Expert Tips to Avoid Common Errors in Group Therapy Leadership

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody today to this presentation. We're going to be talking about leadership skills and common errors in group therapy. I'm Dr. Donnelly Snipes. During this presentation we're going to discuss the characteristics of group leaders and describe the concepts and techniques for conducting substance abuse and mental health treatment group therapy. So one thing we're talking about with leaders is if you go to group therapy, and this is something that I emphasize for a lot of my clients when I'm referring them to group therapy, no two group leaders are necessarily going to lead group in the same way. So it's important for people to recognize if you went to group one time and you didn't like it, it doesn't mean necessarily that group therapy is not a good fit for you. I want to learn more about why it didn't feel like a good fit for you as opposed to just saying, okay, one and done. Group leaders have the ability to choose how much leadership to exercise. Some leaders are very passive and they let the group kind of lead on its own. Some leaders are very active and interactive in the group and leaders can choose this in a therapy oriented group group, you know, you can have situations where a group member shares and the other group members actively support and participate in talking with the sharer about what was going on and they develop a good sense of rapport that way. Some leaders are good with that and they would prefer just to sit back and facilitate and jump in when needed. Other group leaders are going to want to take the lead and and then ask, does anybody else have anything to add to help support John or whatever. Different styles for different folks. And that's great because there's no one size that fits. All group leaders choose how to structure the group. You can choose to structure things in a very didactic way or in a very, you know, traditional way, or you can do anything in between. You can do experiential group therapy. Yes, it's possible. There are a lot of different things you can do. For example, when we do meditation groups, one of the things I will encourage clients to do is we will go out and we will actually do the meditation and then we will process it afterwards. So that's a little bit different than just sitting around in a circle and talking about meditation. Leaders choose when to intervene. Like I said, some leaders are going to let things go a little farther than others. And then there are some leaders who really want to hold tight reins on what's going on in their group. Leaders choose how to affect a successful intervention. We choose what interventions we're going to use and the best way to present it to that group at that point, point in time. When I do groups on a detox unit, I run a very different group than when I do groups for aftercare because you've got two different levels of cognitive functioning, if you will. People who are in early detox are often still in sort of a haze or a fog, so to speak. So I don't expect them to remember as much. And I do a lot more experiential stuff in the detox group. I have a lot more handouts in the group. We do a lot more talking and processing. And in some ways it's more collegial, if you will, because most of the clients that are in the group already have a lot of the knowledge. And you know, I've worked in inpatient, intensive, outpatient and regular outpatient settings. Leaders choose how to manage the group's collective anxiety. And there's a lot of anxiety in group. There's anxiety about shar, you know, what if I share and people laugh or people don't understand? There's anxiety after people share because they've made themselves vulnerable. And there's collective anxiety in the group about how everyone's going to respond to one another and when. If you have an open group, there's anxiety when a new member joins the group. A group leader will help manage that anxiety. A good group leader is going to help incorporate new members and identify sources of anxiety in the group. And sometimes there can be something that is generally provoking anxiety in that group. There's sort of an elephant in the room, if you will. And it's up to group leaders to identify sort of what that elephant is and help the group members feel safer. For example, if you have a new co facilitator join, then the whole group may kind of pull back a little bit if you have some different situation. I know one of the things I always tried not to do when I was supervising a staff was go in and sit in on their groups because it's like having the principal sit in when a teacher's teaching class. It just messes up the dynamics. If I were to go and sit in, it would mess up the dynamics of the group. And the group may be anxious if the director is sitting in there as opposed to what's Going on. If their leader is just leading it, they're like, why is the director sitting there? And they start to become anxious that something's wrong or whatever. And it's the group leader's job to figure out how to resolve other issues. And that can be conflicts between people, that can be someone not showing up, that can be someone dropping out of treatment. A whole variety of things that may happen. We're going to talk about some of those personal qualities of leaders in groups. I want you to think of a group more as a family system or a. What do you call it, A group of employees