Occupational and Group Analysis: Adolescents

Chapter 9


Occupational and Group Analysis


Adolescents





Chapter objectives:



1 Outline the developmental tasks of adolescents as they relate to group interventions.


2 Identify group needs specific to adolescents.


3 Describe strategies for working with adolescents.


4 Discuss group interventions and frames of reference for adolescents.



Key Terms



Adolescence, unique as a time of physiologic changes and psychosocial development, is characterized by exploration, experimentation, and the development of one’s sense of identity. Relationships with parents are redefined, while those with peers are strengthened. Participation in peer activities increases, progressively greater independence is established, and competency in the skills for adult roles are gained. Many adolescents find this time in their lives stressful and there is an increased vulnerability for mental health disorders.


Practitioners need to consider the developmental tasks associated with adolescence. These include exploring intimacy, sexual and gender orientation, and sexual expression. In middle and high school “fitting in” is important, because identifying with a peer group as friends provides a sense of belonging that is key to successfully navigating the developmental tasks.28 However, there are also pressures from peers, parents, and society to perform and conform. The pressures from peer groups to experiment can include engaging in risky behaviors and expressing group membership through actions such as choice of clothing, drinking, and interests that may create conflict with parents. Although other peer groups may create fewer tensions with parents, the need to follow peer trends and belong is perceived as paramount (Figure 9-1).



Adolescents report feeling stressed as a result of the pressure they feel to succeed academically and in areas such as sports and the arts, and to assume greater responsibilities for themselves. These responsibilities include managing finances. Some adolescents work not only for discretionary spending money, but to help support their families. They are increasingly expected to manage their time and to complete their self-care, to self-regulate emotions and behaviors, and to make sound judgments about their new freedom. All these expectations occur while they are still developing cognitive skills and exploring their values and beliefs. Irrespective of the specific group goals, the group-based interventions that occupational therapy practitioners provide to adolescents address the development of the performance skills required to participate successfully and to meet the demands of this developmental stage to assume the roles of adult life.


This chapter reviews the psychosocial milestones that are fundamental to adolescent development and underpin all groups conducted with this population in therapy and recreational settings. The chapter outlines strategies to assist practitioners in leading group interventions for adolescents. The authors provide sample group templates that serve to organize intervention planning.



Psychosocial Developmental Tasks of Adolescents


In adolescence there is a psychosocial vulnerability that can result in behavioral difficulties (e.g., delinquency, participation in criminal activities, social failure, or participation in gangs) or psychopathologic conditions such as the onset of depression, eating disorders, drug and alcohol abuse, self-harming behaviors, and anxiety disorders.11 In contrast, with supportive family, school, and community environments, which include validating adults, healthy psychosocial development results in self-actualization, namely a healthy self-concept, self-esteem, and sense of one’s identity as an autonomous individual.


There are three stages of adolescent development (Table 9-1; Figure 9-2). Early adolescence encompasses the middle school years (11 to 13 years old) and the majority of young people in this age group experience puberty (the maturation of the reproductive system with the development of primary and secondary sex characteristics). Middle adolescence includes the high school years between the ages of 14 and 17. This is the period of the most intense psychosocial development, when the salient relationships with friends and other peer-mediated influences displace parental relationships and opinions. Late adolescence, between 17 and 25 years, is a time of consolidation of values, self-identity, and self-efficacy in performance skills required to meet the choices and demands of the roles of early adulthood such as work and forming a stable intimate relationship.





Advantages of Group Interventions for Adolescents


Research studies empirically support the effectiveness and importance of group interventions (counseling, social skills training, psychotherapy, and preventive programs) for adolescents.16,17,28,29,33 Adolescents prefer group settings; it is where they learn, develop, and seek support. Their lives are structured around formal, informal, and virtual groups, such as the classroom, the sports team, Facebook, and friendship groups. Group interventions assist adolescents to develop peer relationships in a structured, safe environment and to express themselves without fear of criticism, ridicule, or bullying. In therapy groups, structure and activities that are appropriate for age and development assist adolescents to find their voice, articulate their concerns, and receive support from peers and adults.


Adolescents with special needs or disabilities engage in fewer social activities and friendships outside of school. Even adolescents with friends at school report they have less contact with friends outside of school in comparison with their peers.10 Reasons for this discrepancy include not participating in or not excelling in the activities such as sport. During adolescence, social participation and stereotypical characteristics of “physical attractiveness” and interpersonal skills are primary factors of high social status.25,32 Adolescents with disabilities seldom have high social status and those with physical disabilities deal with additional challenges of mobility and community access. The negative consequence of limited participation with peers results in less engagement in the broad range of activities and tasks that promote role and skill development in adolescence (Figure 9-3).



