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Everyday, knowingly and unknowingly, people interact in a variety of groups. Interaction in these groups can be formal or informal encompassing most activities associated with living in modern society.

As a professional psychiatric nurse, possessing specialized education, knowledge and experience in working with groups; I am in a unique position to facilitate group interactions amongst people.

This paper outlines a proposal for a therapeutic group I will conduct to further my understanding of the group process. The proposal provides a description and purpose of the group, a statement of expected goals, objectives and outcomes. Included are descriptions of the type of group, membership, location, time and duration of the group. Ground rules and techniques for operation of the group are defined. Evaluative tools for the group participants; professional observer and I are included to provide measurement of the success and usefulness of the group conducted.

This section explains the link to the theoretical orientation, type of group leadership, client population and rationales for use in this group.

Pioneer House, a 20 bed rehabilitative psychiatric care facility, is designed to allow resident's to maximize their potential for independent living. This is achieved through realistic goal setting by the client. Primary and secondary key workers assist and guide the resident in this process. Ultimately, the desire of the resident for forward movement and self actualization of their potential is the driving force behind each resident's success in achieving independent living.

Program requirements include clients being involved in an in house work program, or outside activities such as educational or volunteer pursuits. Augmentation of these activities is through voluntary and involuntary participation in groups, led by a professional Registered Psychiatric Nurse. One of these groups, improvement of self-esteem, is the subject of this proposal.

The theoretical approach for this proposed group is the person-centered approach developed by the late Carl Rogers. Corey notes that this approach "is grounded on the assumption that human beings tend to move toward wholeness and self actualization" (1995, p. 263). This approach is suited to Pioneer House as the belief that human beings tend to be forward moving toward self-actualization is congruent to the basic philosophy of the facility.

This approach to groups requires the group leader or facilitator to provide a minimal amount of direction to the individual and the group to move forward. This is supported by the view of Corey that the person centered approach allows for "individual members as well as the group as a whole, can find their own direction with a minimal degree of help from the group leader" (1995, p. 263). The role of the group leader with this approach as Corey notes "emphasizes the personal qualities of the group leader rather than techniques of leading" (1995, p. 263). Corey further notes that this emphasis on the qualities of the group leader is "to create a fertile and healing climate in the group" (1995, p. 263). These qualities required of the leader are defined by Corey (1995 pp. 267-273) as being genuiness, unconditional positive regard and empathy. Genuiness refers to the group leaders external expression being congruent to their internal experiences and feelings. As Natillo (cited in Corey, 1995) indicates "genuiness is the state of authenticity that results from a deep exploration of self and a willingness to accept the truths of the exploration". Unconditional positive regard is the communication of caring for the individual without evaluation or judgement of the clients expressed thoughts or feelings. It is acceptance of the person for who, what and why they are. This regard as Corey mentions "is not to be confused with approval; therapists can accept and value their clients as separate persons, with a right to their separateness, without necessarily approving of some of their behavior" (1995, p. 270).

This section is a description of the purpose of the proposed group.

The self-esteem group will begin or continue the process of participants gaining awareness of their own feelings, needs and personal values. It permits participants to look within themselves instead of looking to others for direction as to what they should be thinking, feeling or determining what their needs are. Participants can become empowered to gain and become responsible for self-direction.

The section describes the group including its structure, membership, location time and duration.

This will be a secondary group given it's self help nature. It is heterogeneous in participants will differ in gender and clinical diagnosis. The structure is informal. Although informal, some structural constraints will be placed upon the group.

The group will be closed and consist of 6 members. Membership in the group is voluntary and of interest to clients willing to engage in self-exploration, forward movement and a desire for self-actualization.

The group will be conducted in the downstairs library of Pioneer House for several reasons. The areas is closed, private (assists in maintaining confidentiality) is well lit, has ample equipment (tables, chairs, erasable board and easel) and is free of distractions. The location has successfully been used for other groups for the aforementioned reasons.

The group will be conducted on Wednesday and Thursday evening between 19:00 to 20:00 hours. This time is suitable as dinner ends at 17:30 hours; chores are completed by 18:00 hours and the residents meeting (Wednesdays) ends no later than 19:00 hours. The selected time for the group does not interfere with other scheduled activities of the facility.

This section delineates the goals, objectives and expected outcomes for the proposed group. As the conducted group will run for 4 to 6 sessions, goals objectives and expected outcomes are less than what would be expected of a group lasting for 12 sessions or more.

OBJECTIVES

Each group participant upon completion of this group will:

• Develop Increased self esteem.
• Develop increased self-awareness of individual thoughts, feelings and needs as seen by the individual participant.
• Enhance the desire for continued forward movement of growth and self actualization
• Enhance participation in group interactions.

