Note. This is ‘Part II’ of an article included in the previous issue of The Group Psychologist. Click here to read Part I, which provided background information on concurrent group therapy and prior research on the topic. Part II below details the author’s pilot study.
Exploratory Study of Concurrent Group Therapy for Parents
This exploratory survey looks at the occurrence of concurrent group therapy for parents whose children are being treated in group therapy. The research questions explore the reported incidence of concurrent group therapy by members of the Association for Play Therapy (APT) listserv. Of the APT members surveyed, it was asked how many practice settings have groups, which group modalities are used, and if any groups are concurrent parents’ groups. The study questions concluded with respondents’ feedback identifying potential barriers to treatment of using concurrent group therapy as a treatment modality.
A quantitative survey with open and close-ended questions was created by the author to gather data for the study. The research protocol was approved by the Adelphi University Institutional Review Board for research with human participants. Survey questions were developed by the author and managed through SurveyMonkey software. Questions were presented in both a multiple choice and Likert Scale format. Open ended questions with dialogue boxes were included in order to facilitate more comprehensive data collection.
The sample was taken from the general listserv of the Association for Play Therapy, an international play therapy professional organization founded in 1982. The APT general listserv was chosen for the sample due to the high number of practitioners working with children who may also have contact with or work in a treatment context with the parents of the children in treatment. This author is a member of the Association for Play Therapy.
The invited respondents were participants in the General Community Listserv, an online email discussion group for international play therapists, although most participants are from North America and all are identified as being in good standing with APT. All participants had a valid email address and voluntarily participated in the study. The members of the APT listserv are diverse, both professionally and geographically and includes social workers, psychologists, psychiatrists, licensed professional counselors, licensed marriage and family therapists, licensed mental health professionals, interns and students, both undergraduate and graduate-level. Currently, as reported in November 2010 by the Association for Play Therapy head office, there are 523 professionals that subscribe to the General Community Listserv.
Recruitment for the survey took place in two phases. All members currently enrolled in the listserv received an email with a paragraph explaining the purpose of the survey and a link to the informed consent form and the online survey, which was created through SurveyMonkey software. Ten days later, an additional email with the survey link was sent as a follow-up asking those whom had not yet participated to respond. Due to the anonymous construction of the listserv, it was not possible to only include non-respondents in the follow-up email. Participants did not receive any compensation or incentives for participation.
Profiles of Respondents and their Practices
Demographics. Seventy-three of 523 (14%) members of the listserv consented to participate in the study and answered at least some of the survey questions. Sixty-three of the 73 overall respondents shared their demographic information. Practitioners had a diverse orientation and some held multiple degrees or designations in the mental health field. Twenty-three respondents hold designations of LPC (Licensed Professional Counselors), 19 hold designations of MSW/LCSW (Masters of Social Work or Licensed Clinical Social Worker), 6 hold doctoral degrees such as a Ph.D., EdD. or Psy.D., 3 are LMHC/MHC interns (Mental Health Counselors), and two respondents hold international degrees.
The respondents also varied geographically. Of the 62 respondents that shared their geographic information, the majority were from the United States. Two respondents are international practitioners from the United Kingdom and France. The majority of respondents came from the South (24), with Texas as the highest represented state with six respondents. Fourteen respondents practice in the Northeast while 13 practice in the Midwest and 10 from the West.
Practice. All respondents identified themselves as practitioners working with children between the ages of 0-17. The type of settings in which the respondents practice significantly favored private practice. Forty respondents (62.5%) listed private practice as their primary service setting. Eleven respondents (17.2 %) ranked second as family service agency practitioners. Eight respondents (12.5%) practice in a mental health clinic while another nine respondents (12.5%) practice in school setting. Four responders practice in a Child Advocacy Center. The following settings were only identified by one respondent each: residential treatment facility, outpatient cancer center, inpatient psychiatric hospital, hospital community health center, consultant role and a university clinic for developmental disabilities.
Groupwork. Of the 73 study participants, only 22 respondents (30.1%) have at least one child-age client who participates in some form of groupwork. Of these 22 respondents, all but two respondents reported that 50% or less of their caseload of child-age clients actually participate in groupwork.
