By Dr. Alex Gitterman, Columbia University School of Social Work

Why develop group services? Why bring people together in a group? Mutual aid, integral to the group modality, is the primary rationale for the development of group services. By its very nature, the group mutual aid system has the potential to depathologize members' problems, diminish stigma and reduce social and emotional isolation. As members develop a sense of common purpose and commonality, they begin to exchange their experiences and concerns. In this sharing process, members experience giving as well as receiving help rather than only receiving the worker's assistance. Initially, members may share safer and less threatening materials as they test each other's and the worker's trustworthiness. Since group members share common experiences and life struggles, their support, suggestions, and demands have particular relevance and meaning. As they experience each other's genuine support, members risk more personal, painful, and even socially taboo concerns. A short-term group was formed for people who had experienced the death of someone they loved to cancer. The group's purpose was to bring together bereaved individuals who were struggling with or felt alone in their grief and to provide them a safe and supportive place where they could help each other deal with their losses.

The issues and feelings surrounding the death of a loved one are strong and complex. For the members who lost a spouse, they felt terribly alone and incomplete. For the members who lost a parent, they felt the loss of their longest consistent and often precious relationship. Friends and relatives unable to tolerate the sadness urged group members to bury their grief and to move on with their lives. This pressure added to the members' adaptive burdens. The mutual aid group provided grieving members with a safe place to share their painful losses, their loneliness, their memories as well as their struggles to cope and survive. A vignette from the third session:

Jackie: I hear what my family and friends is saying. But I don't understand how do I simply forget my mother and go on with my life?
Social work intern: Your friends tell you to forget your mother in order for you to move on?
Jackie: That's how they make me feel (begins to cry)... I don't want to forget her. We loved each other. Social work intern: (looking around the room) Do others feel the pressure to forget and get over your grief?
Eva: No matter how hard I try, I can't forget and I won't. Others: (verbalize agreement)
Joan: I feel like I have to forget my mother, place her behind me, or I'm never going to be okay again, but I think about her all the time.
Social work intern: Maybe you can stay connected on some level while still trying to go on with your life.
Gina: Yeah, I never want to lose that connection. I mean, I know my husband is dead, but he was a huge and important part of my life. How could I ever forget him -why would I ever want to forget him?
Betty: (nodded) If I forgot my husband it would be like he never existed — like my life never existed. Why do people want us to forget?
George: Maybe they think that by telling us to forget, our pain will go away. They do not realize that they increase our pain.
Social work intern: (I noticed that Debbie looked like she wanted to speak. Tears were streaming down her cheeks) Debbie, you are feeling a lot right now.
Debbie: Everyone is talking about forgetting, but I can't forget my husband. Maybe I am crazy, but I feel him with me all of the time. At night I wait for the door to unlock at 6:30. Sometimes I even hear his voice. I must have something wrong with me, right?
Gina: If there is something wrong with you then there is something wrong with me too. I'm sure I'm going nuts (laughs). My husband loved his car — he had it washed every week. Well, I was out driving it the other day and I realized that the car had not been washed in several weeks. I heard his voice asking why I hadn't washed it lately. So if anyone is crazy it's me. (Group members laugh)
Social work intern: It is very common to feel a sense of presence or to hear the person saying things that they said before. It's how we all handle loss. I know I did when I lost my father.
Gina: (Laughing) Whew....So you mean I'm not going nuts.
Social work intern: Certainly not, but worrying about going nuts must be scary (looking around the room).
Linda: I don't feel my husband's presence or his voice, but I want to. I want to remember him and feel his presence more than anything, but I can't. I only remember his sickness and his pain. His illness lasted so long that I can't remember him any other way. It's funny because I find myself talking to him, asking him to let me know that he is out of pain now. I also ask him everyday questions. I just wish he could answer me.
Others: (Group members were silent).
Social work intern: (I remained silent to let us all process what had just been concerns."
Mary: "The showers are dirty though."
Jill: "See, I'm not the only one."
Worker: "I realize you all may be concerned about the conditions here...what I am saying is that these things can be discussed with the head nurse."
Ellen: "I don't care what we talk about."

