After working for several months as the parish nurse for two church congregations, Sandra noticed that the long-term needs of individuals experiencing illness, loss, grief or significant life changes were not being met. Sadly, some individuals were suffering alone because they did not want to burden others. Sandra reflected upon this situation, prayed for guidance and began looking for nursing interventions she could initiate in the churches.
Sandra's experience reflects what many parish nurses observe in their congregations. Declining financial reimbursement and stringent treatment guidelines are diminishing access to acute and chronic care, while efficient, cost-effective activities that promote health and prevent illness are increasingly in demand.1 As parish nurses who have co-facilitated cancer, grief, chemical dependency and co-dependency support groups, we believe that psychoeducational support groups not only respond to these concerns but also promote healing.
The church is a perfect place to offer psychoeducational support groups, and parish nurses are well equipped to help individuals make the connection between faith and health. Thomas Droege from the Carter Center Interfaith Health Programs asserts, “[Our current health care crisis] is a spiritual problem calling for changes in behavior, not a medical problem calling for a scientific breakthrough.”2 Chaplain Granger Westberg, founder of the modern parish nurse movement, recognized that many patients' problems were rooted in emotional and spiritual struggles related to grief. If patients' physical problems were to be prevented, someone in the church “needed to be on the scene to deal with people before they become seriously ill.”3 Parish nurses have the opportunity and background to organize and to facilitate psychoeducational support groups that promote wholeness and healing.
Support groups provide social support, empowerment and problem solving around a common issue.4 These groups often include psychoeducation—preventive or growth-focused education that supports skill attainment and coping, such as how to get through a difficult day when grieving.5 Irvin Yalom, writing about group psychotherapy, identifies the curative factors of group work: catharsis, universality, hope, altruism, socialization, cohesiveness, interpersonal learning and corrective interpersonal relationships that occur through group dynamics.6 We believe groups give members time to address grief, loss and/or significant life changes as they are heard, understood and accepted. Educational materials and reflections that promote insight and coping are shared, prompting self-awareness and changed behavior. As group members interact in a caring environment, they connect to support each other, share successes and failures and experience a community where healing is nourished.
Most significantly, church-based psychoeducational support groups focus on the whole person and the connection between mind, body and spirit. The biblical perspective for understanding life events, our responses and God's provisions form the foundation and context for group activities and discussions. In addition, such groups are cost effective. The church can provide for these groups by purchasing curricula, while group members contribute a small fee for workbooks and group upkeep. The major expenditure for support groups is the time required for preparation and group facilitation, which is often volunteered or included in the parish nurse's salary.
How can parish nurses (PNs) start a psychoeducational support group? First, assess the need for support groups, either through a congregational survey or a perceived lack of service. Once a need is identified, begin advocating for the group and obtaining administrative approval that includes a budget. After approval and budgeting, purchase relevant curricula or content and adapt it as necessary. Qualified facilitators who demonstrate a faith commitment and desire to help lead groups should be identified and leader training initiated. Many group curricula include materials on group leadership that can be used for leader training. PNs without counseling or psychodynamic group skills are advised to look for individuals with these skills to be co-facilitators or serve as consultants.
As the time for initiating the group draws near, communicate information about the group through personal contacts and written announcements. Begin planning for group logistics. The environment where the group meets should protect anonymity, have circular seating, include an area for refreshments and have audiovisual equipment. Plans should be made for ongoing management and how safety concerns will be addressed. We recommend weekly meetings between co-facilitators and monthly (or, as needed) meetings with professional resource people. A specific referral plan should be developed for members whose needs exceed the capacity of the support group. If there is a concern about loss of control, as with drug use and/or threats of harm, facilitators need to implement a preset plan.
Where there will be more than one group facilitator, assign specific roles and duties. Facilitators decide on inclusion and exclusion criteria for group membership, if individuals will be interviewed for inclusion and how group members will be oriented.7 For each group cycle, facilitators must decide on group size and whether a group will be open (allowing new members to join at any time) or closed (running the group with beginning members only). A final preparation is to create a Covenant Statement, a one-page listing of “Your Responsibilities” for group members and “Our Responsibilities” for facilitators (see sample Covenant Statement in Table 1).
