+1443 776-2705 panelessays@gmail.com

Discussion 1: Group Leadership Skills

Leading a group of individuals who have suffered trauma can be difficult because the shared stories may result in further trauma to some of the members. Assessing the members and deciding how they will introduce themselves at the first meeting can be a difficult task. Helping these members begin the group therapy process is the first step in facilitating the group.

For this Discussion, watch the video of the “Levy” group session.

By Day 3

Post your evaluation of the group’s social worker’s leadership skills, using at least two items from each of the three categories found in the Toseland & Rivas (2017) piece (facilitation of group processes, data gathering and assessment, and action). Chapter 4, “Leadership” (pp. 97-134) Chapter 5, “Leadership and Diversity” Suggest another way the social worker might have initiated the group conversation.

Competency Chapter

Competency 1: Demonstrate Ethical and Professional Behavior

Behaviors
Make ethical decisions by applying the standards of the NASW Code of Ethics, relevant laws and
regulations, models for ethical decision-making, ethical conduct of research, and additional codes of
ethics as appropriate to context.

1, 7, 13, 14

Use reflection and self-regulation to manage personal values and maintain professionalism in practice
situations

1, 4, 5

Demonstrate professional demeanor in behavior; appearance; and oral, written, and electronic
communication

1, 6, 7

Use technology ethically and appropriately to facilitate practice outcomes 1, 6, 14

Use supervision and consultation to guide professional judgment and behavior 1, 4

Competency 2: Engage Diversity and Difference in Practice

Behaviors
Apply and communicate understanding of the importance of diversity and difference in shaping life
experiences in practice at the micro, mezzo, and macro levels

3, 5, 6, 7, 8, 9, 10,
11, 12

Present themselves as learners and engage clients and constituencies as experts of their own
experiences

1, 5, 8, 14

Apply self-awareness and self-regulation to manage the influence of personal biases and values in
working with diverse clients and constituencies

1, 4, 5, 7, 8

Competency 3: Advance Human Rights and Social, Economic, and
Environmental Justice

Behaviors
Apply their understanding of social, economic, and environmental justice to advocate for human rights
at the individual and system levels

4, 5, 8, 9

Engage in practices that advance social, economic, and environmental justice 3, 4, 5, 9

Competency 4: Engage In Practice-informed Research and Research-informed
Practice

Behaviors
Use practice experience and theory to inform scientific inquiry and research 2, 3, 8, 14

Apply critical thinking to engage in analysis of quantitative and qualitative research methods and
research findings

2, 4, 8, 10, 14

Use and translate research evidence to inform and improve practice, policy, and service delivery 1, 2, 3, 4, 5, 6, 9, 10,
11, 12, 13, 14

Competency 5: Engage in Policy Practice

Behaviors
Identify social policy at the local, state, and federal level that impacts well-being, service delivery, and
access to social services

1, 4, 5, 11, 12

CSWE EPAS 2015 Core Competencies and Behaviors in This Text

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Competency Chapter

Assess how social welfare and economic policies impact the delivery of and access to social services 1, 5, 10, 12

Apply critical thinking to analyze, formulate, and advocate for policies that advance human rights and
social, economic, and environmental justice

1, 5, 8, 12

Competency 6: Engage with Individuals, Families, Groups, Organizations, and
Communities

Behaviors

Apply knowledge of human behavior and the social environment, person-in-environment, and other
multidisciplinary theoretical frameworks to engage with clients and constituencies

2, 3, 6, 7, 9, 10,
11, 12

Use empathy, reflection, and interpersonal skills to effectively engage diverse clients and constituencies 4, 5, 6, 7, 9, 11

Competency 7: Assess Individuals, Families, Groups, Organizations, and
Communities

Behaviors

Collect and organize data, and apply critical thinking to interpret information from clients and
constituencies

4, 7, 8, 12, 14

Apply knowledge of human behavior and the social environment, person-in-environment, and
other multidisciplinary theoretical frameworks in the analysis of assessment data from clients and
constituencies

2, 3, 4, 5, 6, 8

Develop mutually agreed-on intervention goals and objectives based on the critical assessment of
strengths, needs, and challenges within clients and constituencies

6, 7, 8, 9, 14

Select appropriate intervention strategies based on the assessment, research knowledge, and values
and preferences of clients and constituencies

3, 4, 5, 8, 9, 10, 11

Competency 8: Intervene with Individuals, Families, Groups, Organizations,
and Communities

Behaviors
Critically choose and implement interventions to achieve practice goals and enhance capacities of
clients and constituencies

1, 4, 5, 7, 8, 9, 10,
11, 12, 13

Apply knowledge of human behavior and the social environment, person-in-environment, and other
multidisciplinary theoretical frameworks in interventions with clients and constituencies

2, 3, 4, 5, 8, 9, 10,
11, 12, 13

Use inter-professional collaboration as appropriate to achieve beneficial practice outcomes 8, 9, 10, 11, 12

Negotiate, mediate, and advocate with and on behalf of diverse clients and constituencies 5, 8, 9, 10, 12

Facilitate effective transitions and endings that advance mutually agreed-on goals 13

Competency 9: Evaluate Practice with Individuals, Families, Groups,
Organizations, and Communities

Behaviors
Select and use appropriate methods for evaluation of outcomes 6, 8, 11, 14

Apply knowledge of human behavior and the social environment, person-in-environment, and other
multidisciplinary theoretical frameworks in the evaluation of outcomes

1, 4, 5, 6, 8, 14

Critically analyze, monitor, and evaluate intervention and program processes and outcomes 5, 6, 8, 14

Apply evaluation findings to improve practice effectiveness at the micro, mezzo, and macro levels 14

CSWE EPAS 2015 Core Competencies and Behaviors in This Text

Adapted with permission of Council on Social Work Education. These competencies and behaviors also appear in the margins throughout this text.