Adolescents may be referred to occupational therapy because they are experiencing psychoemotional or behavioral problems. They are often reluctant attendees in the group sessions because they perceive that occupational therapy makes them “different.” At this age teens want to conform to the “typical” image for adolescents in their community, culture, and particular peer group. Already challenged emotionally and lacking in the skills to articulate their thoughts, feelings, and needs, they may demonstrate their reluctance and ambivalence in their behavior rather than verbally express their concerns about being stigmatized. They fear what therapy will involve and mean for them. However, group interventions can also reduce their isolation by challenging the myths that one’s emotions and experiences are unique. They can find peer acceptance, perhaps for the first time, and receive adult guidance and support in a context that also offers avenues to assert power and gain independence.6



Types of Groups and the Frames of References that May be Used to Structure Them


By using a frame of reference, a practitioner has a clear understanding of his or her role and a practical template to develop group interventions. Each frame of reference has assessments and strategies, including a perspective for interpreting adolescents’ occupational performance. It defines outcomes that can be expected when therapy adheres to the frame of reference’s evaluation and intervention process. In this section, we have selected frames of reference and paired them with common adolescent group interventions. The group and frame of reference illustrate one example of a group that a practitioner could employ for a given need or problem.


The choice of a frame of reference is based on many factors: the population characteristics, needs, performance skills, and capacity of group members; the occupational therapy goals; and the expertise of the practitioner. Although best practice recommends basing the choice of frame of research on evidence of its effectiveness, the choice may be influenced by the policies, resources, and philosophy of a setting. For example, a residential school setting for adolescents with behavioral problems may have instituted a positive behavioral support [PBS] approach. The practitioner would need to incorporate PBS into his or her practice and therefore might select an acquisitional frame of reference for groups because it meets the needs of the adolescents in the occupational therapy group and it is compatible with PBS.


Occupational therapy group interventions for adolescents occur in many settings. Groups are offered in schools to enhance school performance or to facilitate transition from high school. Groups providing mental health or behavioral interventions may be based in health, justice, or educational settings. Other groups are delivered in the community, including summer camps, city-supported initiatives for youth, and programming that is an extension of school services. Any of these frames of reference–based groups, outlined here, can be provided in these settings.32



Talk-Based Therapy Groups


Occupational therapy with adolescents in mental health multidisciplinary settings is often provided in talk-based groups, such as cognitive-behavioral therapy or psychodynamic therapy. Social workers, psychologists, and youth workers also use these frames of reference.24,32


Adolescents involved in talk-based therapy benefit from structure. A practitioner uses structure to help adolescents manage their anxiety and lessen their resistance to participating in therapy. Self-disclosure and sharing of experiences and feelings to promote insight and self-understanding can be facilitated using projective activities (self-awareness activities), a strategy that an occupational therapy practitioner brings to talk-based therapy. In projective activities, a variety of media such as art activities, music, movement, or sociodrama are vehicles for self-exploration and self-expression. Through an activity, adolescents express themselves and by talking about the theme of the activity they begin to give a voice to their feelings and concerns. For example, the magazine picture collage, a projective activity used to assess adolescents in mental health settings, provides insights into how they perceive themselves and describe their interests (Figure 9-4).12



Practitioners using projective activities need to be skillful at facilitating groups, because through these techniques adolescents may begin to access painful experiences and difficult emotions. The practitioner leading these groups must ensure that the group process proceeds at a rate that is appropriate to the participants’ emotional and cognitive skills to cope. Self-disclosure is not the primary goal of projective activities. The primary goal is for the activity to provide the adolescents an opportunity to explore and gain insight into their experiences, values, beliefs, interests, and personal causation. From these insights they learn to self-regulate their emotions and reframe painful experiences so that trauma or emotional difficulties do not continue to undermine their occupational performance in areas such as social participation and education. It is integral to the therapeutic process of talk-based groups that issues raised in the session are addressed within the group through mutual support, sharing, and learning coping strategies. Therefore, time management is very important to ensure that an appropriate level of resolution of issues is achieved before the group session finishes and no member leaves the group unduly distressed.