GOALS

• Openly discuss individual thoughts, feelings and needs.
• Enhance the ability to openly express individual thoughts, feelings and needs in a group setting (therapeutic or other group setting).
• Develop trust between the individual members and the facilitator (myself).

This section discusses the therapeutic procedures including ground rules and techniques used with the proposed group. First examined is the ground rules followed by techniques employed for this group. Ground rules consist of:

1. Confidentiality of group activity is an expectation of participants including the facilitator. Information provided or elicited remains within the group. Disclosure of information outside the group is prohibited. This includes key and secondary workers. Confidentiality is paramount. Participants are expected and encouraged to discuss openly their thoughts, feelings and needs. An atmosphere of trust must exist for this to occur. Participants not honoring group confidentiality results in expulsion from the group.
2. Participants must attend regularly and be on time for all groups. Failure to attend or lateness on a continuing basis without prior permission results in membership termination. Attendance and promptness indicates commitment to the group. Continued absence and lateness interrupts the group process resulting in other being unable to achieve the goals and objectives of the group.
3. Members should actively participate. They should be open in their discussion of their thoughts, feelings and needs. This openness should be honest and meaningful to the disclosing member. Meaningful input to and from other participants is encouraged.
4. Participants will focus on their individual thoughts, feelings and needs. Intellectual and philosophical discussions are discouraged. Focus will be on the here and now. This encourages verbalization of thoughts and feelings occurring during the group.
5. A supportive environment within the group is encouraged. Verbalization of criticism regarding the group is encouraged providing criticism is constructive.
6. Challenging or confrontation of participant's behaviours within the group is encouraged. Other Participants including the facilitator may challenge or confront. This challenge or confrontation is for the exclusive purpose of achieving congruence to individual expression of thoughts or feelings.
7. The focus of this group does not include problem solving. It is only for the exploration, encouragement and expression of participant thoughts, feelings and needs.
8. Restatement of ground rules occurs throughout the group process as required.

Techniques used in this group are based on the cornerstones of person centered therapy identified by Corey (1995, pp. 267-273) genuiness, unconditional positive regard and acceptance of the client and empathy. Corey notes "as the facilitator projects these attitudes and an accepting and caring climate emerges, it is presumed, members will drop their defenses and work toward personally meaningful goals, a process that will eventually lead to appropriate and useful behavioral change" (1995, p. 263). The person-centered approach is more about the attributes and skills of the facilitator than any one technique to be used in the group process. Skills I will employ in the self-esteem group are those which are defined by Corey (1995, p. 277). These skills defined by Corey have been expanded upon to convey an improved understanding. These skills are:

1. Listening actively and sensitively. This activity is the foundation of therapeutic communication. This skill requires energy in the form of concentration. Active listening minimizes distractions, conveys objectivity, is not evaluative in nature in terms of agreeing or disagreeing and focuses on the clients expressed thoughts or feeling.
2. Reflecting. Is an indicator of the facilitator's level of listening skills. It clarifies the participants thoughts, feelings and needs. Reflecting is useful in it assists in the formation of a trusting relationship. Trust develops as the client receives the message that expressed thoughts, feelings and needs is being received empathetically.
3. Summarizing. This skill allows the facilitator and client to examine themes that may be present during interactions. It is effective for reviewing progress, which has been made between the facilitator, the group member and the group as a whole.
4. Sharing of Personal Experiences. This is self-disclosure. Sharing of personal experiences allows the facilitator to reinforce genuine regard and respect for the client. While the person centered approach uses, self-disclosure as a means of becoming a group member for the facilitator, such disclosures must not become the focus of the group.
5. Encountering and engaging others in the group.
6. Going with the flow of the group rather than trying to direct the way the group is going. In the person-centered group process, the facilitator is to be a group participant. The facilitators aim is to be directive in approach instead of using techniques to achieve an outcome.
7. Affirming a participant's capacity for self-determination. This is one of the foundations of the person-centered approach. The belief that humans are forward moving towards self actualization is to be reinforced as this is one of the goals of the group.

These skills are an essential aspect of being a professional psychiatric nurse. The skills described are not new to psychiatric nursing and have been described by others (Peplau, 1992) (Forchuk, 1993) as essential to any communication between a psychiatric nurse and client. These skills met the criteria as described by the Code of Ethics and Standards of Practice of the Registered Psychiatric Nurses Association of British Columbia (1995).

This section provides an overview of each of the planned sessions and includes strategies and techniques used in each of the planned groups.

One of the first stages of the person-centered group process as mentioned by Cory is milling around. Corey describes this process as "the lack of leadership direction inevitably results in some initial confusion, frustration and "milling around" either actually or verbally" (1995, p. 279). This phenomenon is similar to the initial phase of group development as described by Johnson who indicates that "the initial stage of group development is likely to involve more superficial, rather than open, trusting communication. Members may be unclear about the purpose or goals of the group" (1986, p. 195).