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Harlow, England • London • New York • Boston • San Francisco • Toronto • Sydney • Dubai • Singapore
Hong Kong • Tokyo • Seoul • Taipei New Delhi • Cape Town • Sao Paulo • Mexico City • Madrid • Amsterdam
Munich • Paris • Milan

An Introduction to
Group Work Practice
Ronald W. Toseland
University at Albany, State University of New York

Robert F. Rivas
Siena College, Emeritus

EIghTh EDITIoN

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To our parents, Stella and Ed, Marg and Al

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6

Contents

Preface 13

1. Introduction 17
Organization of the Text 18
The Focus of Group Work Practice 18
Values and Ethics in Group Work Practice 21

Practice Values 21
Practice Ethics 24

Definition of Group Work 27
Classifying Groups 28

Formed and Natural Groups 28
Purpose and Group Work 29
Treatment and Task Groups 29

Group Versus Individual Efforts 32
Advantages and Disadvantages of Treatment Groups 32
Advantages and Disadvantages of Task Groups 34

A Typology of Treatment and Task Groups 35
Treatment Groups 36

Support Groups 36
Educational Groups 38
Growth Groups 39
Therapy Groups 40
Socialization Groups 41
Self-Help Groups 42

Task Groups 44
Groups to Meet Client Needs 44
Groups to Meet Organizational Needs 50
Groups to Meet Community Needs 54

Summary 58

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Contents 7

2. Historical and Theoretical Developments 59
Knowledge f rom Group Work Practice and Practice Research: Treatment Groups 59

Differences Between Casework and Group Work 60
Intervention Targets 61
The Weakening of Group Work 62
Current Practice Trends 63
Divergent and Unified Practice Models 66
Evidence-based Group Work Practice 67
The Popularity of Psycho-educational, Structured, Practice Models 68

Knowledge f rom Group Work Practice: Task Groups 69
Knowledge f rom Social Science Research 70
Inf luential Theories 72

Systems Theory 72
Psychodynamic Theory 75
Learning Theory 76
Field Theory 77
Social Exchange Theory 79
Constructivist, Empowerment, and Narrative Theories 80

Summary 81

3. Understanding Group Dynamics 83
The Development of Helpful Group Dynamics 83
Group Dynamics 84

Communication and Interaction Patterns 84
Group Cohesion 95
Social Integration and Inf luence 99
Group Culture 105

Stages of Group Development 108
Summary 112

4. Leadership 114
Leadership, Power, and Empowerment 115

Leadership, Empowerment, and the Planned Change Process 118
Theories of Group Leadership 119
Factors Inf luencing Group Leadership 120
Effective Leadership 121

An Interactional Model of Leadership 122
Purposes of the Group 122
Type of Problem 123
The Environment 125
The Group as a Whole 126
The Group Members 127
The Group Leader 128

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8 Contents

Group Leadership Skills 129
Facilitating Group Processes 130
Data-Gathering and Assessment 134
Action Skills 136
Learning Group Leadership Skills 143
Leadership Style 144

Co-leadership 148
Summary 151

5. Leadership and Diversity 153
Approaches to Multicultural Group Work 154
A Framework for Leading Diverse Groups 155

Developing Cultural Sensitivity 156
Assessing Cultural Inf luences on Group Behavior 160
Intervening with Sensitivity to Diversity 166

Summary 175

6. Planning the Group 176
Planning Focus 176
Planning Model for Group Work 178

Establishing the Group’s Purpose 178
Assessing Potential Sponsorship and Membership 179
Recruiting Members 185
Composing the Group 188
Orienting Members 194
Contracting 196
Preparing the Environment 198
Reviewing the Literature 200
Selecting Monitoring and Evaluation Tools 201
Preparing a Written Group Proposal 202
Planning Distance Groups 202

Summary 211

7. The Group Begins 212
Objectives in the Beginning Stage 213

Ensuring a Secure Environment 214
Introducing New Members 215
Defining the Purpose of the Group 220
Confidentiality 223
Helping Members Feel a Part of the Group 225
Guiding the Development of the Group 226
Balancing Task and Socio-emotional Foci 231
Goal Setting in Group Work 231

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Contents 9

Contracting 234
Facilitating Members’ Motivation 235
Addressing Ambivalence and Resistance 235
Working with Involuntary Members 240
Anticipating Obstacles 242
Monitoring and Evaluating the Group: The Change Process Begins 243

Summary 245

8. Assessment 246
Conducting Efffective Assessments 247

Focus on Group Processes 248
External Constituencies and Sponsors 249

The Assessment Process 249
How Much Information? 250
Diagnostic Labels 251
Assessment Focus 252
Relationship of Assessment to the Change Process and Problem Solving 253

Assessing the Functioning of Group Members 254
Methods for Assessing Group Members 255

Assessing the Functioning of the Group as a Whole 262
Assessing Communication and Interaction Patterns 262
Assessing Cohesion 263
Assessing Social Integration 265
Assessing Group Culture 270

Assessing the Group’s Environment 271
Assessing the Sponsoring Organization 271
Assessing the Interorganizational Environment 273
Assessing the Community Environment 274

Linking Assessment to Intervention 276
Summary 279

9. Treatment Groups: Foundation Methods 280
Middle-Stage Skills 280

Preparing for Group Meetings 281
Structuring the Group’s Work 285
Involving and Empowering Group Members 291
Helping Members Achieve Goals 293
Using Empirically Based Treatment Methods in Therapy Groups 303
Working with Reluctant and Resistant Group Members During the Middle Phase 305
Monitoring and Evaluating the Group’s Progress 308

Summary 310

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10 Contents

10. Treatment Groups: Specialized Methods 311
Overreliance on Specialized Methods 311

Intervening with Group Members 312
Intrapersonal Interventions 313
Identifying and Discriminating 314
Recognizing Associations 315
Analyzing the Rationality of Thoughts and Belief s 316
Changing Thoughts, Belief s, and Feeling States 318
Interpersonal Interventions 326
Learning by Observing Models 327
Environmental Interventions 333
Connecting Members to Concrete Resources 333
Expanding Members’ Social Networks 334
Contingency Management Procedures 335
Modifying Physical Environments 338

Intervening in the Group as a Whole 339
Changing Communication and Interaction Patterns 339
Changing the Group’s Attraction for Its Members 341
Using Social Integration Dynamics Effectively 343
Changing Group Culture 345

Changing the Group Environment 346
Increasing Agency Support for Group Work Services 346
Links with Interagency Networks 348
Increasing Community Awareness 349

Summary 351

11. Task Groups: Foundation Methods 352
The Ubiquitous Task Group 352
Leading Task Groups 353

Leading Meetings 354
Sharing Information 356
Enhancing Involvement and Commitment 358
Developing Information 359
Dealing with Conf lict 361
Making Effective Decisions 364
Understanding Task Groups’ Political Ramifications 366
Monitoring and Evaluating 367
Problem Solving 368