or however you want to put it. It's a group that works together regularly, and they have to have a leader to run point, so to speak. And there needs to be constancy. You want to go in, and people need to be able to predict kind of what's going to happen. When I would go into a room to facilitate group, clients would know this is kind of how groups gonna go. And, you know, I hope they were thinking, cool, it's gonna be a fun group. But, you know, depends on the person. When one of my mentors would go in and do group, he did group very, very differently than I did. He did a lot of trauma work in his group, which was wonderful, and he ran wonderful groups. But we couldn't have been more different in the way we facilitated groups. But we were both very consistent in the way that we did it. We were both very constant in showing up. We weren't there one day and then gone for six days and then back again. Good leaders are able to actively listen. Well, that kind of goes along with counseling 101. If you can't actively listen, you're going to have a problem. Because one of the things that we're hoping people get out of the group is the ability to learn by observation and learn how to actively listen to one another. Good leaders have a firm identity. And when you go into a room, it can be really easy if you don't have a firm identity of who you are as a clinician and as a leader, to be pulled off course, if you will, trying to cater to the needs or the whims of what one group and then, oh, this group over here wants this. Well, let me go over here and do this. As a group leader, you need to know kind of what you're walking into, what your group composition is, and have an idea about how you're going to try to meet those needs before you go in there. And in a way that works with your Group leadership style. You need to have confidence when you walk into a room. I mean, if it's one person and you've got 8, 15, sometimes 30 in a psycho educational group, people in a room, you know, it's really easy to feel overwhelmed. So you need to have a lot of confidence when you're walking in there that, hey, I know what I'm doing. And not every group is going to go great. You know, just like not every day at work is going to go great. That's okay. Not letting that shake your confidence. Learning from that experience and moving on. Group leaders need to be somewhat spontaneous. Now, you can be real spontaneous if that's your thing. But even the most structured group leaders, and I use that term sort of euphemistically, but because I am one of those really structured people, we have to have an element of spontaneity because you may have something planned to go over, teaching distress tolerance skills, or you're in an anger management series and the group comes in and somebody's in crisis, or things are not going exactly as expected, or maybe you presented an activity and it seems to be falling real flat and the clients don't seem to be getting out of it what you wanted. You've got to be able to drop back and punt. You've got to be able to adjust to the needs of your group at that point in time. And I've also had times in group counseling, unfortunately, where we're right in the middle of a group and we have a fire drill, and it drives me absolutely batty. But, you know, you have to be spontaneous and figure out, okay, how am I going to kind of wrap this up and then get everybody back on board. And we would always meet in the same place during the fire drill. When we went outside, everybody would congregate together. That way it didn't completely obliterate whatever we were going over in group because I wouldn't want to leave somebody hanging emotionally. Good group leaders have integrity. We do what we say and say what we mean. We are trustworthy. You know, that kind of goes with those ethical principles there. And we're humorous, you know, in group, sometimes you got to be able to laugh at yourself, and sometimes you just got to be able to laugh because humor is important. Now. There's hurtful humor, which obviously you don't want to bring into it, but being able to present some concepts in a way that is light, if you will. When we talk about distress tolerance skills or any skills, giving examples sometimes. The research has found that people learn better when they're enjoying themselves, they tend to be more engaged. When they're enjoying themselves, well, go figure. That's not a huge surprise. So if you make a group enjoyable, they're going to learn a lot more. I learned from one of my early on mentors, just a brilliant, brilliant man. And I used to co facilitate our family education with him. And he would do skits and he would tell stories and he had anecdotes, you know, out the wazoo. And he always kept people sort of laughing and giggling and chuckling and going, I can relate to that. And people stayed a lot more engaged as opposed to other group leaders who might get up there and just read at them. This is what the addicted family looks like. And some of the things Lisa points out that sometimes even in somber groups like grief work, yes, there's a time to be serious and people are hurting and I don't want to make light of their grief. But there's also a time to give a little glimmer of lightness, if you will, in the group. And finding the appropriate time to do that takes a little bit of skill. But it is important to help people see that this is really awful right now. And you know, I see where you're at and there