Group development specialist Bruce Tuckman believes all groups go through predictable developmental stages of forming, storming, norming, performing and adjourning.8 To become proficient in facilitating constructive pychoeduca-tional support groups, the parish nurse must understand the goal of each stage of the group's growth and development, the expected member behavior and the appropriate facilitator response.
Forming. In the first stage of group development, which Tuckman calls forming, group members want to belong and come together to test their compatibility. This is a difficult time for individuals disclosing co-dependency or sharing the loss of a loved one, let alone dealing with group dynamics. The facilitator needs to welcome group members, provide structure and focus, remind the group of its purpose and goals, and review the Covenant Statement and answer questions. Group members are assisted to set group norms, the expectations that clarify behavioral standards.9 Common group norms include allowing others to speak without interruption, keeping personal sharing to an agreed-upon time limit and displaying respectful behaviors. These are reviewed at the beginning of each group session.
Group formation and bonding is achieved through group interactions. Co-facilitators monitor behaviors such as who does or doesn't talk and who sits together or is a loner. They intervene appropriately. Facilitators employ active listening skills, such as using open-ended questions, asking for examples, noting non-verbal communication, creating a safe setting for sharing concerns, receiving feedback and solving problems.10,11
In the first meeting, co-facilitators clarify their roles, begin psychoeducation and listen for individual and group themes that connect to the group's goals. For instance, members with chemical dependency must work on relapse prevention and a sober lifestyle. Following each meeting, co-facilitators review the group's work, including themes that surfaced and issues that need addressing. A mental health professional and/or the pastor provide immediate consultation for safety concerns or problems going beyond the group's scope.
Storming. In the storming phase, individuality emerges. Group members feel safer to disagree and to challenge. Subgroups may form and leadership may be challenged. For successful task attainment, the facilitator clarifies the group's goal, restates norms, recognizes that resistive and testing behaviors most likely are not personal attacks, reflects on the group's process, employs conflict management techniques and refocuses to the group's task. Some chaos results in beneficial deliberations, so the facilitator should silently observe before addressing conflict. Storming teaches that members may disagree. But by listening, responding assertively, staying with one issue at a time and facilitating problem solving, conflict need not be destructive.
At this stage of growth and development, however, the facilitator should intervene with certain member behaviors. Silent members are asked for their input. Monopolizers who contribute frequently are acknowledged and thanked for their input.The facilitator then structures the monopolizer by suggesting, “Let's hear from others' about [the topic],”“Let's get back to [the topic],” or “Let's talk about that issue after the group.” An alternative intervention is to reflect on the process, “It seems as though Mary is speaking for everyone this evening,” and invite other group members to contribute. The facilitator may reduce group tension by identifying group needs and encouraging members to meet those needs through reinforcement of task attainment roles such as an initiator, mover or information seeker/giver; and emotional maintenance roles such as an encourager, compromiser or harmonizer.12
Norming. As group members settle in, cohesion and purpose emerge that lead to cooperation, collaboration and consensus. Individual differences are tolerated, and differing opinions are less likely seen as personal attacks. Group members feel free to risk and engage in creative problem solving, often revealing their guilt, shameful secrets, vulnerabilities and needs. Emotional maintenance activities become essential components of group interaction. In a co-dependency group, one member might pray for another or give a gift of a phone call or a social outing, although members are reminded to report on outside contacts so that the group's work does not move outside the group setting.
The facilitator allows the group, with its increased energy, cohesion and commitment, to assume leadership duties. The facilitator offers, “I don't know about you, but it seems as though we have really made some progress in…” and thanks group members for their input and significant work. In a recovery group, members might begin sessions with a reading from the Recovery Bible,13 where Scripture passages and devotionals focus on recovery issues such as faith, shame, loss and spirituality.
Since group growth and developmental stages are not distinct entities, group members may again storm. With regression to storming, the facilitator comments, “It looks as though we are back to storming. I wonder what is happening.” Perhaps a group member is being scapegoated. The facilitator, responsible for member safety, asks Jane (the scapegoat) to share her thoughts about the offending comment and how she would like to respond. The facilitator may encourage the group to stop and to think about what is happening or set boundaries by referring to agreed-upon group norms.