A Model for Effective Problem Solving 369
Identifying a Problem 370
Developing Goals 373
Collecting Data 374
Developing Plans 375

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Contents 11

Selecting the Best Plan 375
Implementing the Plan 376

Summary 378

12. Task Groups: Specialized Methods 380
Small Organizational Groups 380

Brainstorming 380
Variations on Brainstorming 384
Focus Groups 385
Nominal Group Technique 388
Multi-attribute Utility Analysis 392
Quality Improvement Groups 395

Large Organizational Groups 397
Parliamentary Procedure 397
Phillips’ 66 401

Methods for Working with Community Groups 403
Mobilization Strategies 403
Capacity-Building Strategies 405
Social Action Strategies 407

Summary 410

13. Ending the Group’s Work 411
Factors that Inf luence Group Endings 411
The Process of Ending 412
Planned and Unplanned Termination 412

Member Termination 413
Worker Termination 415

Ending Group Meetings 416
Ending the Group as a Whole 418

Learning from Members 418
Maintaining and Generalizing Change Efforts 418
Reducing Group Attraction 424
Feelings About Ending 426
Planning for the Future 428
Making Referrals 429

Summary 432

14. Evaluation 433
Why Evaluate? The Group Worker’s View 435

Reasons for Conducting Evaluations 435
Organizational Encouragement and Support 435

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12 Contents

Time Considerations 436
Selecting a Data Collection Method 436

Evaluation Methods 437
Evaluations for Planning a Group 437

Obtaining Program Information 437
Needs Assessment 438

Evaluations for Monitoring a Group 439
Monitoring Methods 439

Evaluations for Developing a Group 445
Single-System Methods 446
Case Study Methods 449
Participatory Action Research Methods (PARS) 450

Evaluations for Determining Effectiveness and Efficiency 450
Evaluation Measures 454

Choosing Measures 454
Types of Measures 455

Summary 459

Appendix A: Standards for Social Work Practice with Groups 460
Appendix B: Group Announcements 471
Appendix C: Outline for a Group Proposal 473
Appendix D: An Example of a Treatment Group Proposal 474
Appendix E: An Example of a Task Group Proposal 476
References 478
Author Index 507
Subject Index 519

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13

Preface

We are gratified by the wide use of this text by professionals, as well as by educators and
students in undergraduate and graduate courses in schools of social work throughout
the United States and the world.

Because we are committed to presenting a coherent and organized over-
view of g roup work practice f rom a generalist practice perspective, the eighth
edition continues to include typolog ies illustrating group work practice with task
and treatment g roups at the micro-, meso-, and macro-level. Our research and
practice focuses primarily on treatment groups, and the eighth edition continues to
present our interest in improving practice with many different types of treatment
groups.

New to This Edition
• Research on Virtual Groups. In recent years, we have done research on the

uses of virtual group formats (teleconference and Internet groups) and have
included an updated and expanded section on virtual groups in the 6th chapter
of this edition.

• Additional case examples throughout this edition illustrate practice with a wide
variety of groups. These were added based on feedback f rom our students,
reviewers of the book, instructors, and others who have contacted us about
the importance of illustrations of evidence-based practice examples.

• Updated and deeper content of the middle stage chapters on practice with
treatment and task groups. The latest evidence-based treatment and task group
research is incorporated throughout Chapters 9 through 12, and content has
been added, deleted, and changed to ref lect current practice.

• Incorporated the most current literature on working with reluctant and
resistant group members in specific sections of Chapters 7 and 9 and throughout
the text.

• We find that our students face many situations with individuals who have
encountered multiple traumas in their family lives and in the larger social
environment, making them understandably reticent to engage group workers
and fellow group members, and trust in the power of group work to heal. There-
fore, we have updated and expanded sections on working with individuals who
have difficulty engaging in and sustaining work in groups and have added addi-
tional information about conf lict resolution skills as it pertains to both treatment
and task groups.

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• Thoroughly updated Chapter 5 on leadership and diversity as social group work-
ers practice in an increasingly pluralistic society.

• Thoroughly updated reference material and new content f rom evidence-based
practice sources.

About Group Work
Over the years, we have been especially pleased that our text has been used by educators
who are dedicated to improving task group practice within social work. Group work is a
neglected area of social work practice, especially practice with task groups. Most social
workers spend a great deal of time in teams, treatment conferences, and committees,
and many social workers have leadership responsibilities in these groups. Group work is
also essential for effective macro social work practice, and therefore, we have continued
to emphasize practice with community groups. The eighth edition also continues our
focus on three focal areas of practice: (1) the individual group member, (2) the group as
a whole, and (3) the environment in which the group functions. We continue to empha-
size the importance of the latter two focal areas because our experiences in supervising
group workers and students and conducting workshops for professionals have revealed
that the dynamics of a group as a whole and the environment in which groups function
are often a neglected aspect of group work practice.

Connecting Core Competencies Series
This edition is a part of Pearson’s Connecting Core Competencies series, which con-
sists of foundation-level texts that make it easier than ever to ensure students’ success in
learning the nine core competencies as stated in 2015 by the Council on Social Worker
Education. This text contains:

• Core Competency Icons throughout the chapters, directly linking the CSWE
core competencies to the content of the text. Critical thinking questions are also
included to further students’ mastery of the CSWE’s standards.

• For easy reference, a matrix is included at the beginning of the book that
aligns the book chapters with the CSWE Core Competencies and Behavior
Examples.

Instructor Supplements
The following supplemental products may be downloaded f rom www.pearsonglobal
editions.com/toseland.

Instructor’s Resource Manual and Test Bank. This manual contains a sample
syllabus, chapter summaries, learning outcomes, chapter outlines, teaching tips, dis-
cussion questions, multiple-choice and essay assessment items and other supportive
resources.

PowerPoint Slides. For each chapter in the book, we have prepared a PowerPoint
slide deck focusing on key concepts and strategies.