Long periods of silence and withdrawal followed. By attempting to steer group members away from their expressed environmental concerns, the worker reinforces group members' feelings of helplessness. The worker lacks the vision and/or courage to explore group members' concerns about hospital conditions. By ignoring the substance of their concerns, the social worker misses an opportunity to help members gain greater control over their lives. By disregarding the organizational context of members' lives, the social worker promotes passive retreat and inevitably exacerbates feelings of powerlessness.

Mrs. Simmons chimed in with, "They really upset me. Last Friday - Good Friday - actually it ended up being BAD FRIDAY - those research people asked me to do a few studies. They kept me over two hours. In the meantime, my friend Gloria came to accompany me to Good Friday Mass. I can't get out of this place without a chaperone. She left after an hour and I missed Mass." I responded with, "Ouch - is this testing mandatory?" " Well, it helps them with research that might help someone else someday," explained Mrs. King. I asked, "How is it actually helping you?" Mrs. Thomas interjected, "It is not helping me, it is just easier to go along with it than put up a stink." I asked, "Mrs. King, is that the way you also experience it?" She agreed. Mrs. Martin said emphatically, "Well, I don't think we should go along with it!" I said, "Okay - how could you respond differently to them?" Mrs. Martin backed down a bit and said, "Oh, gosh, I don't know, but we shouldn't let people test us, if we don't want to." Mrs. Frankos said, I can't even say ‘no' to my two year old, how am I going to say ‘no' to a doctor?" "You too?" chimed in Mrs. Simmons, "Wait until they are fifteen and we still cannot refuse them." I summed up with, "I think we have a theme song, ladies: "I'm a Girl Who Can't Say No!". We all laughed and Mrs. Martin went on to complete the second line, "I'm in a terrible fix."

The worker's gentleness and sense of humor encouraged members to share their experiences. As members became more comfortable with "complaining," the worker prepared members for future encounters with psychiatrists by introducing desensitization exercises, assertiveness training techniques, and rehearsing alternative responses. We join four sessions later:

Our discussion led us to identify outside forces to which they acquiesced. Mrs. King voiced concern about resuming her outside therapy with her psychiatrist. She began, "I'm a little afraid of my contact with my doctor - I know so much more now about my illness and my medication -thanks to you helping me ask the questions. I don't agree with the way he prescribes new medication - a hundred pills at a time. Then if I have any side effects and we have to change the medication I have all these pills left and wasted money." Mrs. Simmons asked her why she didn't just ask him to prescribe smaller doses?" Mrs. Thomas said, "He'd probably tell her he was the doctor and knew best." I asked Mrs. King "Is that how you think he would respond?" Mrs. King was unsure what the doctor would say. I asked how she thought she might approach him about this. She responded, "Well, I'd tell him (she looked down) ‘no' - I'd ask him, (she looked at me and smiled) - ‘no' - I'd tell him (she was looking down again) - I'd rather you give me fewer pills at one time so if they had side effects it won't end up costing me so much money." I asked Mrs. King if she could close her eyes and visualize her doctor's office - how he would look, and how she would feel as she said those words to him. She looked down for a long time silently, then looked up and said "No!" Everyone applauded and laughed, and Mrs. Simmons congratulated her. Mrs. Frankos imitated a moment with her two year old son saying, "No Johnny, we won't read now, it's time for bed." Mrs. Martin began to sing, "We're Just the Girls Who CAN Say No."

We must be social workers "who say yes" to helping group members deal with environmental issues. By lending our vision about what's fair and just, members can join forces to counteract some of the consequences of imbalance and abuse of power.

Whether group discussions are limited to ventilating complaints, or taking individual or group action, or opening a dialogue between group members and significant environmental persons, group members are helped to feel and actually achieve greater control over their lives.