is light outside of this tunnel that you're in right now so they can have some sort of, some sort of hope. As Kristin points out, that's really important and humor can do that. So I don't want you to think of humor as just being making light of something. In groups sometimes humor is just walking in and sharing a random joke and people kind of laugh and you're like, well, I figured I'd get started off on the right foot. Sometimes that's all you need to do in order to bring in humor. Humor helps clients see that you're real, you're not this, you know, stiff button up person who's not able to understand where they're coming from. Leaders communicate respect and acceptance. Yeah, we figured that we need to encourage people and it's really easy in groups to have people sort of fade out into the background if they're not encouraged to participate. And that's one thing I do in all my groups. We start out group by doing a check in. Everybody goes around, checks in, says how they're doing. That way I can kind of get a pulse of where everybody's at and they generally share something about how their week went, especially in relation to the group or the homework from the last time. So everybody talks and they get used to talking in front of one another with some pretty low threat sharing. And then at the end of group, I go back around and I have everybody share one thing that they got out of group that is going to be beneficial to them in the upcoming week. And again, that's not a real high risk share that I'm asking them to do, but it encourages them to talk and it gives them something to talk about with their peers outside of group. You know, when they're walking to their cars or when they're out on breaks. If you're in a residential facility, we need to be knowledgeable of what clients are going through and we need to make sure that we offer compliments to those. And this kind of goes along with encouraging. But we want to offer compliments to those who share. Offer compliments to those who have made progress in their recovery and they share that. Offer compliments to those who, even the ones who raise their hand and go, I have no clue what you're talking about. Okay, well, thank you for sharing and let me see if I can clarify that for you. Good group leaders tell less and listen more. We really want to try to let clients express themselves as much as possible. And yes, you do have people who can dominate a group, and that's where a good group leader figures out how to deal with that. And we're going to talk about that some in future slides. But it is important to try to do less dominating and let people experience group. One of the great things about group is they get peer support. One of the great things about group is they learn to communicate in group. They're creating a microcosm, if you will, of their social network that exists outside. So in group, if you let people talk and communicate and don't try to control everything, you may get a better idea about where some of their hiccups and hurdles are in the outside world. Because you can see what prompts their anxiety, what causes them difficulty interacting with their group members. Group leaders gently persuade. Obviously, if you're leading a group, you have something in mind that you want people to get out of this, whether it's recovery is possible, that life is worth living, or that this tool will work for you, whatever you're trying to communicate. We want to gently persuade people to be willing to take a look at it and maybe try it. And group leaders provide support, and groups provide support. Because, yes, as Jason points out, it's amazing how isolated people feel before they come to group. They're like, nobody would understand. Nobody else has ever been through this. And then they get to group and they're like, oh, hey, everybody else is going through this. You get it. Because your identified patient, your client, whatever you want to call them may go home and nobody understands what they're going through at home. They may go to work and nobody understands it. They may go to their pastor, and their pastor's like, yeah, I'm out of things to tell you here. Then they come to group, and all of a sudden they're meeting 812 people who share a similar issue, who get it, and they don't feel quite as alone anymore. And I say 8 to 12 because that's the theoretical magic number for groups you don't want to go above 12. Closer to 8 is generally preferable when you're doing therapy groups. If you're doing psycho educational, it can nudge up to 15, but generally any more than 15 is not recommended. When you're leading groups, you want to vary your therapeutic style to meet the needs of clients. If you're working with a group that does really well with cognitive behavioral, well, great. If you're working with a group that is much more emotive and maybe you're doing a trauma group, you're going to have probably a different approach to helping people work through that trauma. Or if you're working with a grief group group, it's probably going to be less psycho educational and less cognitive behavioral in nature and more humanistic in its feel. Leaders model behavior. We need to model the ability, if you're doing a therapy group, for example, to let people cry or to let people get angry and not get all upset about it. Obviously you don't want things to get out of control, and that's where you've got to use your finesse as a group leader to know where to call a