14 Preface

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Acknowledgments
The ideas expressed in this book have evolved during many years of study, practice,
and research. Some of the earliest and most powerful inf luences that have shaped this
effort have come about through our relationships with Bernard Hill, Alan Klein, Sheldon
Rose, and Max Siporin. Their contributions to the development of our thinking are evi-
dent throughout this book. The ideas in this book were also inf luenced by Albert Alissi,
Martin Birnbaum, Leonard Brown, Charles Garvin, Alex Gitterman, Burton Gummer,
Margaret Hartford, Grafton Hull, Jr., Norma Lang, Catherine Papell, William Reid, Beulah
Rothman, Jarrold Shapiro, Laurence Shulman, and Peter Vaughan. Our appreciation
and thanks to the reviewers of the seventh edition who gave us valuable advice for
how to improve this new eighth edition: Tom Broffman, Eastern Connecticut State
University; Daniel B. Freedman, University of South Carolina; Kim Knox, New Mexico
State University; Gayle Mallinger, Western Kentucky University; John Walter Miller, Jr.,
University of Arkansas at Little Rock. We are also indebted to the many practitioners
and students with whom we have worked over the years. Reviewing practice experiences,
discussing group meetings, and providing consultation and supervision to the practitioners
with whom we work with during research projects, supervision, staff meetings, and
workshops has helped us to clarify and improve the ideas presented in this text.

We would also like to acknowledge the material support and encouragement given
to us by our respective educational institutions. The administrative and support staff of
the School of Social Welfare, University at Albany, State University of New York, and
Siena College have played important roles in helping us to accomplish this project. Most
of all, however, we are indebted to our spouses, Sheryl Holland and Donna Allingham
Rivas. Their personal and professional insights have done much to enrich this book.
Without their continuous support and encouragement, we would not have been able to
complete this work. A special note of thanks also goes to Rebecca, Stacey, and Heather
for sacrificing some of their dads’ time so that we are able to keep this book current and
relevant for today’s practice environment.

Ronald W. Toseland
Robert F. Rivas

Acknowledgments for the Global Edition
Pearson would like to thank the following people for their work:

Contributors:
Henglien Lisa Chen, University of

Sussex
Pooja Thakur, writer
Elizabeth Wright, Murdoch University

Reviewers:
Bruce Gillmer, Northumberland, Tyne

and Wear NHS Foundation Trust
Pooja Thakur, writer
Elizabeth Wright, Murdoch University

Preface 15

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17

This text focuses on the practice of group work by professional
social workers. Group work entails the deliberate use of interven-
tion strategies and group processes to accomplish individual, group,
and community goals using the value base and the ethical practice
principles of the social work profession. As one prepares to become
an effective social work practitioner, it is important to realize the
effect that groups have on people’s lives. It is not possible to be a
member of a society without becoming a member or leader of
groups and being inf luenced by others without direct participation.
Internet groups are also becoming more popular as people choose
to meet others in virtually as well as face-to-face. Although it is pos-
sible to live in an isolated manner or on the f ringes of face-to-face
and virtual groups, our social nature makes this neither desirable
nor healthy.

Groups provide the structure on which communities and the
larger society are built. They provide formal and informal struc-
ture in the workplace. They also provide a means through which
relationships with significant others are carried out. Participation
in family groups, peer groups, and classroom groups helps mem-
bers learn acceptable norms of social behavior, engage in satisfying
social relationships, identify personal goals, and derive a variety of
other benefits that result f rom participating in closely knit social
systems. Experiences in social, church, recreation, and other work
groups are essential in the development and maintenance of people
and society. Putnam (2000) points out that there has been a sharp
decline in participation in clubs and other civic organizations and
that social capital is not valued in contemporary society. At the same
time, web-based social network and self-help group sites continue
to grow enormously in popularity, enabling users to keep up con-
tacts with more and more people. One goal of this book is to under-
score the importance of groups as fundamental building blocks for
a connected, vibrant society.

L E A R N I N G O U T C O M E S

• Describe how group work is carried
out using a generalist perspective.

• Demonstrate how values and
professional ethics are applied in
group work practice.

• Define group work and its practice
applications.

• Compare the differences between
task- and treatment-oriented groups.

• List the advantages and
disadvantages of using groups to
help people and to accomplish tasks.

• Describe the types and functions of
treatment groups.

• Define the types and functions of
task groups.

1
Introduction

C H A P T E R O U T L I N E

Organization of the Text 18

The Focus of Group Work
Practice 18

Values and Ethics in Group Work
Practice 21

Definition of Group Work 27

Classifying Groups 28

Group Versus Individual Efforts 32

A Typology of Treatment
and Task Groups 35

Treatment Groups 36

Task Groups 44

Summary 58

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18 Chapter 1

OrganizatiOn Of the text

Group work is a series of activities carried out by the worker during the life of a group.
We have found that it is helpful to conceptualize these activities as being a part of six
developmental stages:

1. Planning

2. Beginning

3. Assessment

4. Middle

5. Ending

6. Evaluation

Groups exhibit certain properties and processes during each stage of their development.
The group worker’s task is to engage in activities that facilitate the growth and development
of the group and its members during each developmental stage. This book is divided into
five parts. Part I focuses on the knowledge base needed to practice with groups. The remain-
ing four parts are organized around each of these six stages of group work practice. Case
studies illustrating each practice stage can be found at the end of Chapters 6 through 14.

the fOcus Of
grOup WOrk practice

Social work practitioners use group work skills to help meet the needs of individual group
members, the group as a whole, and the community. In this text, group work involves the
following elements.

group Work practice
• Practice with a broad range of treatment and task groups
• Generalist practice based on a set of core competencies described in the Educa-

tion Policy and Accreditation Standards (EPAS) of the Council on Social Work
Education (2015)

• A focus on individual group members, the group as a whole,
and the group’s environment

• Critical thinking and evidence-based practice when it exists for
a particular practice problem or issue

• Application of foundation knowledge and skills f rom gener-
alist social work practice to a broad range of leadership and
membership situations

• Specialized knowledge and skills based on a comprehensive
assessment of the needs of particular members and groups

• Recognition of the interactional and situational nature of
leadership

Intervention

Behavior: critically choose and implement
interventions to achieve practice goals and
enhance capacities of clients and constituencies

critical thinking Question: Generalist social
work practice involves many systems. How is
group work related to generalist social work
practice?

M01_TOSE0283_08_SE_C01.indd 18 01/05/17 11:30 AM

Introduction 19

This text is firmly grounded in a generalist approach to practice. To accomplish the
broad mission and goals of the social work profession, generalist practitioners are ex-
pected to possess core competencies based on the Council on Social Work Education’s
(2015) Educational Policy and Accreditation Standards (EPAS) that enables them to inter-
vene effectively with individuals, families, groups, organizations, and communities. This
text highlights the importance of the generalist practitioner’s acquisition of the core
competencies defined in the EPAS standards.

