It's an exciting development, and has been months in the making. The biggest challenge left for us to tackle will be actually running a program in this opening period when our census is really low. Referrals are hard to predict no matter what, and even more so with a totally new program in a new location. It's great that we have as many as we have (3 in PHP, and 2 in IOP, with a few more slated for later in the week). However, when group therapy is the primary treatment modality, that kind of census is definitely challenging.
The program will definitely look a bit different this week than it will look later on. We may not be able to follow our group schedule exactly, especially since clinicians, dietitians, and psychopharmacologists have to take clients out of groups for individual meetings. A group of two, with one person pulled out, is no longer a group! We don't want people to get used to whatever adjustments we have to make for the low census, but it does offer an opportunity to think about what makes (or breaks) a group.
At these levels of care, groups look a little different than they do in standard outpatient care, where there is usually stable membership - a set number of people who attend a predetermined number of session, the same people each time. Even in long-term groups with rolling membership, there is a core of members who attend over time. As a result, we see groups develop their own character as a group, and move from disconnected people to a unified cohort.
Other levels of care, such as PHP and IOP, have a more fluid population, so group membership is constantly changing. Clients attend multiple groups with the same people each day, but various clients may be pulled out of various groups without warning. It's a constantly changing picture, and interpersonal connections that form tend to be to the program rather than to the group per se.
Nevertheless, group composition can drastically change the tone of the group, and therefore, of the treatment clients receive. In my ideal world, I like groups to have between 6-10 members, who have enough in common that they can relate to one another, and enough NOT in common to offer each other new perspectives. Our clients already have something in common by virtue of having an eating disorder, but when it's a mix of anorexia, bulimia, and binge eating disorder, that similarity may not go very far. We typically have all adults, and they tend to be similar functional levels, which helps...but in this beginning period, we've had to accept a few adolescents mixed in with the adults, which could make it harder for group members to relate to each other.
At these levels of care, people tend to be at varying stages of recovery, with varying degrees of motivation for change; I think that's an asset to groups, as people further along in recovery can serve as role models and exert some healthy peer pressure. Of course, the opposite process is also possible: when a majority of the group is early in recovery and/or unmotivated for change, they can bring the group as a whole down to their level. Part of the facilitator's job is to keep that from happening. Another challenge is when most group members are reluctant to speak; it can be pretty painful to get through an hour with a bunch of people who just stare at you, their feet, or the clock! I really hope that, with such a small group this week, they will at least be willing to talk.
What factors do you think make for a productive, or detrimental, group dynamic? How would you navigate this awkward period of low census, and the shifting census that will always be part of the equation at this level of care?