationships with one another and the worker. They come to trust each other and to rely on the therapeutic advice and suggestions given by the worker and fellow members.The Process of EndingIn therapy, support, and growth groups, termination may be accompanied by strong emotional reactions. However, in educational and socialization groups, termination rarely results in the expression of strong emotional reactions.Terminating the relationships that may have influenced the members of treatment groups is quite different from terminating the relationships formed in task groups. In task groups, members’ self-disclosure is generally at a relatively low level. Because the focus of these groups is on a product, such as a report or the development of a plan of action, members often look forward to the end of a group with a sense of accomplishment or with relief that their work is finished. Because they have not let down their defenses or shared their personal concerns to any great extent, there is rarely an intense emotional reaction to ending. Also, members of task groups may work together again on other committees, teams, or councils. Therefore, the endings of task groups do not have the same sense of finality as do endings of treatment groups.In the task group literature, the focus is on the skills the leader uses to end individual group meetings rather than on how the leader ends the entire group experience (Tropman, 2014). This focus contrasts sharply with treatment group literature that generally focuses on ending work with the group rather than ending work in a particular meeting.Planned and Unplanned TerminationAt the beginning of closed, time-limited groups, workers and members decide how many times the group will meet. At the beginning of other groups where there is no fixed number of meetings, terminations can result from a variety of factors that are not under workers’ control, such as when a person leaves an inpatient or residential setting. In other situations, the worker should discuss with members how termination should occur. For example, the worker may ask for a two-meeting notice. The extra week can be used to integrate the changes that are made and to plan for the future. It also discourages members from ending without notice.Member TerminationSometimes members stop attending before the planned ending date. Unplanned termination of membership is a relatively common experience. Review studies have found unplanned termination rates of about 30 percent (Barlow, 2013; Burlingame, Strauss, & Joyce, 2013).Case Example Premature TerminationIn a group for separated and divorced persons, three people did not return to the second group meeting. When they were contacted, it was found that one person lived 40 miles from where the group met and, after driving home on foggy rural roads after the first group meeting, had decided not to return. Another member’s job had unexpectedly changed and required the person to be at work during the group’s meeting times. It was learned from the third person’s employer that one of his children had experienced a serious accident. The member called two weeks later to explain that “I have been running between the hospital and my responsibilities to the other two [children].” Research-Informed PracticeBehavior:Use and translate research evidence to inform and improve practice, policy, and service deliveryCritical Thinking Question:Members often drop out of groups. What do research findings suggest about how the group worker might prevent premature termination?In treatment groups in which participation is voluntary, a reduction in membership sometimes occurs after the first or second meeting of a group. After the initial drop, groups often develop a stable core of members who continue until the group ends.When leading groups, workers sometimes find themselves asking rhetorically, “What have I done to cause members to fail to return to the group?” In follow-up contacts with members who terminated prematurely, many workers find they did not cause premature termination.There is also empirical data that indicates that workers may not be responsible for some unplanned terminations. For example, when evaluating a smoking-cessation group treatment program, it was found that members left treatment prematurely for a variety of reasons (Toseland, Kabat, & Kemp, 1983). Several were dissatisfied with their group or their group’s leader, but others left for reasons unrelated to their treatment experience. Although it is commonly assumed that dropouts are treatment failures, in evaluating eight smoking-cessation groups, it was found that one of seven dropouts left treatment prematurely because he had stopped smoking and believed he no longer needed treatment. Another dropout quit smoking before a follow-up evaluation. Thus, it is important to realize that unplanned termination of members may be the result of their lack of interest or motivation, particular life circumstances, or other factors beyond the control of the worker that have little or nothing to do with a worker’s leadership skills. Toseland and colleagues (1997), for example, found that attendance at group meetings by older adults in nursing homes was greatly affected by their health status.Yalom (2005) lists nine factors that may cause group members to drop out of treatment prematurely. Yalom points out that some members leave because of faulty selection processes and others as the result of flawed therapeutic techniques (Yalom, 2005). These factors are presented in the following list.Factors Leading to TerminationExternal factors, such as scheduling conflicts and changes in geographical locationGroup deviancy, such as being the richest group member, the only unmarried member, and the likeProblems in developing intimate relationshipsFear of emotional contagionInability to share the worker’s timeComplications arising from concurrent individual and group therapyEarly provocateursInadequate orientation to therapyComplications arising from subgroupingHowever, sometimes members do drop out as a result of their dissatisfaction with the group or its leader. For example, in therapy and growth-oriented groups in which confrontation is used as a therapeutic technique, members occasionally become so angry when confronted with an emotionally