GROUP PROCESSES WITH FAMILY MEMBERS: THE PERCEPTION OF UNDERGRADUATES IN SPEECH AND LANGUAGE PATHOLOGY Processos grupais com familiares: percepção de graduandos de fonoaudiologia

(1) Programa Saúde da Criança e do Adolescente – Centro de Investigação em Pediatria (Ciped) da FCM/UNICAMP, Universidade Estadual de Campinas, Campinas, São Paulo, Brasil. (2) Curso de Graduação em Fonoaudiologia e Mestrado Saúde, Interdisciplinaridade e Reabilitação da FCM/UNICAMP, Universidade Estadual de Campinas, Campinas, São Paulo, Brasil. Study conducted in the Undergraduate Course in Speech and Language Pathology at the School of Medical Sciences of the University of Campinas, Campinas, São Paulo, Brazil, with the scholarship of the Scientific Initiation Program – PIBIC, granted by the National Council for Scientific and Technological Development (CNPq). Conflict of interest: non-existent 1930s, initially for the purpose of socialization of the mentally ill. This approach is present in some Health areas such as in Speech and Language Pathology and Occupational Therapy (OT). In the history of OT, group processes have been intensified as a form of treatment, considering that group experiences have gained greater sense and meaning, such as the therapeutic effect1. In Brazil, the Speech and Language Pathology interventions with groups began to be used in the 1980s, considered initially as a way to absorb the great demand of users and to reduce the waiting lists, particularly in public health services. However, from the 1990s, with the expansion of studies in relation to group practices, the establishment of groups gained more strength, such as the possibility of therapeutic interventions, and they now have a preventive and educational  INTRODUCTION


INTRODUCTION
The use of activities with groups was systematically employed in the United States after the the participants and not just between the therapist and patient. In this sense, it is important for the therapist to promote the establishment of a frame that allows the construction of relations between its members and the possibility of a significant listening 8 . This issue deserves to be emphasized in the training of the undergraduate, which justifies the interface between the Occupational Therapy and the Speech and Language Pathology regarding the discussion of the analysis of activities carried out in the group space with a view to a training guided by completeness.
Completeness assumes, among other aspects, the expansion and development of the care dimension in the performance of health professionals, which will contribute to the training of agents that are more accountable, welcoming and able to build relationship with the target population and the health service actions 5 .
Given the above, the objectives of this research are to verify the perception of undergraduates in Speech and Language Pathologyin relation to the management of family groups and to analyze the process of selection, management of activities and repercussions of the group in the therapeutic process.

Study design and composition of the sample
This study is linked to the research "Speech and Language Pathology intervention in family group of children with language disorders" approved by the Research Ethics Committee (CEP) of FCM/ UNICAMP, under number 179/2009. The research was explained to the subjects and the consent and signature of the informed consent was requested.
This is a qualitative cross-sectional study, whose sample was constituted of 19 undergraduates in speech and language pathology, FCM/UNICAMP. Inclusion criteria were: being a regular student of the fourth year of the undergraduate course in Speech and Language Pathology and having managed family groups of children with language disorders. Exclusion criteria included students from other years of the undergraduate course at the time of data collection and students with experience managing adult groups in speech therapy monitoring.
For the identification of the participants, we used the symbol P (Participant) followed by 1 to 19 (ex: participant 1 -P1), thus ensuring the ethical aspects of confidentiality of the identity of the subjects pursuant to Resolution 196/96 of CONEP. nature, in order to favor language and to promote health 2 .
The group constitutes a space where difficulties, needs and expectations may emerge and feelings may be shared in order to promote greater autonomy and confrontation of the problems by the subjects 2 .
In this sense, one of the possibilities of the group work is focused on the families of subjects in therapeutic monitoring. The work with the family has been highlighted in the therapeutic work because a group formed by family members is a social support network that encourages dialog, reflection and discussion about the needs of those in the therapeutic process, while it enables the participation and contribution of the family in the improvement of the quality of work -Speech and Language Pathology work in this case -and improvement of the results 3 .
The Speech and Language Pathology group is also a practice with little description in the literature of the area, and we may observe a limited number of publications, mainly involving family groups 4 .
This therapeutic activity allows caregivers to know the singularities of the subjects in a group monitoring, as well as the needs common to the participants. The knowledge of the other is important for the development of intervention strategies, as provided by article 43 of the Brazilian Law of Guidelines and Bases (LDB). It provides that the Higher Education system should, among its purposes, stimulate the knowledge on the problems of the world today, providing specialized services to the population and establishing with them a reciprocal relationship 5 .
The performance of undergraduates from the Health area with groups may contribute to the analytical development of the ability to understand subjects and their demands and to establish a space of trade with the user 6 . As this author points out "the look is not limited to see the visible. It questions, researches, penetrates and interferes with things and their movements. The look creates sense to what it looks at and gives back this sense." So that a group can flow and develop as such, it is essential that the therapist is able to develop a therapeutic setting that meets the peculiarities of the group itself. It is a space that is influenced by the intrinsic characteristics of the professional that coordinates it, which therefore must be able to manage the group and to develop relevant activities, in addition to build new possibilities along the group, so that this space can effectively become a therapeutic tool 1,7 .
It is also important to consider in the management of groups the differences between group and individual processes, as in the group there is the possibility of an interactive game among that the family members shared in each group meeting, i.e. those perceived as meaningful by the facilitators during the groups. They were discussed under supervision when the next meeting was planned seeking to propose activities that were of interest to family members, so that the goals could be more easily achieved.
Some of the topics of the activities worked in these groups are exemplified here: ways to handle the children given the difficulties of communication, oral functions and the role of play in the development of language. All topics were discussed from the preparation of activities in which the family members were responsible for building the answers through the mediation of therapists.