This text is designed to help generalist practitioners understand how group work
can be used to help individuals, families, groups, organizations, and communities func-
tion as effectively as possible. Most group work texts are focused on the use of groups
for clinical practice, and many focus only on therapy or support groups with little
attention paid to social, recreational, or educational purposes. Scant is made of commit-
tees, teams, and other task groups that all social workers participate in as members and
leaders. Despite the distinctive emphasis of the social work profession on the interface
between individuals and their social environment, in most group work texts, even less
attention is paid …

RESEARCH

Coming Home: A Group-Based Approach
for Assisting Military Veterans

in Transition

Marvin J. Westwood
Holly McLean
Douglas Cave
William Borgen
Paul Slakov

University of British Columbia

This study is an evaluation of the Veterans Transition Program, a residential,
group-based program designed to assist the transition of military personnel back
into Canadian society by aiding with their personal and career readjustment.
Participants in the program included 18 male soldiers who experienced varying
degrees of combat-related trauma. Standard measures of traumatic stress symp-
toms, depression, and self-esteem were administered to the participants in
addition to participant interviews. The measures were administered before,
immediately after, and 3 months post-program. Post-program research interviews
were conducted and analyzed using the Critical Incident Technique research
approach. An overview of the program is presented, along with research results
and recommendations to practitioners working with soldiers experiencing
trauma-related stress reactions.

Keywords: group therapy; military; transition

BACKGROUND AND RATIONALE

Research with military personnel demonstrates that soldiers partici-
pating in overseas missions are subjected to considerable traumas that

Manuscript submitted November 3, 2009; final revision accepted November 4, 2009.
Marvin J. Westwood and William Borgen are with the Counselling Psychology Program
(ECPS), University of British Columbia. Holly McLean is a clinical manager with
Connexus Family & Children Services, Vancouver. Douglas Cave is with the Centre
for Practitioner Renewal, Providence Health Care, Vancouver. Paul Slakov is in private
practice, Jerusalem, Israel. Correspondence concerning this article should be addressed
to Marvin J. Westwood, Counselling Psychology Program (ECPS), University of British
Columbia, 2125 Main Mall, University of British Columbia, Vancouver, British
Columbia V6T 1Z4, Canada. E-mail: [email protected]

THE JOURNAL FOR SPECIALISTS IN GROUP WORK, Vol. 35 No. 1, March 2010, 44–68

DOI: 10.1080/01933920903466059

# 2010 ASGW

44

can have debilitating consequences for successful post-service reinte-
gration to civilian life. Many soldiers are at risk of developing
post-traumatic stress reactions (Friedman, Warfe, & Mwiti, 2003).
Soldiers have a greater chance of developing post-traumatic stress dis-
order (PTSD) than of being fired upon, physically injured or killed in
combat (Rosebush, 1998). Along with involvement in active combat,
soldiers are often exposed to events, or contextual stressors, such as wit-
nessing atrocities including the torture of civilians, the handling of civ-
ilian adult and child casualties, and the retrieval and disposal of human
remains (Lamerson & Kelloway, 1996; MacDonald, Chamberlain, Long,
Pereira-Laird, & Mirfin, 1998; Passey & Crocket, 1999).

The human costs are high as military personnel and their families
are at substantial risk for developing not only PTSD but also other
very serious psychiatric disorders, health and social problems
(Herman, 1997). Approximately 80% of soldiers with PTSD also suffer
from related major depression, anxiety disorders, and alcohol or
chemical abuse=dependency (Foa, Keane, & Friedman, 2000).
Research in the United States and Canada has shown that former
military personnel with war-related trauma are more likely to use
medical services and have hypertension, asthma, and chronic pain
symptoms than veterans without exposure to traumatic stress. They
are also at higher risk than their peers for premature mortality from
accidents, chronic substance abuse, and suicide (Buckley, Green, &
Schnurr, 2004; Drescher, Rosen, Burling, & Foy, 2003).

The impact of these serious stress-related injuries occurs within the
first months of coming home. Veterans with PTSD are 10 times more
likely to be unemployed than other veterans, and in general earn 22%
less per hour than their veteran peers without PTSD (Fairbank, Ebert,
& Johnson, 1999). The impact on marital relationships is significant.
Elevated rates of domestic violence and divorce are more likely with
veterans with PTSD than veterans without PTSD (Orcutt, King, &
King, 2003; Riggs, Byrne, Weathers, & Litz, 1998). In short, research
shows that untreated combat trauma becomes a chronic, debilitating
condition associated with a range of negative psychological, physical
and social outcomes for both soldiers and their families (Rosenheck
& Fontana, 1996). Summarizing the need for the treatment of veter-
ans, Ray (2006) stated, ‘‘For healing to take place, peacekeepers need
to voice their grief and love not only for their dead military brothers
but the loss of innocence, the loss of their band of brothers, their mili-
tary family and their military careers’’ (p. 18). It is imperative that
treatment models are developed to counteract the effects of combat-
related trauma and prevent the descent of soldiers with post-
traumatic stress reactions into chronic disability, unemployment and
underemployment (Benotsch et al., 2003).

Westwood et al./VETERANS IN TRANSITION 45

According to Solomon and Johnson (2002) and Ruzek et al. (2001),
the strongest support in the research literature, currently, is for treat-
ment interventions that combine cognitive and behavioral methods,
with emphasis on measured exposure-type techniques. Flack, Litz,
and Keane (1998), for example, describe a cognitive-behavioral treat-
ment program for individual soldiers involving multiple components
such as direct therapeutic exposure to the traumatic memories, eye
movement desensitization and reprocessing (EMDR) and vocational
counselling. Positive outcomes have been linked with investigations
of PTSD treatment models that include exposure therapy (Solomon
& Johnson) and specific group approaches with PTSD treatment
(Rozynko & Dondershine, 1991). The majority of programs offered to
veterans focus on the treatment of PTSD and do not address the sec-
ondary social difficulties associated with relationships, family or career
that are significantly affected by the primary trauma injury symptoms.