charged issue that they threaten to terminate. To prevent premature termination, Barlow (2013) and Walsh (2010) suggest using a careful pregroup screening interview to select members who have the capacity to benefit from the group. It is not always possible, however, to screen out members whose defensiveness, anger, and impulsivity may cause them to abruptly leave a group. Therefore, some workers also specify in the initial contract that members must give two weeks’ notice before leaving the group so that members have a chance to rethink their decisions.Pregroup training has also been found to be an effective way to prevent premature dropouts from therapy groups (Barlow, 2013; Burlingame, Strauss, & Joyce, 2013; Mangione, Forti, & Lacuzzi, 2007). The most common form of pregroup training is for the worker to meet with individual members to thoroughly review group procedures and processes (see also Chapter 6). Pregroup training can also take many other forms, such as listening to or viewing recordings of similar groups, sitting-in on a group, and talking with members or the worker about where the group is in its developmental stage. Piper, Debbane, Bienvenu, and Garant (1982) found a reduction of 13 percent to 30 percent in the dropout rate attributed to the successful management of anxiety and the development of interpersonal bonds that resulted from a pregroup training program. Many other studies have been conducted over the past 20 years about the benefits of pregroup training, which seems to work by reducing the ambiguity and uncertainty in beginning group meetings. For a summary of these studies, and the findings from them, see Barlow (2013) or Mangione, Forti, and Lacuzzi (2007).When workers take the time to explore members’ reasons for terminating, the data gathered can help reduce premature terminations in subsequent groups. Sometimes, for example, workers learn that arranging for child care while the group is in session helps reduce the number of dropouts. Arranging transportation to and from the group may also help. At other times, workers may find that there are ways they can improve their own skills to prevent members from dropping out of the group. For example, they may learn to be more gentle or tentative when they use confrontation methods. A survey of 275 workers who were members of the American Group Psychotherapy Association engaged in long-term group work found that the top reason for unplanned termination was that the member was asked to leave because of disruptive behavior (33 percent). This was followed by 29 percent being asked to leave the group because there was a poor fit or match between the group and a member. Other reasons included client threatening to the group (20 percent), member not committed to the group (19 percent), disruptive dual relationships with another member of the group (16 percent), and the group was not appropriate for the member (18 percent). It should be noted that these figures are based on a low response rate to the survey (11 percent), and over half of the respondents being in private practice and leading mostly long-term groups (Mangione, Forti, & Iacuzzi, 2007). Occasionally, an entire group may end prematurely. Just as there are many reasons for the premature termination of individuals, there are also many reasons for the premature termination of groups. A group that begins with a small number of members may lose several members and thus be unable to continue functioning effectively. Groups may not receive sufficient support from their sponsoring agencies to continue functioning, or groups may be unable or unwilling to respond to external pressure to change their functioning. Groups may also end prematurely as a result of internal dysfunction. For example, communication and interaction patterns may be poorly distributed and cause subgrouping, scapegoating, or domination by a few members. The group may lack sufficient attraction for its members and, therefore, may fail to coalesce or function as a cohesive unit. Social controls, such as norms, roles, status hierarchies, and power, may cause severe tension and conflict when some members rebel against the control of the worker or other members. Lack of appropriate social controls may cause chaos or an aimless drift that eventually leads to dissolution of the group as a whole. Members may also have great difficulty deciding on common values, preferences, ways of working together, or other aspects of the group’s culture. Whenever workers confront the possibility that a group may end prematurely, they should carefully examine the factors that are contributing to the problem. It is often possible to trace a group’s dysfunction back to the planning stage. Careful examination of the factors that contributed to a group’s demise can help workers avoid such pitfalls in future groups. Worker Termination Ethical and Professional Behavior Behavior: Make ethical decisions by applying the standards of the NASW Code of Ethics, relevant laws and regulations, models for ethical decision-making, ethical conduct of research, and additional codes of ethics as appropriate to context Critical Thinking Question: Group workers sometimes leave their groups. What ethical issues should be considered when a worker starts the termination process? Although rarely mentioned in the literature, there are times when workers have to terminate their work with a group. Probably the most common reason for worker termination is that students leave at the end of their field placements, but change of employment or shifting job responsibilities also lead to worker termination. In a study of two groups in which workers terminated their participation, Long, Pendleton, and Winter (1988) found that the termination of the worker led to testing of the new worker and to a reorganization of the group’s processes and structures. Several steps can be taken to reduce the disruption that can be caused by worker termination in an ongoing group. Steps to Reduce Disruption Group members should be told as early as possible when termination will occur. The reasons for termination should be shared with the group, and members should be encouraged to discuss their feelings frankly. Unfinished business should be completed. The new worker should be introduced to the