Form of data analysis
The focus groups were videotaped and transcribed. Categories were established according to the objectives of the research and analyzed according to the criteria of repetition and relevance. From the criterion of repetition, we grouped what was common among the subjects, that is, repeated placements are highlighted. From the criterion of relevance, we selected the data that are significant in content for the researcher for the purposes of the research 10 .
We read several times the transcribed material, which allowed us to highlight several aspects for viewing and understanding the productivity and contribution of the groups in this study, which, in turn, led to the establishment of categories of analysis, as follows: • Feelings of the undergraduates when managing a family group • Process of selection and management of activities • Contribution of the selection, development and management of the activities on the training as speech therapists • The trainee's role in managing the group • The repercussion of the group in the therapeutic process

RESULTS
Below, we show the results by category of analysis.

a) Feelings of the undergraduates when managing a family group
In this category, eight of the 19 students have put their feelings when managing the family group, although this was not an issue mentioned by the mediators. It was observed that the undergraduates

Procedures for data collection
For data collection, we performed three focus groups with distinguished undergraduates, respecting the training of the groups in which they were part. Two groups were constituted of six undergraduates each and one group with seven, managed by two professors/supervisors, one occupational therapist and one speech therapist, having as an observer another researcher, a undergraduate student at the time, signatory of this work. A meeting was held with each group, with an average duration of 60 minutes.
The essence of the focal group consists in the interaction between participants and coordinator in order to gather data from the discussion focused on specific topics, according to understanding of the different perceptions and attitudes about a fact or practice 9 .
In the focus groups, we used guiding questions to know how the students evaluate the process of selection, development and management of activities in family groups as well as the role of the groups and of this process during their professional training. Below we show the guiding questions: 1 -How do you assess the selection of activities carried out in the groups of parents/family members that you managed? 2 -How do you asses this process in the training as speech therapists? 3 -Tell us a little about the role of guiding the group of caregivers/family members. 4 -Tell us a little about the process of selection of the activities developed in the group of caregivers/family members.

The activities developed in the family groups
The activities mentioned in this study refer to the therapeutic resources used by the undergraduates, prepared in order to provide greater involvement and understanding of the issues of the children that were accompanied by the family members in the speech clinic as well as to provide a favorable environment for the establishment of dialogs and reflections.
The proposed activities were intervention tools mediated by the facilitators of the group in order to answer the questions of family members. Such proposals were elaborated by trainees of Speech and Language Pathology and guided by the supervisors of the area of Speech and Language Pathology and Occupational Therapy. The groups, which happened monthly, were managed at each date by a couple of trainees.
Initially, the choice of the activity was planned from the goals of the speech therapy care of the children, and subsequently they started to be selected and developed according to the demands groups is not an easy task, neither is the selection of the activities to be developed. In Table 1 we show the main feelings expressed by the subjects.
demonstrated the need to address this issue in front of the subject.
The feelings shared among students were similar, indicating that the management of family We can note that in the participants, even after having received theoretical training in class as subsidy to the group intervention, feelings such as fear of failing and failing to achieve the goals are present in their speech. It is significant to note that such feelings are ameliorated only over time, from the experience gained in the experience with groups. Such findings indicate that to start this experience at the undergraduate course is relevant for a more solid formation in the intervention with groups.
The change of feelings during the process of management of groups, from the experiences had, is mentioned by several participants. Below, we show two examples illustrating this trajectory followed by the undergraduates.