Researchers emphasize the importance of proactive involvement
with peer groups as ‘‘the group process more readily protects patients
from being overwhelmed by the power of therapy-released emotions
and also provides a guilt-reducing distortion-correcting, ‘fool proof’
peer group’’ (Rozynko & Dondershine, 1991, p. 158). Furthermore,
Glynn et al. (1999) noted that soldiers’ interpersonal difficulties that
arise from exposure to traumatic stress do not necessarily improve
with individual approaches. Support from peers is often sought outside
the programs. More recently, a number of researchers have recom-
mended approaching the treatment of traumatized combat veterans
with group approaches as benefits are considerable (Coalson, 1995;
Greene et al., 2004; Ruzek et al., 2001; Shea, McDevitt-Murphy,
Ready, & Schnurr, 2009; van der Kolk, 1987).

B.A. van der Kolk (personal communication, March 7, 2008) reminded
us that veteran groups involve built-in peer input and the potential for
interpersonal support and social regulation benefits. He stressed the
value of group for trauma work with veterans by stating, ‘‘in a group
the therapist can facilitate re-empowerment by encouraging mutual
support . . . .’’ (van der Kolk, 1987, p. 163). van der Kolk (1987) stated
‘‘that group therapy is widely regarded as a treatment of choice for many
patients with PTSD’’ (p. 164). Group-based therapeutic approaches offer
additional therapeutic support beyond what is possible in individually
oriented clinical therapies. The advantages of group-based therapies
are summarized by Coalson (2005), Foa et al. (2009), Ford and Stewart
(1999), Rozynko and Dondershine (1991), and Ruzek et al. (2001). In
particular, the group setting serves to counteract and confront the
socially avoidant and self-isolating tendencies of traumatized indivi-
duals (Fontana, Rosenheck, Spencer, & Grey, 2001; Green et al. 2004).
Carefully planned and facilitated groups can provide a structured and

46 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / March 2010

safe environment for promoting self-awareness, emotional expression
and cognitive reframing to aid coping and symptom reduction.

Schnurr, Friedman, Lavori, and Hsieh (2001) pointed out that ‘‘few
studies have examined the effectiveness of group therapy for PTSD with
veterans and it’s due largely to the complexities inherent in conducting
well controlled research in this area’’ (p. 78). To summarize, the benefits
of group therapeutic approaches include: time and cost-effectiveness,
universality among group members that relieve feelings of isolation
and negative uniqueness, the sharing of information and the promotion
of member support outside the group experience (Klein & Schermer,
2000; Yalom, 1995). Further, Rozynko and Dondershine (1991) empha-
size the value of treating trauma injuries in a group format because the
group approach offers: (a) the development of a sense of belonging; (b)
overcoming feelings of isolation; (c) the restoration of a ‘‘broken’’
military group relationship by establishing warm relationships among
therapy group members; and (d) the acceptance and control of patients’
anger. As Yalom pointed out, the group is the place where, ‘‘the knowl-
edge that others share similar experiences and distress a sense of
universality is helpful as clients often feel isolated, embarrassed and
misunderstood prior to starting treatment’’ (p. 324). Peer support,
belonging, cohesiveness and member-to-member learning and feedback
are central to this approach. Analysis of data from our recent prelimi-
nary evaluation of the Veterans Transition Program (VTP) (Westwood,
McLean, & Cave, 2004) supports the research literature highlighting
the benefits of peer interaction in a small group format.

Many of the above-referenced researchers in the areas of military
trauma agree that more studies are required, especially in the area
of group as a treatment model. This article describes one such group
approach for veterans and presents outcome findings. The Veterans
Transition Program (VTP) is a particular residential group approach
that addresses the impact of trauma exposure through the reduction
of symptoms and the provision of necessary knowledge, skills and
the social support to promote improved overall coping thereby facili-
tating successful re-entry into civilian life.

Program Overview

The VTP program focuses on: (a) creating a safe, cohesive environ-
ment wherein soldiers can experience mutual support, understanding
from others who have ‘‘been there’’ and process their reactions; (b) nor-
malizing of the soldiers’ military experiences overseas and the difficul-
ties with re-entry back to civilian life; (c) offering critical knowledge to
understand trauma and its origins, symptoms, impact on self and
others along with provision of specific relational and self-regulation

Westwood et al./VETERANS IN TRANSITION 47

strategies for trauma symptom management; (d) reducing the symp-
toms of the stress-related issues arising from their military experi-
ences; (e) teaching of interpersonal communication skills to help
manage difficult interactions or enhance relationships with others
(e.g., spouses, friends, co workers); (f) generating life goals and learn-
ing how to initiate career exploration; and (g) involving spouses and
other family members in family awareness sessions.

The various components of the VTP presented above are conducted
in a structured fashion in order to reduce re-activation, promote
increased trust formation, and permit greater self-awareness, self-
disclosure, emotional expression and cognitive reframing. The parti-
cipants of these groups involve veterans only, unlike most trauma
recovery groups in which veterans are expected to join with civilians.

The leading team consisted of three professional clinicians (i.e., com-
bination of psychologists, counselors and a physician) assisted by two
paraprofessional soldiers. The paraprofessional soldiers have pre-
viously participated in the VTP and have received additional training;
they assist by modeling caring and supportive behavior and by
engaging in the expected behavioral outcomes of the program (Alcock,
Carment, & Sadava, 2001). Veterans report trusting others ‘‘who have
been there’’ and therefore the witnessing and validation from other
soldiers is an essential component in the repair of war-related traumas.

Six to eight veterans meet for approximately 80 hours in a residen-
tial program. The format of the program is several weekend sessions.
Consistent with military nomenclature, participants refer to the pro-
gram as a ‘‘course’’ rather than a therapy group. Therapy or counsel-
ing are terms which are seen as stigmatizing to the veterans and
these latter terms result in discouraging others from joining the group.
Research has demonstrated that military personnel are cautious about
revealing information to others regarding a possible ‘‘weakness,’’ such
as a psychologically based injury (Rosebush, 1998). There exists
a stigma associated with seeking psychological care and therefore
military personnel rarely do so (Hoge et al., 2004).