group and, if possible, co-lead the group for a while with the terminating worker.Ending Group Meetings Scheidel and Crowell (1979) list four generic worker tasks in ending group meetings: (1) closing the group’s work, (2) arranging another meeting, (3) preparing a summary or report of the group’s work, and (4) planning future group actions. In preparing to close, the worker should help the group keep to its agenda. The worker should ensure that all items of business and all members’ concerns are given sufficient attention, but the group should not be allowed to spend too much time discussing one item of business or one member’s concerns. To move the group along, the worker can do the following: Keep members focused on the topic of discussion. Limit the time that each member has to discuss an issue. Summarize what has been said. Obtain closure on each issue or concern as it is discussed. In closing the group’s work, the worker should avoid bringing up new issues, concerns, or items of business. Instead, the ending of a session is a good time to engage in a process of reflection. This process entails (1) focusing on the session, (2) looking back on what transpired to see what it meant for members, (3) analyzing the significance of what occurred, and (4) examining what members can take away from the discussions and put into practice in their own lives. It is also a good time to identify unfinished work and to think about work that should be accomplished in future sessions (Birnbaum & Cicchetti, 2000). A discussion of what was accomplished and what needs to be done in future sessions lends continuity to the group. Enabling members to have a role in setting the agenda for future sessions and to give feedback about the group experience empowers them (Birnbaum, Mason, & Cicchetti, 2002). It provides an opportunity for members to express their satisfaction and sense of accomplishment with what occurred in the meetings, as well as any concerns they have about how the group is functioning. Birnbaum and Cicchetti (2000) point out that it is helpful for group leaders to invite members to raise discrepant points of view during ending discussions. Leaders who solicit discrepant viewpoints and feelings about how the group is going can help group members to express and resolve conflicts before they can become inflamed. At the same time, soliciting different points of view can help members to discuss group processes as well as the content of group meetings. In this way, members of the group take increasing responsibility for both the content and the process of future group meetings. Despite efforts to structure the agenda to ensure that there is enough time to discuss important issues at the end of a meeting, Shulman (2016) points out that members occasionally raise “doorknob” issues just before ending. If consideration of these issues can be postponed, they are best handled during the next meeting when they can be given fuller consideration. When discussion of an important issue cannot be postponed, the worker should ask group members whether they prefer to continue the discussion for a brief period. If not, the issue may be taken up outside the group by the worker and any interested members. In closing the group’s work, the worker should also help members resolve any remaining conflicts. Resolving conflicts helps members to work in harmony for the decisions reached by the group as a whole. In addition, the worker may want to discuss the strengths and weaknesses of the working relationship that has developed among members during the group meeting, particularly if the group will work together in the future. During the ending minutes, the worker should help the group plan for future meetings. When considering whether to meet again, it is helpful to review and summarize the group’s work. A summary of the group’s activities during the meeting clarifies issues that have been resolved and points out issues that remain unresolved. A clear summary of the group’s progress is a prerequisite for arranging another meeting. Summaries also remind members of the activities or tasks they have agreed to work on between meetings and help the worker become aware of items that should be included in the agenda for the next meeting. If a group has completed action on a particular task, the final minutes can also be used to ensure that all members understand and agree to the oral or written information that will be presented at the conclusion of a group’s work. Some task forces may prepare extensive written reports of their findings and conclusions. In these groups, it is not productive to prepare the report during the group meeting. The closing minutes can be used to formulate and highlight the major conclusions to be enumerated in the report, to assign members responsibility for preparing major sections of the report, and to develop a mechanism for obtaining approval from members before disseminating the report. The endings of group meetings can also be used to plan future group actions. However, because planning action steps is time-consuming, plans are usually developed during the middle of a group meeting. At the ending of a meeting, plans are summarized, and members select (or are assigned) tasks to carry out. The worker should help members maintain their motivation, commitment, and responsibility to implement and carry out the tasks they have agreed to complete between meetings. To help members maintain their motivation, the worker should praise members for their work in the group and for their willingness to commit themselves to tasks outside the meeting. The worker may also want to mention any benefits that will accrue to members for maintaining their commitment to the plans and activities they have agreed to complete.Ending the Group as a WholeA variety of tasks are associated with ending a group as a whole:Learning from membersMaintaining and generalizing change effortsReducing group attraction and promoting the independent functioning of individual membersHelping members deal with their feelings about endingPlanning for the futureMaking referralsEvaluating the work of the groupWith the exception of evaluating the work of the group, which is discussed in Chapter 14, the remaining portion of this chapter examines each ending task and