b) The selection process and the management of activities
The undergraduates generally characterize the activities as a resource to facilitate the development of the group. The statement of subject P16, in a sense, summarizes the position of the other students regarding the role of the activity: "So, I guess that the activity has this purpose of encouraging the reflection, it helps, fosters, it's the basis of the discussion." (P16) One of the issues that deserves to be highlighted by being present in several statements is the understanding of the role of the selection of activities, in addition to the goal of introducing issues deemed c) Contribution of the selection, development and management of the activities on the training as speech and language pathologist The students express the contribution of acting with groups, highlighting the value of this experience: "I think the importance for our training is how to form a group, why we should do it, at what point to do it, how to manage this group, what activities we prepare and why we prepare these activities." (P9) "The opportunity to have participated in these groups that year was a very rich experience and certainly helped us feel safer in our professional life when managing groups, leading groups." (P11) On the speech of this same subject, we can verify the importance of acting with the family in the therapeutic process: "I think we come out with a training that goes far beyond the theoretical content that we have to apply; we have to think that this subject is inserted in an environment and this environment will influence him; in the case, the family will influence a lot. Thus, we need to be together, participate, guide so that we can bring them to work together with us." (P11) In addition, the results show that the practice contributes to the training as the undergraduates gain a distinctive look through the experience acquired; they are more attentive to the other, as the following statements exemplify: "I think that every internship is about practice, we start getting the hang of it ... it stops being mechanic, becomes something you're thinking more about the other, the patient, the parents, in the case of the group, than in your attitudes ..." (P1) "The importance of the group was really fundamental and we wouldn't know this if it happened only in therapy, because it's very natural how they speak ... the information that the group brings is vital for us to think, sometimes rethink and plan a few things in our therapy and so I think it was vital in our training, we're learning to handle the parents, we watch them from another point of view, also hear them differently. .." (P7) necessary to the group, because they were issues observed by the speech therapy trainees or were proposals from the family, and also the meaning in itself of preparing the activities. Here are some examples of the undergraduates in relation to it, which represents the lines repeated in the group, relevant to the understanding of this subject.
"We always thought of an activity which prioritized some discussion that we wanted to propose there . .." (P16 The findings highlight the process of selection of activities by the undergraduates aimed at encouraging and promoting the discussion between the members of the family group. They show that the subjects consider the activity as important for the beginning of the discussion, and they also show that, by being chosen, it demonstrates that the therapist wants to work and achieve results. In addition, the undergraduates express that the expected goals and results do not always happen, since family members can bring other needs at the time of the group, which promotes a new direction in the development of the activities.
Such perceptions of the subject allows us to highlight that, in the period of training, the students are being prepared to elaborate topics relevant to the demands of the families, since these are part of the therapeutic process of any subject in a Speech and Language Pathology, and the frustrations that in a few moments the preparation of the activities did not occur as anticipated are important for the formation of therapists who know how to handle biases, which must be taken as significant and relevant, and thus they rework their conduct.
supervision -talking less and listening more, sometimes that's all that matters." (P13)

d) The trainee's role in group management
Along with the exposure of feelings experienced when managing a family group and the process of selection, development and management of activities as presented, the students also reflected on the role lived as responsible for the group.
From the experiences in the internship, the students could address in focus groups their role before the management of the family groups, which refers to the importance of the training of professionals able to welcome and meet the context of a group dynamics, aware of the role they must assume and the importance of developing activities, so that answers are not given in a pre-established format but built together with the subjects. The testimonials below summarize, in general, the recurring statements of the students: Below, the expressions used in the speech of the participants are illustrated, which represent the role of the speech therapist in relation to a group (Table 2): Another aspect addressed by one of the subjects concerns the contribution of the self-assessment process that the management of the group provides: "I evaluate myself every time I leave the group, I know when I did the right thing and when that didn't work, we evaluate ourselves." (P4) We can observe that the self-assessment is closely related to how much the undergraduate managed to contribute to the production of the group, which involves reflection about the attitudes developed and the activity chosen. The P4 participant complements as follows: "Everything that we had, we learn here to learn as a professional speech therapist and in life, because we understand how the speech has meaning, has a lot of impact on the patient, we learn that there are certain things that we should not speak close to the patient, or that there are certain things that we need to talk about, this sensitivity to have the right time to talk." (P4) Another issue fairly addressed by the undergraduates as an agent for assistance in the selection, development and management of the activities, as well as in the professional training, was in relation to supervision. For them, the supervision contributed to clarify questions and encouraged reflection, as shown in the following statements: "I think that the supervisions really helped, when we work the feelings we had and the attitudes, it helps a lot." (P3) "Being part of the group, managing a group, for me at least, it was an lesson on learning to listen, because we have the impression that the group coordinator is the person who speaks ... and I think that it helps in the Family Group in the therapeutic process of their children:

"They bring things to the group that they would not bring to us when talking individually ... the information that the group brings is vital for us to think, sometimes rethink and plan a few things on our therapy ..." (P7)
"This family group is a job that helps a lot in the therapeutic environment, because only individual therapies don't account for the complexity of the subject." (P19) The statements also show that the group, in addition to encouraging children in therapy, also favors their family and, in this way, favors the construction of a relation of partnership between interns and caregivers. The testimonials below illustrate this issue: "The story of a father, that he put the importance of the group as a welcoming moment for them, that they also felt important; so it isn't just a therapeutic space for the children, but a space for parents to talk about them." (P9) "A specific work with the family is vital, you can't separate the child from the family, the elderly from the caretaker; they are always a set, and there is no point in working here and then the family goes against everything you've done, or they aren't your ally ... it is essential that you have them as allies, and then the patient will always be benefited. And for us it was very good, it's another vision, As we can see, the students put themselves as agents of mediation, that is, as facilitators of discussion among the members of the group, created from observing and listening, attentive to the language group, which is expressed both in the oral and nonverbal forms, when carrying out the activities in the group context.

e) The repercussion of the group in the therapeutic process
The following statements illustrate the speech of the students in relation to the importance of the group in the Speech and Language Pathology as a space for exchange of experiences and placing of desires and anxieties:  ." (P11) In addition, the subjects discuss the contribution and participation of parents and caregivers in the To mediate P6 To create situations in which answers can appear and sensitivity to know the needs P11 To mediate, feel the group and listen P13 To host, see the needs and know how to listen P14 To be a facilitator P15 To instigate constructions P16 To encourage discussions and to mediate P18 To feel the needs of the group P19 To mediate, contribute development of actions that meet the needs of the group.
From the knowledge of the other, they manage the group through activities defined as a resource to mediate issues, and the activity is the basis to promote discussion; it is the starting point for reflections. The subjects studied expose in their testimonials that the activities chosen are what they themselves are thinking in relation to the group. This statement is also present in the literature, in which the characteristics of the professional who coordinates the group will reflect on the group setting 1 .
Another important point put by the students is that when they manage an activity the route planned by them may not always occur, differently directing according to the intrinsic needs of the group.
The contribution of the selection, development and management of activities in the training as speech therapists is perceived as a construct that already begins in the theoretical disciplines and in the supervision of the internship. According to the students, it is a space in which they can clarify their doubts and reflect with colleagues and professors how to form a group, how to manage it, what activities should be developed to meet the goals of the family group, since, as pointed out in the literature 13 , it is not easy to select appropriate and meaningful activities, and it is necessary a careful analysis of the activity to adapt it to each particular case, acting with an integral vision of the subject.
In addition to these aspects, the findings show that, with the experience in the group, the students feel that the development of a group goes through the theoretical content learned, and only with experience it is possible to develop a posture of a therapist with the family members, seeing them differently, and especially when self-assessing themselves. The self-assessment action should be used as a contribution towards a humane training with positive repercussions in the professional and personal development 14 .
This finding corroborates with another described in the literature 11 , in which students who coordinated group activities demonstrated changes in feelings and attitudes in relation to the group, such as responsibility, evolution of insecurity to safety, sensitivity, affection, self-knowledge, and more able to understand the complexities involving the care of the family.
The findings highlight the importance of the group welcoming in the life of family members, the experience of managing groups in the training of undergraduates, as well as the repercussions in the therapeutic process of the child in the speech therapy monitoring. Such reflexes reiterate the statement that if the family is not regarded as an it's not just going in there and taking care of them, there's a family that also needs to be taken care of." (P13) DISCUSSION We can verify that when they share their feelings in relation to expectations when managing Family Groups, the undergraduates express that it is not a task experienced with tranquility and that internal changes occur from the experience gained in their training with the management of groups. Feelings of fear and apprehension were also found in the reports of nursing students who have experienced in their training the care of family members 11 . The students brought the difficulty in handling the overexposure of the feelings of the family members that appeared on the group dynamics, mentioning, as an example, the crying, which left them aware and concerned about what attitude to take in relation to these shared issues and reactions.
The feelings are transformed as the students discover their potential and the role in the group, in addition to the goal in itself, as evidenced by the results. The undergraduates no longer worry about their performance, with the need to talk and clarify doubts and they start to look more to the other.
The subjects say that it is their role to act as facilitators and mediation agents. Therefore, it is important to exercise the listening and observation and to capture and value the language relevant to the group. Such findings show the maturation of the students, as expressed by their statements regarding the management of the group.
The aim of working with family members, taken by the students, confirms other studies, which reiterate the importance of group activities with family members beyond the simple transmission of guidelines, being important the reconstruction of senses and subjectivities that often are hidden in the family members 12 .
This maturity provided in the training contributes to students to acquire the true meaning of a family group as a space in which they can monitor the therapeutic process of the care of children. This way, through dialog and reflections, a network of social support is formed that will reflect the possibilities of participation of the family in the child's daily life, enriching the speech therapy work and enhancing the results 3 .
Regarding the process of selection and management of activities, the findings show that the characteristics of the family and the needs they bring are taken into consideration, i.e. the students develop observation skills and become more sensitive to the knowledge of the other and to the to needs of the family members shown in each meeting, were an important resource in the group itself and also in the therapeutic process of the children, in addition to favoring the training of future speech therapists, prepared to develop a therapeutic setting suitable for the management of groups.
In this study, the selection, development and management of activities in a family group, when discussed in the interface between speech and language pathology and occupational therapy, aggregate values during the training and shows that the undergraduates seemed to be confident and prepared to manage groups. Consequently, there is a favoring in the training of more humane professionals aware when choosing activities that meet the needs of each group, giving particular importance to the knowledge of each family in the speech clinic. The undergraduates also stressed the importance of the groups in the therapeutic processes of the monitored children.
The approach of a health education that considers the family members in the learning process in the undergraduate education is required for a proper training in the health area, which includes public policies, appropriate environments and reorientation of health services beyond clinical and curative treatments, as well as liberating pedagogical proposals committed with the development of solidarity and citizenship, abandoning informational communicational strategies and adopting a dialogic communication 18 .
The results presented in this study reiterate the importance of Undergraduate Courses in Speech and Language Pathology in propitiating training in group processes to undergraduates, since the participation of the family and the bond established are fundamental tools for the therapeutic success in a perspective of comprehensive and humane care.