Following the first phase of establishing a solid working group, the
therapists begin to assist individuals to address symptoms and begin
the work of trauma repair. This is accomplished by having the member
share life-narratives through a group-based life review process (Birren
& Birren, 1996; Birren & Deutchman, 1991). In this process parti-
cipants write short autobiographical accounts on pre-selected themes
(civil and military) between sessions then read these stories aloud in
the group in a manner similar to the Trauma Focus Groups developed
by Ruzek et al. (2001). After each story has been read, others respond
to what they have heard without interpretation letting the speaker
know what they said was heard and understood (Birren & Birren;

48 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / March 2010

Birren & Deutchman). Hearing the reactions of others to one’s story
can help normalize difficult feelings such as anger, guilt and shame.
Sharing common military experiences in particular promotes trust
and greater group cohesiveness (Corey, 1990). Life review is a rela-
tively low risk way to initiate self-disclosure as it allows individuals
to engage and disclose at their own pace. This structured narrative
process helps to highlight the soldiers’ strengths and capabilities that
have been shown to decrease depressive symptoms at the same time
(Birren & Birren; Birren & Deutchman; Rife, 1998).

Following the telling of their individual narratives the members are
now ready to enact critical life events through the therapeutic enact-
ment process. Therapeutic enactment (TE) is the group intervention
by which individuals begin to integrate the trauma event into their life.
TE is a highly structured intervention in which participants are able to
externalize internal processes of trauma by enacting specific trauma
narratives. The soldiers refer to this process as ‘‘dropping the baggage.’’
Through the enactment process group members are able to learn about
their triggers, stressors, and patterns of activation, relapse and
regression. They begin to understand that their reactions of numbing,
shame, and helplessness are normal responses to abnormal events that
prevent emotional release (Herman, 1997). They come to recognize that
the experience of letting ‘‘baggage go’’ through TE in a structured, safe
environment is highly therapeutic as trauma symptoms begin to lessen.
To maintain a feeling of safety and in order to remain grounded through
the enactment process group members are taught emotional self-
regulation skills preventing them from moving into hyper-activation
(i.e., heightened anxiety response) or hypo-activation (i.e., decreased
sympathetic nervous system responding). By attending to ways of reg-
ulating the client, the therapists work to keep them within the window
of tolerance (Ogden & Minton, 2000) between these two states of res-
ponding. Active expression of emotion (verbally, emotionally, and soma-
tically) while describing the event for the group integrates the trauma
reactions, helps make sense of what occurred, and promotes cognitive
re-integration. Thus, participants are able to more successfully inte-
grate their reactions at a thinking, feeling, and experiencing level,
thereby promoting a story of coherence versus confusion and reactivity.

The process follows a distinct number of steps (see Figure 1 for a list
of these steps). In the planning phase, the therapist and group mem-
ber work together to plan a critical event to be enacted. This is fol-
lowed by the enactment itself in which group members are asked to
take on the key roles of significant others who were part of the event
or to act as witnesses to the enacted event. Techniques such as
‘‘doubling’’ and ‘‘role reversal’’ are used to help the soldier access
and express the buried feelings and negative cognitions attached to

Westwood et al./VETERANS IN TRANSITION 49

the problematic event. The enactment phase is closed by having mem-
bers who took roles and the witnesses tell what they experienced, what
they observed and how the enactment affected them personally.
Completion of this process deepens trust among members and further
strengthens group cohesiveness and support. TE has been investi-
gated and shown to be well suited to the treatment of combat-related
traumas (Black, 2003; Cave, 2003; Coalson, 1995; Ragsdale, Cox, Finn,
& Eisler, 1996; Westwood, Black, & McLean, 2002).

Having released much of the trauma stored within from the past,
participants begin to shift their focus to the future. Consolidating
new learning and creating clear and achievable goals and objectives

Figure 1 Therapeutic enactment: A 5-stage model.

50 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / March 2010

for the future is part of the third phase of the VTP. This latter phase
could be referred to as a type of post-traumatic growth phase as
described by Tadeschi & Calhoun (2004). Participants are encouraged
to discuss and generate life goals including initiating possible career
paths not previously considered. The group ends with members setting
up a post group network of communication with one another. The pro-
gram is captured in summary form (see Figure 2).

METHOD

In order to evaluate the effectiveness of the Veterans Transition
Program (VTP), the participants took part in the following study. This
research addressed the following question: What are the immediate
and longer-term effects of participation in this program designed
to reduce traumatic stress reactions and promote transition and adjust-
ment among returning military veterans? The specific objectives of the
study were to: (1) Compare measures of the soldiers’ well-being (levels
of depression, self-esteem and posttraumatic stress) before, immedi-
ately after and 3 months following the program; and (2) examine the
soldiers’ narrative experiences of change during the program, identify-
ing helpful and hindering factors related to program participation.

Participants

The VTP was offered to three groups of six male soldiers for a total
of 18 study participants following the same group format and protocol.
The soldiers were recruited through referrals made by veterans who
completed previous programs and by mental health practitioners in
the community. Their ages ranged from 32 to 73 years old, with each
group having a mix of ages. Eleven participants were married or in
common-law partnerships and three participants were single at the

Figure 2 Description of group-based transition program activities.

Westwood et al./VETERANS IN TRANSITION 51

time of the VTP. Four participants had no children, the rest had
between one and six children, ranging in age from infants to adult.
Nine of the participants were employed, three were retired and six
were on long-term disability. All but three of the men were retired
from military service. Group participants served in a range of peace-
keeping and=or special operations overseas including Cyprus, Israel,
Bosnia, Croatia, Korea, Vietnam and the Gulf War.

Procedures

This research incorporated both quantitative and qualitative meth-
ods in a repeated measures quasi-experimental design. The soldiers
participating in the study were involved in three phases of data collec-
tion: before beginning the VTP, immediately after the program and
3 months following the end of the program. The first phase of data
collection consisted of administering quantitative measures of PTSD
symptoms, depression and self-esteem (i.e., Trauma Symptom Inventory
[TSI; Briere, 1995], Beck Depression Inventory–II [BDI–II; Beck, Steer,
& Brown, 1996], and Self-Esteem Rating Scale [SERS; Nugent &
Thomas, 1993]). In addition, qualitative interviews were conducted to
collect demographic information and understand the soldiers’ experience
before the program. The second data collection phase was to administer
the depression and self-esteem tools and complete more in-depth quali-
tative interviews regarding the participants’ experience through the pro-
gram. The final data collection phase was only administering the three
measures of PTSD symptoms, depression and self-esteem.

Quantitative measures. The soldiers participating in the program
completed three self-report measures pre-program, post program
and 3 months after the program. All the measures have demonstrable
psychometric validity and reliability. They were also chosen for their
sensitivity to change.