the skills and techniques the worker can use to facilitate the effective ending of a group. Many of these tasks may be carried out simultaneously. The specific order in which each task is completed depends on the group the worker is leading.Learning from MembersIn the last session of a group, in addition to any formal evaluation procedures, workers should give members a chance to describe what it was like for them to be in the group. One way to do this is a final group go-round where each member gets a chance to say what they enjoyed about the group, what they learned, and how they will use what they learned in the future. Members should be encouraged to talk about what they think could be improved in future groups. All members should also have a discussion of what they learned from one another. It is also an important time to give individual members a chance to give some final feedback to other members whom they would especially like to thank for their contributions to the group. Workers can make a statement about what they learned from individual members and what individual members contributed to the group. Workers should also give positive but realistic feedback about what each member accomplished and what each member should remember about their resiliency and strengths, and how they can use them in the future to work on any issues that arise after the group ends. If there are no follow-up group sessions planned, it can also be useful to schedule individual follow-up meetings with members a month or two after the group ends to get additional feedback from them about the group experience, to praise them for any changes in their lives that they have started or sustained, and to help them with any problems or issues that may have arisen since the last group meeting.Maintaining and Generalizing Change EffortsAfter treatment plans have been developed and carried out, workers should ensure that the changes that have been achieved are maintained and generalized to other important aspects of members’ lives. Evaluations of results of therapeutic interventions suggest that positive changes are often difficult to maintain over time. For example, in an evaluation of two different group intervention programs for caregivers of the frail elderly, it was found that some of the positive changes found immediately after group intervention were not sustained at one year (Labrecque, Peak, & Toseland, 1992; Toseland, 1990).Positive changes are even harder to maintain in group treatment programs that are focused on individuals with addictive disorders. For example, in an evaluation of a group treatment program for smokers, it was found that although more than 60 percent of members who attended the program initially stopped smoking, the cessation rate had dropped to 36 percent after three months (Toseland, Kabat, & Kemp, 1983). Results obtained for a variety of other addictive disorders, such as narcotics use, alcohol use, and overeating, show similarly high relapse rates (Boyd-Franklin, Cleek, Wofsy, & Mundy, 2013; Chiauzzi, 1991; Marlatt, 1996; Marlatt & Barrett, 1994; Vaillant, 1995). Maintenance is also difficult to achieve in working with antisocial group members, such as juvenile delinquents, and in working with group members who have severe psychological disorders.Both novice and experienced workers often mistakenly believe that changes in specific behaviors can be taken as a sign of generalized improvement in a member’s level of functioning. These workers do little to ensure that specific behavior changes generalize to related, but untreated, behaviors. Results of a variety of different treatment programs have shown, however, that therapeutic changes occurring in specific behaviors do not always generalize to similar behaviors performed by a member in other contexts (Masters, Burish, Hollon, & Rimm, 1987). For example, a parent may learn how to reduce a child’s temper tantrums, but this success may not affect the parent’s ability to help the child play cooperatively with other children.Although some people seek group treatment only for changes in specific behaviors, most people enter group treatment with the expectation that there will be a generalized improvement in their life situations. Therefore, it is important for workers to help members generalize changes achieved in specific behaviors and performed in particular situations to related behaviors performed in other contexts. With the notable exception of Rose (1989, 1998), little has been written about these topics in group work. Almost all the theoretical and clinical work on maintenance and generalization of change has come from the literature on behavior modification and learning theory. The literature suggests several things workers can do to help members maintain and generalize the changes they have achieved.Maintaining and Generalizing ChangesHelping members work on relevant situationsHelping members develop confidence in their abilitiesUsing a variety of different situations and settings in helping members learn new behaviorsUsing a variety of naturally occurring consequencesExtending treatment through follow-up sessionsPreventing setbacks in an unsympathetic environmentHelping members solve problems independently by providing a framework for organizing data and solving problems that can be used in many different situationsRelevant SituationsTo achieve long-lasting changes that will generalize to similar situations in members’ lives, the concerns and issues worked on in the group should be a relevant and realistic sample of concerns and issues experienced by members in their daily lives. Sometimes members become distracted by issues that are not central to their concerns, a possible sign that the members are avoiding difficult issues and the changes they necessitate. The worker can help by drawing members’ attention back to the central concerns that brought them together as a group.In other cases, the situations discussed may be highly specific and individual. Although it is important to be as specific and concrete as possible when developing treatment plans, it is also important to ensure that situations that are relevant to all group members are included in the group’s work so that members are prepared for situations they are likely to encounter in the