Mary: "The showers are dirty though."
Jill: "See, I'm not the only one."
Worker: "I realize you all may be concerned about the conditions here...what I am saying is that these things can be discussed with the head nurse."
Ellen: "I don't care what we talk about."

Long periods of silence and withdrawal followed. By attempting to steer group members away from their expressed environmental concerns, the worker reinforces group members' feelings of helplessness. The worker lacks the vision and/or courage to explore group members' concerns about hospital conditions. By ignoring the substance of their concerns, the social worker misses an opportunity to help members gain greater control over their lives. By disregarding the organizational context of members' lives, the social worker promotes passive retreat and inevitably exacerbates feelings of powerlessness.

Mrs. Simmons chimed in with, "They really upset me. Last Friday - Good Friday - actually it ended up being BAD FRIDAY - those research people asked me to do a few studies. They kept me over two hours. In the meantime, my friend Gloria came to accompany me to Good Friday Mass. I can't get out of this place without a chaperone. She left after an hour and I missed Mass." I responded with, "Ouch - is this testing mandatory?" " Well, it helps them with research that might help someone else someday," explained Mrs. King. I asked, "How is it actually helping you?" Mrs. Thomas interjected, "It is not helping me, it is just easier to go along with it than put up a stink." I asked, "Mrs. King, is that the way you also experience it?" She agreed. Mrs. Martin said emphatically, "Well, I don't think we should go along with it!" I said, "Okay - how could you respond differently to them?" Mrs. Martin backed down a bit and said, "Oh, gosh, I don't know, but we shouldn't let people test us, if we don't want to." Mrs. Frankos said, I can't even say ‘no' to my two year old, how am I going to say ‘no' to a doctor?" "You too?" chimed in Mrs. Simmons, "Wait until they are fifteen and we still cannot refuse them." I summed up with, "I think we have a theme song, ladies: "I'm a Girl Who Can't Say No!". We all laughed and Mrs. Martin went on to complete the second line, "I'm in a terrible fix."

The worker's gentleness and sense of humor encouraged members to share their experiences. As members became more comfortable with "complaining," the worker prepared members for future encounters with psychiatrists by introducing desensitization exercises, assertiveness training techniques, and rehearsing alternative responses. We join four sessions later:

Our discussion led us to identify outside forces to which they acquiesced. Mrs. King voiced concern about resuming her outside therapy with her psychiatrist. She began, "I'm a little afraid of my contact with my doctor - I know so much more now about my illness and my medication -thanks to you helping me ask the questions. I don't agree with the way he prescribes new medication - a hundred pills at a time. Then if I have any side effects and we have to change the medication I have all these pills left and wasted money." Mrs. Simmons asked her why she didn't just ask him to prescribe smaller doses?" Mrs. Thomas said, "He'd probably tell her he was the doctor and knew best." I asked Mrs. King "Is that how you think he would respond?" Mrs. King was unsure what the doctor would say. I asked how she thought she might approach him about this. She responded, "Well, I'd tell him (she looked down) ‘no' - I'd ask him, (she looked at me and smiled) - ‘no' - I'd tell him (she was looking down again) - I'd rather you give me fewer pills at one time so if they had side effects it won't end up costing me so much money." I asked Mrs. King if she could close her eyes and visualize her doctor's office - how he would look, and how she would feel as she said those words to him. She looked down for a long time silently, then looked up and said "No!" Everyone applauded and laughed, and Mrs. Simmons congratulated her. Mrs. Frankos imitated a moment with her two year old son saying, "No Johnny, we won't read now, it's time for bed." Mrs. Martin began to sing, "We're Just the Girls Who CAN Say No."

We must be social workers "who say yes" to helping group members deal with environmental issues. By lending our vision about what's fair and just, members can join forces to counteract some of the consequences of imbalance and abuse of power. Whether group discussions are limited to ventilating complaints, or taking individual or group action, or opening a dialogue between group members and significant environmental persons, group members are helped to feel and actually achieve greater control over their lives.