Six Steps to Creating Active Group Participants

Therapists- have you ever wondered why your patient who actively participates in individual therapy becomes invisible during group treatment? They may be shy or socially anxious, or perhaps autistic traits are impacting their participation. Researchers have demonstrated an overlap between eating disorders and autism spectrum disorder (Westwood, H. Et al, 2015). Up to 32 % of women with anorexia nervosa may meet criteria for autism spectrum disorder (ASD) with traits such as social communication deficits, narrow interests, repetitive routines, rigidity in thinking and behaviour, executive functioning challenges, and issues with empathy (Anckarsäter H., et al, 2012). In a 10-person therapy group, up to 3 participants may experience the world from this ASD lens and may likely not have a formal diagnosis. Groups are the ultimate challenge for someone with autistic traits; not knowing where to look, what to say, when to say it, how much to share, and for how long. It is difficult to simultaneously process the multitude of communication from group members while attempting to formulate something to say themselves.  So, how can you transform group practice to involve the voices of all persons? Listed below are 6 simple modifications that can help make your treatment groups more inclusive:

1. Assume competence:  A person struggling to share in a group setting still has something valuable and interesting to say. Before starting group treatment, have members complete a communication survey to find out what the group leaders can do to help encourage participation. Questions with options are the best way to elicit information. For instance:

“What can group facilitators do to assist you to contribute to the group?”

a) Ask me questions to draw me out and help me participate more

 b) Let me know if I have gone on for too long

c) Let me know ahead of time when it will be my turn

                                                                              
Be sure to leave a comments section so participants can elaborate.

2. Plan ahead to promote participation: Whenever possible, let participants know the discussion topics ahead of time so they can formulate their ideas in advance. During the group session, encourage participants to take notes. Writing helps some people on the spectrum remember and process what is being said. It also reduces impulsive sharing as it gives them a place to write down their thoughts so they don’t feel anxious about forgetting what they want to say. Also, give participants a couple of minutes to brainstorm ideas before responding. The extra time will give them the opportunity to process discussion topics at a more relaxed pace.

3. Provide clear expectations and structure for social communication: When seeking responses, provide a predictable structure for sharing, such as going around the circle and giving each person an opportunity to speak. If the group leader randomly calls on people to share, this would greatly increase the anxiety of the participants in the room.  If you find participants making inappropriate comments, give examples of appropriate and inappropriate responses, and explain why a comment is not suitable. This can help them understand the unwritten social rules that other people may automatically pick up on.

4. Establish and enforce group norms: People on the spectrum often live by rules. Rules spell out clear expectations regarding how to behave, which is helpful because they have difficulty picking up on social norms. Group norms that are focused on confidentiality, respect, and support assure participants that it is safe to share. This is particularly important for women on the spectrum as many have experienced bullying and exclusion throughout their lives. Have an established process for dealing with interpersonal conflict so they know what to do should issues arise.

5. Utilize a variety of teaching techniques: For some, learning through listening and group participation is not the best way. Introduce other modes of teaching such as readings, presentations, visuals, video, role play, and small group or partner discussions.

6. Offer breaks or downtime: Too much sensory or social exposure can be exhausting and often lead to overload. The best antidote to this excess is sensory deprivation. Have a quiet, dark, soothing space available for people to escape to when needed.  Have “silent breaks” where participants are free from pressure to talk to one another. Another modification is to offer a modified or reduced treatment schedule for people who cannot be stimulated all day. Fidget toys or knitting can be a great way for people to reduce stress and stay focused during group.

I encourage you to follow the steps provided above for a more inclusive group experience. We can learn a lot from our peers on the autism spectrum, but often times their insights are lost in the group process.

Anckarsäter H, Hofvander B, Billstedt E, Gillberg IC, Gillberg C, Wentz E, Råstam M. (2012). The sociocommunicative deficit subgroup in anorexia nervosa: autism spectrum disorders and neurocognition in a community-based, longitudinal study. Psychological Medicine, 42,  1957-1967

Westwood, H., Eisler, I., Mandy, W., Leppanen, J., Treasure, J., Tchanturia, K. (2015). Using the Autism-Spectrum Quotient to Measure Autistic Traits in Anorexia Nervosa: A Systematic Review and Meta-Analysis. Journal of Autism and Developmental Disorders, 1-14.

Dori Zener, M.S.W., R.S.W., is an Individual, Couple and Family Therapist in Toronto specializing in the Autism Spectrum. She is passionate about neurodiversity and strives to increase the awareness of the unique talents and struggles of women on the autism spectrum.