The TSI is a 100-item self-report assessment measure for PTSD
containing three validity scales and ten clinical scales. The three val-
idity scales assess Response Level (RL), Atypical Response (ATR), and
Inconsistent Response (INC). The ten clinical scales include Anxious
Arousal (AA), Depression (D), Anger=Irritability (AI), Intrusive
Experiences (IE), Defensive Avoidance (DA), Dissociation (DIS), Sex-
ual Concerns (SC), Dysfunctional Sexual Behaviour (DSB), Impaired
Self-Reference (ISR) and Tension Reduction Behaviour (TRB). The
TSI evaluates traumatic stress symptoms as well as the intra- and
inter-personal difficulties often associated with PTSD. Pursuant to
frequency administration guidelines, the TSI was given only at pre-
and follow-up data collection periods.

52 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / March 2010

The BDI–II is an instrument designed to assess the respondent’s
level of depression. Twenty-one questions regarding symptoms and atti-
tudes are rated on a 4-point scale and reflect the way the respondent has
been feeling during the preceding 2 weeks. The BDI–II provides a total
score that can be used to screen for the severity of depressive symptoms.

The SERS is a self-report measure consisting of 40 items scored on a
7-point Likert scale. It provides a measure of the respondents’ assump-
tive beliefs about their self-worth.

Qualitative component. In addition to quantitative measures,
qualitative interviews were conducted by a researcher who was not
one of the therapists. The interview data was collected at the same
three intervals as the qualitative data.

In the pre-group interviews, demographic data as well as a brief
military history was taken. Participants were asked to describe their
experience of re-adjustment to their home life. The interview questions
were open-ended in order to facilitate the soldiers’ relating their experi-
ences in their own terms (Kvale, 1996). The interviewer elicited ela-
borations on the soldiers’ descriptions using questions such as, ‘‘What
does that mean for you?’’ and ‘‘Can you tell me more about that?’’

The second phase of interviews was conducted immediately following
program completion to elicit the soldiers’ experiences during and imme-
diately following the program. The third phase of interviews occurred
at the three-month follow-up period. The post-group and follow-up
interviews followed the Critical Incident Technique (CIT) approach
(Flanagan, 1954). Questions at both of these times addressed the ele-
ments the soldiers’ found helpful and hindering while participating in
the program. The CIT (Flanagan, 1954) method is designed to elicit criti-
cal incidents or events from the participants’ experience. Therefore, it is
especially appropriate for identifying the helpful or hindering experi-
ences of change during the program and following program completion.
CIT has been used extensively to study various psychological experi-
ences and constructs as well as helpful and hindering factors in group
employment counselling (Butterfield, Borgen, Amundson, & Maglio,
2005). CIT is also useful in eliciting outcomes of incidents and allows
for elaboration of the personal meaning the soldiers’ ascribed to their
experience through the interview (Butterfield et al., 2005).

DATA ANALYSIS

Quantitative Measures

Analysis of the quantitative data followed a descriptive model of
tracking scores across time. Only descriptive statistics were employed

Westwood et al./VETERANS IN TRANSITION 53

due to the low power of statistics with a small number of participants
(Neter, Wasserman, & Kutner, 1990). Cohen’s d (Cohen, 1988) was
used to assess the levels of improvement on the outcome measures.
Histograms were used to illustrate the changes across time.

Qualitative Data Analysis

All interviews conducted with the participants were audiotaped and
transcribed. For the first and second interviews, categorical content
analysis was conducted (Lieblich, Tuval-Maschiach, & Zilber, 1998).
The data collection and analysis team used Kvale’s (1996) meaning
condensation method of analysis. The steps in this process are to first
read through each transcript, determining the natural meaning units
as expressed by the participant, then state a theme that seems to
dominate the meaning unit. In other words: ‘‘Long statements are
compressed into briefer statements in which the main sense of the text
is rephrased in a few words’’ (Kvale, p. 192). Themes that emerged
from the meaning units were considered in context of the research
question. Quotes were also pulled from transcripts to exemplify the
themes. For the phase three interviews, Butterfield et al.’s (2005)
guidelines for the use of the Critical Incident Technique (CIT) were
used for analysis. All the soldiers’ statements resembling critical
incidents from the interview data were extracted and examined then
grouped categorically. The team worked with 90% of the items, once
the critical incidents were identified, and developed the category
system to describe the major themes. The remaining 10% of the
incidents were used to test for exhaustiveness of the categories. Two
additional categories emerged when these remaining incidents were
sorted.

RESULTS

Quantitative Results

All 18 participants who began the VTP completed the program.
The averaged TSI profile is presented for the pre- and posttests. The
TSI pre- and posttest validity scales indicate valid and interpretable
profiles. Although each participant’s score is not shown here individu-
ally, all participants had at least one elevation reflecting clinical sig-
nificance. The 10 clinical scales of the TSI are broken into two types
of overlapping symptoms: trauma symptoms and self-dysfunction. To
help understand the results in Figure 3, the trauma symptoms reflect
distress associated with the impact of traumatic events or processes

54 THE JOURNAL FOR SPECIALISTS IN GROUP WORK / March 2010

and include: Anxious Arousal (AA), Depression (D), Intrusive Experi-
ences (IE), Defensive Avoidance (DA), and Dissociation (DIS) as
primary scales and also include the Impaired Self-Reference (ISR)
and Tension Reduction Behavior (TRB). Possibly indicating a lack of
sufficient resources to modulate or address the distress caused by
trauma, the scales that measure self-dysfunction include: Dysfunc-
tional Sexual Behaviour (DSB), Impaired Self-Reference (ISR), and
Tension Reduction Behavior (TRB) as primary scales and also include
Anger=Irritability (AI) and Sexual Concerns (SC). The impact of a
traumatic event must take into consideration both the reflected dis-
tress and the personal resources to cope.

The results indicate improvement in trauma symptoms, depression
and self-esteem. The average scores on the TSI were lower at posttest
on all clinical scales except for an increase on the IE scale (Cronbach’s
a for the TSI results was 0.96). Between the first and the third

Figure 3 Participant validity and clinical scale scores of Trauma Symptom
Inventory (TSI) across pre- and post-program administration. AA ¼
Anxious arousal; AI ¼ Anger=irritability; ATR ¼ Atypical response;
D ¼ Depression; DA ¼ Defensive avoidance; DIS ¼ Dissociation;
DSB ¼ Dysfunctional sexual behavior; IE ¼ Intrusive experience;
INC ¼ Inconsistent response; ISR ¼ Impaired self-reference; RL …