Social Learning Theory as a Frame of Reference


Life and social skills are two common areas of occupational performance addressed through group programs. In skill-based programs, goals must clearly delineate the area of occupational performance being addressed.24 The label social skills has become an umbrella term for the interpersonal and communication skills necessary for successful social participation, relationships, and community engagement. However, the performance skills (e.g., social interaction skills, communication skills, and social skills) consist of distinctive areas. Similarly, the frame of reference selected is based on the evidence of its effectiveness to promote development of the targeted skills. The context of the group program is also critical to the facilitation of the skills and the generalization of the learning to adolescents’ everyday occupations. For example, a practitioner planning a group program to develop functional community mobility skills would select an occupation-based frame of reference so that the skills are acquired in the naturalistic setting (the adolescents’ community). Although occupation-based learning in the natural context is optimal, practitioners addressing a limited performance skill frequently select a frame of reference that works on acquisition of the components of skills in a simulated context. Therefore, the psychiatric rehabilitation model may be the choice for a group of late adolescents who need to acquire activities of daily living skills to transition to a group home. We have chosen the category of social skills to illustrate a communication group program that would focus on acquisition of component skills in a simulated context.24,29,33


Social skills group programs may focus on the techniques of conversing and the mechanics of communicating. Other group programs within this broad area of skills may focus on the more complex principles of interacting that involve understanding interactions and developing multidimensional performance skills that support maintaining relationships through skillful communication.


Box 9-1 provides a description of the aspects of social skills. Selected subareas may be identified and expanded into a specific group program such as assertiveness, anger management, or self-regulation strategies for the classroom setting. This list emphasizes the importance of focusing on a comparable level of social skills and building a group program that is congruent with the performance capacity of the group participants. It is better to limit the focus and achieve skill competency, because the adolescent’s self-efficacy (belief in one’s ability to perform) in social skills builds self-esteem and increases the likelihood of social participation.



BOX 9-1   Group Interventions that Build Social Skills for Social Participation






Practitioners planning to implement social skills groups with adolescents are strongly encouraged to make use of resources available in the health and education literature. Practitioners use task analysis to identify the components of the skills to be addressed. The skills listed in Box 9-1 are divided into behavioral units according to the performance capacity of the adolescent group participants. For example, a group working specifically on communications skills might have sessions on conversing using verbal and nonverbal interactions such as greeting, initiating a conversation, and asking questions.


The predominant frame of reference used for many social skills interventions by occupational therapy practitioners is social learning theory (SLT) (more recently referred to as social cognitive theory). SLT groups are used to decrease behavioral problems, improve social behaviors and social skills, and to improve adolescents’ self-efficacy in their performance. This approach is employed in groups that provide assertiveness training, anger management, or seek to change behaviors (e.g., stop smoking and develop healthy eating patterns).


SLT focuses on learning that occurs within social contexts and how people learn from one another through observation, imitation, and seeing other people model behaviors. In keeping with adolescents’ need for a sense of autonomy, this frame of reference recognizes adolescents as self-determining—as able to make choices about their behaviors, and able to understand the importance of choices. It uses reciprocal interaction among them and their peers to foster vicarious learning. A fundamental concept of SLT is that adolescents will most likely learn new behaviors by watching other adolescents like themselves (especially a person they hold in high esteem) who can competently perform the desired skill or behavior. Vicarious learning can also inhibit undesirable behaviors. When an adolescent observes adverse consequences associated with behavior, this may lead to an inhibition of similar behaviors to avoid an unpleasant outcome.


Social skills groups following the SLT frame of reference employ strategies for learning and rehearsing new behaviors including activity analysis, role modeling, coaching, and role playing.



image Clinical Pearl: Using Role-Play Techniques


Role play is useful in providing situations to try out or practice new behaviors. Safe and appropriate use of this learning and therapeutic technique follows a protocol of explicit steps and the practitioner’s role as a “director and facilitator” is delineated. The practitioner leading a role play in a group session clarifies the objectives of role play for group members, describes the roles and tasks of participants who will perform the role play, and the tasks of the audience (other group members). Then he or she prepares role-play participants and coaches individual participants or models skill or behavior through the role play. At the end of the acting, the practitioner facilitates feedback to participants, debriefs the participants, and then integrates learning through discussion related to the role play and the session’s goals. Before using role playing, a practitioner must learn how to use this technique correctly. Poorly executed role playing can be ineffectual or, worse, cause distress or harm to participants and observers, especially if the level of emotional intensity or demands exceed the emotional integrity or skills of the group members. Resources can be found in the educational and therapy literature and, depending on whether one’s use is primarily educational or therapeutic, it is best to refer to material in that domain. Advance training in action techniques is available from sociodrama and psychodrama workshops.

Related posts:

  1. Occupational and Group Analysis: Children
  2. Emerging Occupational Therapy Practice Areas
  3. Activity Analysis
  4. Therapeutic Use of Self: Applying the Intentional Relationship Model in Group Therapy

Stay updated, free articles. Join our Telegram channel
Tags:
Apr 12, 2017 | Posted by in MEDICAL ASSISSTANT | Comments Off on Occupational and Group Analysis: Adolescents

Full access? Get Clinical Tree
Get Clinical Tree app for offline access