Performing. In the performing stage, group members demonstrate commitment, personal growth and increased self-confidence, working to problem solve and to complete tasks while demonstrating empathy and caring. Group members now possess increased expertise and coping skills brought about by education, reflection upon personal experiences, and adherence to biblical principles and a values-based approach to dealing with life's stresses. In our grief group, members are encouraged to propose group activities.
Adjourning. Group termination is discussed in personal interviews, at the group's inception and periodically during group meetings. The facilitator addresses goal attainment and reintroduces termination issues if group members have not broached the topic. Plan for emotional maintenance through a farewell celebration. Some facilitators ease the loss of termination by extending the time between the last few meetings.
Since saying goodbye causes stress, the facilitator sets the stage for adjournment by speaking to the loss of the group experience and sharing felt emotion. Failure to focus on adjournment amounts to missing an important part of a relationship. Acknowledging struggles and celebrating gains leave group members with a sense of gratitude for a challenging but beneficial experience. Members may be asked to write down self-care behaviors that they plan to incorporate into their lives and seal them in a self-addressed envelope. The facilitator then mails the envelopes three months after the group adjourns. Facilitators may plan a six-week post-adjournment meeting to finalize termination and ask members to complete a survey evaluating group outcomes.
In our “Celebrate Recovery!” program, group members reviewed life situations over which they were powerless. Through working the 12-step program undergirded with biblical principles, group members strengthened their relationship with God—the one who has control—gaining continued support, strength and guidance.14When asked for evaluative feedback, congregation members who attended our year-long group commented, “Celebrate Recovery! opens their arms to the broken and the poor in spirit” and “I never thought my painful past would lead to such a rewarding now.”15
Increasingly, nurses are being prepared to facilitate support groups by virtue of their educational experience. We have provided an overview of psychoeducational support groups. With adequate preparation, parish nurses can learn to be effective facilitators and use psychoeducational support groups as one way to meet the needs of parishioners. One group member summed it up, saying, “Recovery is a process that can be hard, painful and scary. But with the knowledge of God's love and the support of his children, people who attend Celebrate Recovery! have been able to experience hope, strength and growth.”16
For more information, contact Janice E. Hurley at[email protected] or Susanne Mohnkern at [email protected]regarding the development of psychoeducational support groups.
1 Lois Lorenz, “Selecting and Implementing Support Groups for Bereaved Adults,” Cancer Practice
, 6, no. 3 (1998): 161–66.
2 Thomas A. Droege, “Congregations as Communities of Health and Healing,” Interpretation: A Journal of Bible & Theology
49, no. 2 (1995): 118.
3 Ramona Cass, “Parish Nursing's Pioneer: An Interview with Granger Westberg,” Nursing in the Church
, ed. Judith Allen Shelly (Madison, Wisc.: NCF Press, 2002), 73.
4 Verna Benner Carson, Mental Health Nursing: The Nurse-Patient Journey
, 2nd ed. (Philadelphia: WB Saunders, 2000): 551.
5 Beverly M. Brown, “Psychoeducation Group Work,” Counseling and Human Development
29, no. 7 (1997): 1, 2.
6 Irvin Yalom, The Theory and Practice of Group Psychotherapy
, 2nd ed.(N.Y.: Basic Books Inc., 1975): 71.
8 Bruce W. Tuckman and Mary Ann C. Jensen, “Stages of Small-Group Development Revisited,” Group & Organization Studies
2, no. 4 (1997): 419.
9 Edward Sampson and Marya Marthas, Group Process for the Health Professionals
, 3rd ed. (Albany, N.Y.: Delmar Inc., 1990): 68–71, 80.
10 Jay T. Knippen and Thad B. Green, “How the Manager Can Use Active Listening,” Public Personnel Management
23 (1994): 357.
11 Building Citizen Involvement: Strategies for Local Government Training Workbook, “Active Listening,” Public Management (US)
79 (1997): 25.
12 Sampson and Marthas, 59.
13 Verne Becker, ed., Recovery Devotional Bible: New International Version
(Grand Rapids, Mich.: Zondervan Publishing House, 1993).
14 John Baker, Celebrate Recovery! Leader's Guide
(Grand Rapids, Mich.: Zondervan, 1998), pp. 9–11.
15 Lois Pappa, “Celebrate Recovery!
What Is It?” The Messenger
, Pearce Free Memorial Church, Rochester, N.Y., Fall, no. 1 (2001): 8.