CONCLUSION
The results evidence that different issues emerged during group discussions in the perception of the undergraduates, which involved change of feelings, development of an analytical view, knowledge of the therapeutic setting as a space to reconstruct meanings and subjectivities, the meaning of activities as resources to achieve objectives, supervision as a space to clarify questions, self-assessment of the performance in group dynamics, and the contribution of the information shared in the group in the therapeutic process of the subject.
The selection, development and management of the activities in a family group, discussed on the interface between Speech and Language Pathology integral part of the process, therapeutics can fail, since both the family and the child require care, thus being a center of affection and inclusion 12 .
On the perception of the students about the constitution of the group setting, the family members could learn more about the work developed with children in the therapy and reflect about the activities at home, so that actions can go beyond the clinic space.
Family members bring information to the group that leads students to rethink their therapeutic practice. This exchange in the group activity generates positive effects in the therapeutic process of the children, as in the experience of the subjects in society and in the family the aspects of their subjectivity are closely related to their language 3 .
The importance in managing groups, in order to encourage a humane training, is addressed by several authors, who argue that the process of professional training is still centered in the technical and individualized learning, and there must exist a reflection regarding this process, with a view to humane proposals in the health area, favoring professionals that are critical, creative and sensitive to the construction of an efficient practice to users and their family members 11 .
The findings refers to another study on the experiences of groups on the internship, in which the share of the knowledge arising from experiences with groups impact on the professional training because the students develop better conditions to handle more closely the collective needs and demands of various social groups, strengthening them as social subjects and citizens 15 .
The results also corroborate another work with a family group. According to the author, in the group care, the time of the family member which before was dedicated to waiting is now rescued as subject with personal projects, and the role assumed by the therapist is to listen, look, facilitate participants in occupying an active place, and the activities developed are important in the support of the group 16 . It was also observed the emergence of aspects of relations of the participants with their children in the group, which indicates changes in the rehabilitation process; these issues are also discussed in this study.
Recent studies on groups in Speech and Language Pathology indicate that, from the experiences in various contexts and areas of expertise (voice, breastfeeding, written language), the group showed to be important as a therapeutic instrument, solving and/or easing the social impact of disturbances of communication [17][18][19][20] .