future.Although group meetings should provide a protected environment in which members receive support, encouragement, and understanding, the group should also be a place in which members can get honest feedback about how their behavior is likely to be seen outside the group. Members should be encouraged to try out new behaviors in the group, but they should not be misled into thinking they will receive the same level of support and encouragement for trying new behaviors outside the group. In short, although the group should provide a supportive and caring atmosphere in which to work, the group should help members understand, cope with, and prepare for reactions likely to be experienced outside the group.Helping Members Develop ConfidenceMany treatment groups spend much time discussing members’ problems and concerns as well as their inappropriate ways of handling situations. Although ventilating thoughts and feelings may be therapeutic, Lee (2001) points out that too much time in treatment is often spent on the negative aspects of members’ problems and not enough time is spent empowering members and building their self-confidence. Lee suggests that emphasis on negative thoughts, feelings, and experiences reinforces the members’ tendency to continue to express these problems outside the group.As the group progresses, workers should encourage members to focus on adaptive alternatives to the problematic situations they are experiencing. If members dwell on poor performances and inhibiting thoughts in the group, they are less likely to feel confident about their abilities to cope with or resolve the problems they experience in their daily lives. Although it is not possible or desirable to avoid discussions of problems in treatment groups, workers should help members become more aware of their own abilities. Members should be encouraged to use their abilities and their resources to resolve the problematic situations they encounter as they prepare for leaving the group (Saleebey, 2013). Program activities, role plays, and exercises are particularly useful in helping members to become more aware of their strengths and to build confidence in their ability to solve problems. This process, in turn, will help members gain confidence in their abilities to continue to function adaptively after they leave the group.Case Example An Adolescent GroupA worker in a day treatment program asked members of her group to think about a situation when they were scared or anxious about their performance, but when they actually got into the situation it worked out well. The worker then asked each member, in turn, to describe the situation and what happened. After each member shared, the worker asked the group what they had learned from these experiences and how they could use them in the future to develop confidence in their abilities to get through difficult situations.Using a Variety of Situations and SettingsAnother aspect of maintaining and generalizing change is preparing members for different situations that may interfere with their abilities to maintain the changes they have made. Although preparations for maintaining changes are emphasized during ending-stage meetings, such activities should be given attention throughout members’ participation in a group. Issues and concerns brought to group treatment are rarely, if ever, confined to one situation or setting in a member’s life. A member who experiences communication difficulties, for example, often experiences them in many situations with different people. Therefore, it is helpful in treatment groups to have members practice responses with different members in a variety of situations. Because of the availability of group members who will respond differently from one another, group treatment is ideally suited for this purpose. Bandura’s (1977) research confirms that the use of multiple models (group members) promotes generalization of treatment effects.Easier situations should be role-played before more difficult situations. What constitutes an easy or a difficult situation varies from person to person, so the worker should assess each person’s needs when developing a hierarchy of situations to work on in the group. Once a member demonstrates the ability to handle a variety of situations in the group, the member should be encouraged to get additional practice by trying new ways of behaving between meetings.Program activities can also be used to simulate situations that may be encountered outside the group. For example, children referred to a group because they have difficulty playing with classmates can be encouraged to participate in team sports in which cooperative play is essential; long-term psychiatric patients may be encouraged to prepare and participate in a group dinner as a way of practicing skills that will help them when they are placed in a community residence.Using Naturally Occurring ConsequencesAlthough it is often difficult to make changes initially, changes are maintained and generalized by the resulting positive consequences. For example, although losing weight is initially uncomfortable, loss soon results in positive compliments from peers and feeling better about oneself. To maintain and generalize behavior changes, the worker should help group members experience the positive consequences of changes as soon as possible and maintain the positive consequences for as long as possible.Case Example An End Smoking GroupOnce members have decided to stop smoking they should be encouraged to seek out the reactions of family members and friends about their decision. Members might talk with these individuals and think to themselves about the benefits of quitting. They might talk and think about the following: (1) they will save money by not buying cigarettes, (2) their breath will no longer smell like stale cigarettes, (3) their clothes, their home, and their car will no longer smell like cigarette smoke, (4) food will taste better, (5) they will have increased lung capacity and greater vitality and endurance while walking and climbing stairs, (6) they will no longer live in smoke-filled rooms with the dangers of secondhand smoke, and (7) they may feel better and live longer. Members should be encouraged to replace urges to smoke with thoughts of the previously mentioned