The person-centered approach is being used for the first time with self-esteem as a group focus at Pioneer House. An initial introduction with explanation on how this group process works will be provided to all participants. During this initial phase or introduction, an explanation of the group objectives, goals desired outcomes and the group norms will be provided. Participants are to introduce themselves to one another, including I and will be provided with an information package. This package includes evaluation tools to be completed at the closure of each session, a copy of the stated objectives, goals and outcomes, and the group norms to be observed by all participants during each session of the group. Questions from the participants are encouraged and answers will be provided as needed. This is inconsistent with the typical approach to person-centered groups. I feel that time constraints combined with the limited number of group sessions, this approach allows the group to move forward in a reasonable amount of time through the "milling" stage. Another consideration is I know the participants and there is little confusion to who the facilitator of the group is. This session should last approximately 45 minutes to 1 hour in duration.

Session two will begin a combination of the working phase and exploration phase of the group. Typically during person-centered therapies, the facilitator can expect to see a number of patterns emerge. These patterns as noted by Corey (1995, pp. 279-281) include:

1. Resistance to personal expression or exploration
2. Description of past feelings
3. Expression of negative feelings
4. Expression and exploration of personally meaningful material
5. Expression of immediate interpersonal feelings in the group
6. Development of a healing capacity in the group
7. Self acceptance and the beginning of change
8. Cracking of facades
9. Feedback
10. Confrontation
11. The helping relationship outside the group sessions
12. The basic encounter
13. Expression of feelings of closeness
14. Behaviour changes in the group

• Resistance to personal expression or exploration
• Expression of negative feelings
• Expression and exploration of personally meaningful material
• Expression of immediate interpersonal feelings in the group
• Self-acceptance and the beginning of change.

Accomplishment will occur in these areas through direction and achieved by maintaining adherence to the core principles of person-centered therapy. In particular, the communication skills and patterns expected of the facilitator.

This is a continuation of the working and exploration phases of the group. The continuation of openness amongst members should further build trust amongst the members and the facilitator. Self-disclosures of myself will assist in developing openness and trust with group members. Self-awareness will ensure that my disclosures do not become the focus of the group activity and direction. Adherence to the core principles, in particular, listening actively and sensitively, reflecting, summarizing, sharing of personal experiences and affirming each participants capacity for self-determination will foster a sense of trust and develop that sense of openness amongst the group participants.

Evaluation tools completed by the participants, professional observe and I provide the necessary feedback to determine how the group is moving forward and how individual members and the group as a whole is thinking and feeling about the group experience. This session should last approximately 1 hour in duration.

This will be the closure or termination phase of our group. Summarization provided by myself and other members will assist the process of closure. Exploration of participant thoughts and feelings occurs and final thoughts and feelings are appropriately expressed and acknowledged.

Evaluation tools is provided to each of the members for both the individual group session and the four group sessions as a whole. These evaluation tools are also to be completed by the professional observer and me. Duration of this session is approximately 1 hour in duration.

This section illustrates the evaluation tools used by the group participants, the professional observer and me to evaluate the group process and the qualities of my leadership as facilitator. These tools include instructions for the use and rationale for use of the evaluation tool.

Upon completion of session one, participants and I will complete a self-assessment scale outlining the kind of group participant they perceive themselves as being. Corey states that " one of the best ways of preparing for effective group leadership is to first become an effective group member" (1995, p.47). This belief is consistent with the person-centered approach that I will be using. The evaluation tool used post session one (Appendice A) is adapted and modified as found in Corey (1995, p. 47).

Upon completion of session two, three and four, participants will complete a questionnaire (Appendices B). The evaluation tool used post session two three and four is adapted and modified as found in Corey (1995, p. 49). This tool will measure on a rating scale various aspects of the clients perception of their participation. It examines the usefulness of the group, participation within the group and the leadership abilities of the facilitator. As facilitator, I will complete a questionnaire (Appendices C). This evaluation tool used post session two, three and fours is adapted and modified as found in Corey (1995, p. 51-52). This tool will measure on a rating scale various aspects of perceptions related to the level of participation of the members and I, usefulness of the group and my own leadership abilities.

Upon completion of session four and termination of the group, participants the professional observer and I will complete a questionnaire that describes the group (Appendices D). This tool is adapted and modified as found in Corey (1995, p. 50-51). This tool is in addition to the daily completed questionnaires completed the participants, the professional observer and I.