The majority of children participating in groupwork were identified as participating in social skills groupwork. In addition to the modalities listed on the survey, other forms of groupwork which respondents facilitate were identified as short-term brief group therapy, trauma-related sexual abuse groups, child-centered play therapy groups, bereavement/grief groups, and Parent Child Interaction Therapy (PCIT), a specific form of treatment for young children diagnosed with conduct disorder (http://pcit.phhp.ufl.edu, retrieved on December 5, 2010).
Parent participation. The majority of respondents (69 of 73) answered questions about parents participating in treatment. Sixty-one respondents (88.4%) reported that parents/guardians could also receive treatment at their place of service. However, of these 61 respondents, very few reported that parents participate in groupwork. Of the 58 who shared their estimation of the percentage of parents who receive any treatment at the place of service, 32 (55.1%) stated that none of the parents participate in group treatment. Another 15 respondents (25.9%) reported that less than 10% of parents who participate in treatment engage in groupwork. Only 5.2% reported that 50% of the parents participate in group work, and no one reported a higher rate than fifty percent.
Orientation of group therapy. Of the modalities listed, parents who participate in groups appear to most frequently participate in cognitive behavioral groups (33%) and/or substance abuse groups (25%). In addition to the group modalities listed on the survey, respondents were asked to identify other types of group therapy in which the parents participate. The following types of groups were also identified: non-offending parent/caregiver groups related to sexual abuse, CPRT (Child Parent Relational Training), Filial Therapy groups, family therapy groups, parenting groups, PCIT groups, support groups, psychoeducational groups, groups specifically relating to cancer, anger management groups, mandated domestic violence groups, humanistic/object relations groups, ‘transparenting’ groups, parent coaching, marital counseling groups, sex offender groups, and bereavement/grief groups.
Familiarity and use of Concurrent Group Therapy. Respondents were asked to share their familiarity with the modality of concurrent parent group therapy. Sixty-two respondents provided information on their familiarity with concurrent group therapy as a modality. Of these respondents, 21% reported they were completely unfamiliar with the modality, 30.6% reported they were mostly unfamiliar, 32.3% reported that they were somewhat familiar, and 16.1% reported that they were very familiar with concurrent group therapy.
Of the 62 respondents who answered this question about familiarity with concurrent group therapy, 31 (50%) offered detailed and diverse explanations in their answers to this open-ended question. One respondent stated “never heard the term” and another stated “not familiar”, while many reported vague familiarity, such as “have attended conferences where it was presented in detail” and “…have heard of some in the past” or “heard of it, never done it.” In contrast, many respondents reported familiarity with running parent groups, but not in conjunction with their children’s group treatment. One respondent stated, “I only know of parent support groups, not therapy group for parents, and have no knowledge of any providers doing group therapy in my area.” Other respondents stated they were familiar with blended parent-child groups such as those offered through filial therapy, conjoint therapy, and multi-family group therapy. Only three respondents (5%) answered with having direct contact or knowledge of concurrent parent therapy groupwork: one of whom uses this model at their agency; one of whom had experience with it at a prior agency; and one whose school district offered concurrent parent group therapy as a model.
The overwhelming majority of respondents do not offer concurrent parent group therapy as a treatment modality at their place of service. In fact, only 8 (12.9%) respondents work at a service site where concurrent parent group therapy is offered as a treatment option. Of these eight respondents, their experience with parents participating in concurrent group therapy varies considerably. Two respondents state that 100% of groups at their service sites are run concurrently, while the other 6 reported that they either “don’t know” the percentage of parents participating or their answers ranged from 0-20% as the reported participation rates. The types of concurrent parent group therapy were identified as social skills groups, task-oriented, cognitive-behavioral, substance abuse, and art/expressive therapy in addition to trauma-related, domestic-violence related, PCIT and NOPS (the author was unable to identify this type of group treatment), sexual abuse groups, and groups for parents who abuse their children. One respondent stated they did not know what type of concurrent group therapy was offered. In regards to the type of attendance, of these eight respondents, one stated that group attendance was mandatory, six stated it was voluntary, and one did not respond.