soon-to-be expected positive effects of quitting. With members’ permission, the worker can also contact significant others in members’ lives and ask them to continue to reinforce the ex-smoker’s resolve not to smoke after the group ends. The worker can also discuss with members the possibility of setbacks and relapse and how to return to being a nonsmoker.One method is to help members focus on positive rather than negative consequences. Another way to enhance naturally occurring contingencies is to help members modify environmental consequences so that behavior change is more readily maintained and generalized. For example, a buddy system may be established so that group members receive positive feedback for changes between group sessions. Group members may be asked to modify friendship patterns, social activities, or their home environment in ways that provide positive consequences for changes they have made through their efforts in the group. By enhancing and highlighting naturally occurring positive consequences and by reducing negative consequences, initial changes can be maintained and generalized.Follow-Up SessionsAnother way to help ensure that treatment results are maintained and generalized is to provide members the opportunity to meet together for follow-up sessions after the completion of a formal group treatment program. For example, a time-limited, outpatient psychotherapy group might meet for twelve weekly sessions and then for six follow-up sessions at one-month intervals. After this time, two quarterly meetings during the rest of the year might complete the treatment contract.Follow-up sessions reinforce members’ commitment to maintaining changes. They remind members of the changes that have taken place in their lives since they began treatment. Members can share similar experiences about their difficulties in maintaining changes and trying to generalize changes to new situations and new life experiences.Follow-up sessions are generally not used to introduce members to new material. Instead, they are used as an opportunity for members to share their experiences since the previous meeting. Members should be encouraged to discuss new problem situations they have encountered and to describe how they have handled these situations. The emphasis should be on helping members identify the coping skills they have developed to maintain changes achieved during treatment.Follow-up sessions are particularly helpful for members who have difficulty maintaining treatment gains. Members can discuss the circumstances surrounding particular relapses and consult the group worker and other members about how best to handle these occurrences. The additional support provided by follow-up sessions is often sufficient to help members overcome brief relapses that might otherwise turn into treatment failures.The popularity of self-help groups can, in part, be attributed to the flexible, open-ended, long-term membership that is encouraged in many of these groups. Self-help groups often have a small group of members who regularly attend meetings, along with many other members who attend as needed (Toseland & Hacker, 1982). For self-help group participants who have attended sessions regularly in the past, occasional attendance at future meetings can maintain treatment gains and gradually reduce dependency on the group. InterventionBehavior:Critically choose and implement interventions to achieve practice goals and enhance capacities of clients and constituenciesCritical Thinking Question:Unsympathetic environments are often identified as causing relapses and setbacks. How can the worker help members decrease the effects of pernicious environments so that gains in the group can be maintained?Preventing Setbacks in Unsympathetic EnvironmentsEven when careful attention has been given to the environment that a member faces outside the group, the support, trust, and sharing found in well-functioning treatment groups is rarely duplicated in the members’ home or community environments. Members should be prepared to face possible setbacks in the unsympathetic environment they are likely to experience outside the group. Rose (1989) suggests that the experiences of the worker in leading previous groups, as well as the experiences of former group members, are useful in developing vignettes that describe realistic and typical situations group members are likely to encounter outside the group. During the final few group sessions, members should discuss how to respond to such situations and practice responses with one another by using modeling, role play, rehearsal, and coaching.Because members are likely to experience situations that threaten their treatment gains soon after changes are initiated, members should be encouraged to describe such situations in the group sessions. It is especially important to examine likely triggers for relapses and to plan for how to avoid or cope with them when they occur (Boyd-Franklin, Cleek, Wofsy, & Mundy, 2013). In this way, all group members become exposed to a variety of situations and reactions to changes, and they can learn to handle reactions before the situations occur in their own lives.Members may encounter difficult situations any time of the day or night. Because the group worker may not be available to members at those times, the worker should inform members about how to contact on-call workers, emergency hotlines, and other 24-hour services.The difficulty of maintaining changes among members with drug, alcohol, and other addictive behavior problems suggests a need for intensive and extensive treatment. One way to augment group treatment with a professional worker is to link members to self-help groups. Alcoholics Anonymous groups, for example, often meet each evening, or at least several times each week and can provide members with an alternative to spending their evenings in a neighborhood bar or drinking alone at home. These groups also encourage recovering alcoholics to form close relationships with new members, which provides new members with models of sobriety and encourages the development of a network of supportive relationships. Similarly, organizations such as Recovery, Inc., Parents without Partners, Parents Anonymous, and Gamblers Anonymous help members with other types