Reference

Corey, G. (1995). Theory and practice of group counseling (4^th ed.). Pacific Grove, California: Brooks/Cole

Corey, G. (1995). Student manual for theory and practice of group counseling (4^th ed.). Pacific Grove, California: Brooks/Cole

Forchuk, C. (1993). Hildegarde E. Peplau interpersonal nursing theory. Newbury Park, California: Sage

Johnson, B. S. (1986). Psychiatric-mental health nursing adaptation and growth. Philadelphia: J. B. Lippincott

Peplau, H.E. (1992). Interpersonal relations in nursing. New York: Springer

Registered Psychiatric Nurses Association of British Columbia. (1995). Competencies expected of the beginning practitioner of psychiatric nursing (revised). Coquitlam, B.C.: Registered Psychiatric Nurses Association of British Columbia

Appendice A

This assessment scale allows you, as a group participant, to determine how you respond in a group situation. This information is helpful to the group leader in assisting you to maximize your individual experiences in the self-esteem group.

In the available space next to each question, please indicate a yes or no response.

1. I'm an active and contributing group member
2. I'm willing to raise personal concerns and explore them in the group
3. I share my perceptions of other members, telling them how I see them and how I am affected by them
4. I listen attentively to others, and I respond to them
5. I confront others with care, yet I do so directly
6. As a group participant, I not only give direct feedback to others but am also open to feedback from them
7. I'm willing to openly express my feelings about and reactions to what is occurring within the group
8. I'm active in taking steps to create and maintain trust in the group
9. I'm able to provide support to others in the group at appropriate times

In today's session I could best be described as:

1. Understood by others 1 2 3 4 5 not understood by others
2. Understanding of others 1 2 3 4 5 not understanding others
3. Independent 1 2 3 4 5 dependent
4. Distant from others 1 2 3 4 5 close to others
5. Involved 1 2 3 4 5 uninvolved
6. Unprepared 1 2 3 4 5 prepared
7. Tense 1 2 3 4 5 relaxed
8. Competitive 1 2 3 4 5 co-operative
9. Active 1 2 3 4 5 passive
10. Helpful to others 1 2 3 4 5 not helpful to others

Appendices C

This questionnaire allows me at a participant and a group leader, to examine my thoughts, feelings and perceptions of how I participated and facilitated today's group.

The purpose of this assessment is to provide myself as a participant and facilitator with feedback as to my perceptions of how I responded, reacted and participated in the activities occurring in today's group.

Beside each question is a rating scale from 1 to 5. I will circle the number best representing my impressions of today's group.

1. Understood by others 1 2 3 4 5 not understood by others
2. Understanding others 1 2 3 4 5 not understanding others
3. Competent 1 2 3 4 5 incompetent
4. Distant from others 1 2 3 4 5 close to others
5. Involved 1 2 3 4 5 uninvolved
6. Tense 1 2 3 4 5 relaxed
7. Co-operative 1 2 3 4 5 competitive
8. Active 1 2 3 4 5 passive
9. Helpful 1 2 3 4 5 not helpful

Appendices D

This questionnaire allows you the participant to comment on the overall effectiveness of the group. It examines your overall thoughts, feelings and perceptions of your participation in the self-esteem group as well as your perceptions of the group leader. The observer of the group will complete this questionnaire and I will complete this questionnaire.

The purpose of this questionnaire is to provide yourself and the leader of the group with feedback as to your perceptions of your performance in the group as well as my performance in the group as its leader.

This questionnaire has two parts. The first part rates my performance as the leader of the self-esteem group. The second part rates your performance as a participant in the self-esteem group.

Beside each question is a rating scale from 1 to 5. Having completed sessions one to four of the self-esteem group, the group leader could best be described as:

1. Understood by others 1 2 3 4 5 not understood by others
2. Understanding of others 1 2 3 4 5 not understanding others
3. Competent 1 2 3 4 5 incompetent
4. Distant from others 1 2 3 4 5 close to others
5. Confusing 1 2 3 4 5 clarifying
6. Uninvolved 1 2 3 4 5 uninvolved
7. Unprepared 1 2 3 4 5 prepared
8. Co-operative 1 2 3 4 5 competitive
9. Active 1 2 3 4 5 passive
10. Helpful 1 2 3 4 5 not helpful
11. Concerned 1 2 3 4 5 unconcerned

Beside each question is a rating scale from 1 to 5. Having completed sessions one to four of the self-esteem group, I could be best described as:

1. Mutually supportive 1 2 3 4 5 conflicting
2. Governed by rules 1 2 3 4 5 free from rules
3. Independent of the leader 1 2 3 4 5 dependent on the leader
4. Satisfied 1 2 3 4 5 dissatisfied
5. Uninvolved 1 2 3 4 5 involved
6. Tense 1 2 3 4 5 relaxed
7. Important 1 2 3 4 5 unimportant
8. Co-operative 1 2 3 4 5 competitive
9. Helpful to others 1 2 3 4 5 not helpful
10. In constant conflict 1 2 3 4 5 rarely in conflict
11. Off the task 1 2 3 4 5 on the task

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