For parents who do not participate in concurrent group therapy, the majority of respondents (81%), stated that parents do not participate in group therapy because it is not offered at their place of service. Eight (12.7%) stated that parents chose not to participate in concurrent parent group therapy. Two respondents identified scheduling conflicts as the reason for not participating and two reported that they did not know the reason.
Respondents identified varied reasons for service locations not providing concurrent group therapy as a treatment option. However, the responses could be divided into various categories. Twelve respondents stated that their setting made offering the modality a challenge due to the fact that they were in a small private practice or small agency, worked in a school, or saw clients at their homes. Another common answer was that many of the respondents work in private practice as solo practitioners. One respondent stated “I run a private practice, not an agency. Group treatment is not part of our contracts with ‘referrants’.” Another primary reason cited was space limitations. Of the forty-six respondents who answered, seven respondents listed staffing as an issue, while six respondents cited space as the primary issue. Six respondents stated they had not considered using concurrent group therapy as a treatment modality. Five respondents listed that concurrent group therapy was not used due to unfamiliarity with the modality, and five stated that concurrent group therapy was not offered due to parent resistance, although it was not made clear if the parents were resistant to treatment overall or group treatment in particular. Billing issues were also mentioned. Three respondents stated that it was due to not being a reimbursable modality or was unfunded. Two respondents stated that time and scheduling were issues in offering this modality.
Respondents were asked choose their identified top three barriers to providing concurrent parent group therapy from a provided list. Sixty-two (62) respondents answered the question and the answers were ranked as the following listed in Table 1:
Table 1 – Ranking of identified barriers to treatment (respondents listed their top 3)
Staffing issues – 31
Child Care issues – 28
Time/Day of the group – 26
Space Constraints – 24
Billing Issues/Reimbursement for services – 20
Lack of client interest – 14
Practitioner’s lack of familiarity with the modality – 13
Other – 8
Of those that answered other, parental transportation issues was the number one answer. Additional “other” responses included: reimbursement issues; lack of interest both on behalf of the clients and of the practitioner; not enough homogeneity among parents; and it was unethical in their practice to use such a modality. One respondent also mentioned that the parents in their population believed it was the child who needs help and not the parent.
Respondents were given the opportunity to elaborate on their answers to identified barriers to treatment with an open-ended question. Thirty-five respondents chose to share their opinions as to why concurrent group therapy with parents was not used as a modality in their work. Most respondents shared reasons why any type of group therapy with parents is a challenge and/or may not be used in treatment. Resistance to treatment appeared to be one significant and underlying issue, both on the part of the parents and the therapists. For example, one respondent stated “…doing groups has its challenges in terms of billing, space, scheduling, so therapists tend not to pursue it, even though it may be a good offering for parents.” Child care of siblings, the second highest ranking identified barrier, also appears to be a significant issue in terms of staffing, affordability, and the space to offer it at the site of service. For those who identified staffing issues as a barrier, they stated that there was just not enough staff or that their practice was too small to offer group therapy as a viable option. Finally, a larger scale issue appears to be the type of service setting and how it relates to group therapy as a form of treatment. One respondent said, “…the contract with the agency mandates individual or family treatment. Group therapy is not an option.” Another said, “our agency only serves children” indicating that treatment for parents was not even an option.
Given the dearth of information discussing and showing the benefit of concurrent group therapy, it was anticipated that few practitioners would be incorporating this treatment modality into their practice. As previously discussed, this appears to be the case. An unexpected finding coupled with this was the percentage of therapists who admitted being unfamiliar with any group work, in addition to being unfamiliar with concurrent group therapy. While this may relate to the sample and diversity of the practitioners in the APT regarding the types of training curriculums of the various designations under which respondents practice, the unfamiliarity of group work practice with members of the Association for Play Therapy would be another facet to explore in future studies of group work with children and their parents. One final unanticipated finding that the frequency with which the role of identified patient may play in parents participating in group work. These results indicate the need to explore the meaning of the role of identified patient in family group work and how this factors into parental resistance and family services.