of problems and concerns to become involved with a network of people to whom they can turn at particularly difficult times. Safety plans and relapse prevention plans can also be put in place during the ending part of the group, and reminders about them and other helping resources can be placed in prominent places in members’ homes so they are available after the group ends.Members of task groups can also benefit from preparing for an unsympathetic environment. Plans, reports, and other products of a task group’s work may encounter resistance as they are considered by others outside the group. Resistance is especially likely when the products of a task group are controversial or have negative implications for a particular program, an entire organization, or a social service delivery system. Also, resistance is more likely to be encountered when proposals must go through several levels of review before they are approved (Tropman, 2014). Therefore, it is important for task group members to anticipate resistance to implementing the group’s work and to plan strategies to counteract the resistance.Helping Members Solve Problems IndependentlyNo matter how many different situations are discussed and practiced within a group, it is not possible to cover the full range of situations that members may experience outside a group. Therefore, during the group, members should learn how to solve their own problems independently. This gradually lessens the need for continued treatment. Teaching problem-solving skills should begin as early as possible in the group experience and be given particular emphasis in the last few meetings.Throughout the group treatment process, workers can support independent functioning by building members’ confidence in their existing coping skills and by helping members develop and rely on new coping skills. Workers should also teach members the principles underlying the intervention methods used in the group. Workers sometimes fail to teach members the underlying therapeutic principles of an intervention because they think professional knowledge should not be shared with clients, group members may not be able to understand therapeutic principles, or members may misuse the information they receive. Most group members who enter treatment voluntarily are eager to learn more about ways to cope with their concerns. For example, having members of an assertion-training group read Your Perfect Right (Alberti & Emmons, 2008), having members of a parent-training group read Parents Are Teachers (Becker, 1971), or having members of a weight-loss group read Slim Chance in a Fat World (Stuart & Davis, 1972) helps them learn basic principles that they can use as they encounter situations not discussed in the group.Some treatment approaches, such as Albert Ellis’ rational-emotive therapy (Ellis, 1962, 1992, 2002; Ellis & Joffe-Ellis, 2011), encourage workers to help members understand the basic principles underlying their treatment approaches. Workers who use other treatment approaches should also consider spending time teaching members the basic principles underlying therapeutic interventions. When teaching members, workers should translate technical terms into jargon-free explanations, especially if members use English as a second language.Having members summarize what they have learned in the group and deduce general principles from the summaries are other effective ways to help members see how principles can be applied to other situations. For example, in summarizing what they have learned, members of a couples’ group became aware of general principles regarding communication, such as maintaining eye contact to show that they are listening, summarizing the core content of messages to ensure understanding, and using “I” messages to communicate their feelings and thoughts.Reducing Group AttractionIn addition to helping members maintain and generalize the changes they have made in a group, the ending stage should help members become less dependent on the group. This goal can be achieved by helping members rely on their own skills and resources as well as on sources of support outside the group. Planning for termination should begin with workers’ awareness of their own feelings about terminating with individual members and with the group as a whole. Particularly in support groups and therapy groups, it is not uncommon for workers to become emotionally attached to individual members or to the group as a whole. Workers should be careful not to foster dependence. They should carefully assess whether they are being overly protective of members or covertly or overtly undermining members’ efforts to function without the group. Supervision can be useful in helping workers examine their feelings about terminating.To ensure that members are prepared for ending, it is good practice to begin discussions of termination at least four sessions before the planned termination date. Members should be fully involved in planning for termination. Program activities can be used effectively at the end of a group to help members prepare for termination (Nitza, 2014). Workers should describe the ideas they have about program activities for ending the group, solicit members’ feedback, and ask for additional suggestions. Appropriate program activities for ending a group include the following principles.Principles for Program ActivitiesDemonstrate or encourage reflection about the skills members have learned in the group.Encourage members to express their feelings about the group and each other.Focus on future activities.Encourage participation in activities outside of the group.For example, getting together for a dinner is a program activity that is commonly used at the ending of a group. Planning for a dinner encourages both individual and group-oriented participation. During the dinner, members often discuss the things they have learned in the group, their feelings about ending, and their plans for the future.Endings are often marked by ceremonies. Program activities, such as having a party or a potluck dinner, awarding certificates of merit, or having each member say or write something special about other members, can be viewed as ceremonies that signify the end of the group. Barlow, Blythe, and Edmonds (1999) have developed a series