timeout. But a lot of times, and even young counselors, you know, brand new counselors out of graduate school, are very uncomfortable when someone starts to get upset, whether they're crying or angry or whatever, and they need to feel like they need to calm them down. A good group leader can model behavior about just sitting with somebody while they're upset for a moment. Or if you've got someone who dominates group, a good group leader can model how to effectively kind of, I don't want to say shut the person down, but give everybody in the group an opportunity to share and model turn taking. Leaders are sensitive to ethical issues. We want to have an overriding group agreement for your groups. And if you're in a residential treatment center, this may happen during orientation. I know at the residential place I worked at, we had an overriding group agreement. But then there were certain intensive therapy groups, generally trauma oriented groups that had their own unique agreement that people signed before going in. In order to protect people's sense of safety, we are obligated to inform clients of options. Options to group treatment if they don't feel comfortable in group treatment. If you're working with somebody who has a high level of social anxiety, they may not feel comfortable in group. I had a client that I worked with one time when he would get stressed, he had a tic disorder and that disorder would become exacerbated and he could not, literally could not speak and the tics would get so incredibly pronounced and then he'd get embarrassed. So we had to talk about, what are some other options for you besides group treatment? We need to let them know what their options are. We need to prevent enmeshment in group. You know, just like we want to prevent enmeshment in families, we need to ensure that group members are allowing each other to have their own ideas, opinions and feelings. There's no you should feel this way. We want to encourage people to be supportive of one another and we need to make sure we're acting in each client's best interest. In groups, this includes discharging people when they're ready to be discharged. This includes discharging people. Hopefully it doesn't happen often, but discharging people if they're inappropriate for group. Sometimes people are not able to handle the structure of group either because they insist on dominating it, or because they don't have the ego strength to be in group or because they continually show up late or under the influence. Had those a lot. And it's dangerous or triggering for the rest of the people in group to let that person continue to come while they are exhibiting those behaviors. So it's important for group leaders to know when to call a timeout and say, okay, this is not kosher for my group because it's going to disrupt the sanctity of the group room. Leaders improve motivation when members are engaged at the appropriate stage of change. And when I first started, you know, my first job out of college, I did a. I worked for felony probation and parole. And all of these people had been convicted of felony drug offenses. And they were with me for 16 weeks, none of them admitted to feeling like they needed to be there. Whether some of them did feel like that or not remains to be seen. Trying to work with them as if they were ready to change their substance using behaviors would have fallen flat because that's not where their mind was. That's not what they were motivated to change at that point. What were they motivated to change? They wanted to get off papers. They wanted to get off probation and be done with me. Okay, So I am engaging them at that level, and we would form a mutual understanding, if you will. Your goal is to get off papers? My goal is to help you learn ways that you can live healthier and happier. And you're stuck with me for 16 weeks. So let's talk about how we can make this a workable solution. Most of my groups in that period of time didn't focus on substance abuse, stopping substance abuse behaviors. Instead, it focused more on enhancing preventative factors in people's lives, like community engagement and lifestyle behaviors and healthy support systems. They were on board with those. They were more motivated to participate and learn because I wasn't lecturing them about something that they weren't interested in. Likewise, if you've got somebody who is just itching to change, you know, and they are ready to do the hard work that they need to do to get better, Providing superficial information or tangential information may not engage them. They want to know, doc, what's going to make me feel better tomorrow? And I want a tool that I can use. I want a strategy to address my depression or my anxiety or my ptsd. Members need to receive support for change efforts, which is why when I do the go around at the beginning of group, you know, people share what they did in the past week that helped them, whether it's in relation to homework or anything else. So I can encourage them to keep moving forward. If they're having a bad day, you know, or a bad week leading up to group, and they come in and they share that, well, at the very least, I can say, you know, it really took a lot of courage to come back to group today, even though it feels like you're not making any progress forward right now. So anything you can do to encourage people and give them a pat on the back is helpful. Because a lot of times in their support networks outside