There were several reasons respondents identified as to why concurrent group therapy is not offered at their site. Less respondents than expected identified and discussed billing as a treatment barrier to providing concurrent group therapy as a treatment modality. Instead, other resource deficiencies presented much higher on the list of identified treatment barriers regarding space, time and the number of therapists able to provide services. Another unexpected result was the frequency with which transportation issues were identified in providing treatment services to families. Although it is mentioned only sporadically throughout the articles discussed in the literature review, the possible significance of the role of transportation difficulties in receiving services indicates a larger policy concern in service provision for families participating in treatment.
Another issue that highlights the need for further research is the high rate of responses that identify the significance of role of child care issues in working with families. Exploring successful models of agencies or other service sites that either provide some form of child care or reimbursement for child care while the parents participate in treatment would lead to a better understanding of how to address this issue.
This exploratory study had several methodological limitations. The first is that the data were collected through an online survey which often results in low response rates and can result in non-respondent bias (Monette, Sullivan & DeJong, 2008). Due to the nature of gathering online data, it is difficult to compare the respondent group to a subsample of non-respondents to manage the potential of non-respondent bias. Also, the online format of the survey requires a working knowledge and understanding of the English language, which may have excluded some international participants. Another issue with this data collection instrument and the anonymous response format is that there is no way of clarifying or elaborating on the answers given, particularly for the open-ended questions after the survey is submitted by the respondent.
Another limitation of the study is the sample population which contained a limited amount of respondents who work with parents and children participating in group therapy. A different purposive sample of group practitioners more familiar with group work modalities may provide alternative information regarding the incidence of concurrent group therapy for parents.
Based on the responses gathered, a complex picture of the needs of parents of children participating in group work emerges. While prior research clearly demonstrates that groups for parents and children are an effective way of providing services, concurrent group therapy appears to be an unfamiliar and under-utilized modality for most play therapists, despite their treatment population being primarily comprised of families who would potentially benefit from this holistic modality. The lack of familiarity with concurrent group therapy demonstrated by those surveyed sheds light on a potential gap in group curricula and trainings available. Further research into why this modality is not taught and/or how it can be incorporated into current group therapy curricula would provide further information.
The respondents also provided important implications for practice. Most private practitioners who responded stated that they were constrained by staff availability and space limitations for group work in general, let alone concurrent group therapy. Exploring the lack of presence of group therapy in play therapy private practice and how this can be addressed is another important piece of discovering ways of providing the most comprehensive services possible to families in treatment.
While this exploratory study successfully identified barriers to treatment regarding concurrent group therapy for parents whose children are participating in treatment, it is clear that more in-depth research is necessary. For those who present research on successful concurrent groupwork models, understanding the researcher’s or agency’s rationale for choosing it as a model would be helpful in developing more detailed data to analyze, would build upon the limited studies currently available, and would provide a rich addition to the knowledge base of group social work for children and their families. Focus groups for group work practitioners and in-depth qualitative interviews with family practitioners, both those who offer and do not offer concurrent group therapy treatment, would provide a richer understanding of how and why the modality is (or is not) used.
Concurrent group therapy continues to remain an under-recognized and under-utilized form of groupwork. However, the limited research published shows some promising results both in terms of successful implementation and the achievement of multiple treatment goals. In addition, this study’s respondents, many of them direct practitioners who work with families, appear to be curious about why and how concurrent groupwork might be implemented to complement the current and diverse forms of groupwork already in place. This study’s results present an opportunity for growth and development of this potentially rich and valuable addition to the other, more widely practiced groupwork modalities.
Association for Play Therapy (2010).About APT, Mission and Scope. Retrieved from http://www.a4pt.org/ps.aboutapt.cfm.
CHP Parent-Child Interactional Training (PCIT) (n.d.). What is it? Retrieved from http://pcit.phhp.ufl.edu.
Monette, D.R., Sullivan, T.J., DeJong, C.R. (2008). Applied Social Research: a tool for the human services, 7th edition. Belmont, CA: Brooks/Cole Publishing.