of exercises that can be done in the last meetings of a group. These include exercises that are focused on ending the group on a positive note, celebrating the ending of a group, summarizing progress, reflecting on what has been accomplished, and thinking about the future. Used creatively, ceremonies can also help to maintain and generalize changes made by members. One example of the creative use of ceremonies and program activities is illustrated in the following case.Group attraction can be reduced in other ways. Members can be encouraged to summarize their accomplishments and discuss why they no longer need the group. They can celebrate their successes and talk about what they have accomplished. Workers should be positive and upbeat, giving praise for members’ accomplishments and celebrating successes along with members. Workers should express confidence in members, noting their resiliency, capacity, strengths, and ability to maintain changes in the future (Saleebey, 2013).Feelings about EndingThe feelings that members and workers have about ending are related to the relationships that have developed in the group. Feelings about ending are also affected by whether the group is planned to be time-limited or open-ended, how long the group meets, the nature of the group’s work (e.g., primarily task or socio-emotional), the intensity of the relationships that develop among members, and the extent to which the ending is associated with a sense of progress, achievement, or graduation (Germain & Gitterman, 2008). After examining reactions to termination, Fortune and colleagues (Fortune, 1987; Fortune, Pearlingi, & Rochelle, 1992) concluded that the strongest reactions were positive affect, positive flight to constructive outside activities, and objective evaluations of treatment goals and processes.Many positive feelings can result from a skillfully facilitated group ending.Positive Feelings about EndingA feeling of empowerment and potency as members realize they are capable of accomplishing goalsA feeling of independence resulting from being in greater control of their own livesA sense of satisfaction and pride in successfully completing the group experienceA feeling of usefulness resulting from helping other members during group interactionsA feeling of confidence that problems can be coped with or solvedAt the same time, however, members may experience negative feelings about the ending of a group. A common reaction is denial (Levine, 2012). Not wanting to show that they will miss the worker or others in the group, members sometimes ignore workers’ attempts to prepare them for ending by changing the topic of discussion or by indicating that they are looking forward to ending. Other common reactions are feelings of disappointment, powerlessness, abandonment, or rejection. Members may act out these feelings by becoming angry or hostile. In other cases, they may engage in regressive behavior that exhibits the symptoms or problems they had when they first entered the group (Malekoff, 2014). Other reactions include emotional or psychological clinging to the worker, acting out, and devaluing the group experience or the skill of the worker (Malekoff, 2014).More often, members simply wish they could continue with the warm, supportive relationships they have found in the group. Therefore, they may experience a sense of loss and accompanying sadness at the ending of the group. Members may also question their ability to maintain changes without the help of the group.As mentioned earlier, workers are not immune to reactions to ending a group. Some of these reactions follow.Worker Reactions to Group TerminationPride and accomplishment in the members’ successPride in worker’s own therapeutic skillsSadness, sense of loss, or ambivalence about no longer working with the membersDoubt or disappointment about the members’ progress or ability to function independentlyA re-experiencing of their own lossesRelief, doubt, or guilt about their therapeutic effectivenessWorkers should be aware of their own reactions to ending to fully appreciate the difficulties that members may be experiencing. If workers are not aware of their own feelings, they may withdraw emotionally or they may encourage the dependence of members and prolong treatment beyond what is needed. Workers may also want to share their reactions as a way of helping members identify and express their own feelings and reactions.It is helpful to begin termination several meetings before the end of the group. As members begin to react to ending, the worker can point out that conflicting or ambivalent feelings during this stage are common. Members should be encouraged to discuss their conflicting and ambivalent feelings.Workers can help members with their negative emotional and behavioral reactions to ending by developing increased awareness of the connection between their feelings and behaviors and the termination process. It is also helpful to encourage members to discuss the coping abilities and other gains they have achieved as a result of being in the group. The worker can prepare members for ending by clarifying what the role of the worker and the sponsoring agency will be in helping members maintain gains after the group ends.Planning for the FutureIn time-limited groups, some members may wish to contract for additional services. When considering new services, the worker should help members clarify (1) their continuing needs, (2) the goals they hope to achieve, (3) the duration of the new service period, and (4) any appropriate modifications of the original contract. Re-contracting should occur when there is a clear need for additional services and when members are highly motivated to achieve additional goals or to continue work on original goals that they have only partially completed. Occasionally, all members of a group may express interest in continuing to meet. In such cases, the worker may re-contract for additional meetings with all members or may encourage members to meet on their own without the worker.When workers encourage members to continue to meet on their own, they are participating in the development of a self-help group. The worker helps groups continue to meet by developing natural leadership and by helping with any resources that may be needed (