of group, they are not getting that kind of support. Their support systems are going, why aren't you better yet? Or why are you still doing this? In group, the leader explores choices and consequences with members. So we're talking about if, for example, if we're doing an anger management series, we may talk about the choice to explode and exhibit rage or the choice to use a different tool and what are the benefits and consequences of each. So then we can Talk about why choosing a tool might be more beneficial in the long term. In the short term, yeah, anger may get them what they want, also may get them arrested in some cases. However, this other tool might give them more long term peace. So we talk about that. And I use a lot of decisional balance exercises when I do groups where you look at the benefits and the drawbacks to the current behavior. In this case, exploding with rage. And you look at the benefits and the drawbacks to the new behavior. And in this case it would be using an anger management tool because both choices have benefits and both choices have drawbacks. And we need to recognize that and help clients recognize that because clients, well, anybody will choose the response that has, that's most reinforcing at that point in time. So we need to help them see how this new behavior remember that gentle persuasion using this anger management tool is actually more rewarding to them in the long term. Maybe not in the moment, but in the long term. As a leader, we need to communicate care and concern for members. If they're upset, we need to, you know, be able to process that with them. If they come into group and they already look like they're upset or they've had a bad day, maybe pulling them aside before a group and noting that, or if they're withdrawn or behaving differently during group, pulling them aside after group and noting that because they may have something not related to group that they're not feeling like sharing with the whole group. As leaders, we need to point out members competencies. One of the cognitive errors that people make when they're depressed, when they're anxious, when they're struggling with a mental health or addiction issue is they tend to minimize their strength, maximize their weaknesses in their mind. They really focus on all the crap that they can't do right. And they don't even pay attention to the stuff that they do do right. So it's up to us to help them switch that and really start paying attention to what tools they have, what competencies they have, what strengths they have, and encourage them to develop a sense of self efficacy and self esteem. And the group, you know, I have teenagers at home and we're at the stage where mom knows nothing and peers know everything. So the same sort of thing is true to a certain extent in group. A counselor can point out positive changes and reward and all that kind of stuff. And that's great, but that's kind of like mom doing it. You're thinking, well, you're my mom, you gotta tell me, I'm great. When the group provides positive feedback that may hit home because number one, it's peer to peer and there's no benefit, overt benefit to peers providing support for one another. You know, that's something that seems to come from a more genuine place than positive comments that may come from the therapist who's being paid to be there. Positive changes are noted in encouraged by the group. Encourage people to support one another. And we used to do this one group on Sundays and it was a long group, but it was so poignant. And we would have each member of the house. This was when I was working in residential. Each member of the house sit in the center of the circle and everybody in the circle would go around and provide that person feedback about what growth they saw in the person over the past week. And they would also provide constructive feedback sometimes, but most of the time it was pretty positive and. And clients were able to take all of that stuff and use what was useful and disregard the rest. Leaders work with, not against, resistance. If the group is resisting something, instead of trying to cram it down their throats, which ain't going to work, at least it's not going to carry past that group room. Ask them why it's not working. You know, if you're presenting something and it's falling flat, or people are disinterested, or they're saying, yes, but to everything you say, that's resistance. That means for some reason whatever you're presenting is less rewarding than the alternative or whatever you're presenting. They don't see how it could be useful to them. So then you need to back up and figure out, what am I missing here. Leaders protect against boundary violations, emotional and physical. So that's one of those things we want to watch out for. In my groups, I encourage people to be very cognizant of using the word should. If they're giving feedback, I want them to say, in my experience, you know, this is what I've done. You know, instead of saying, you should do this because you don't know what somebody should or shouldn't do. Encouraging people to own their feelings and own their thoughts and their ideas and their experiences, this teaches them to use that I blank because I feel because, or in my experience, this worked because they're owning it. And instead of putting it out there and saying, well, this. This will work for you. Leaders maintain a safe, therapeutic setting, looking at emotional aspects of safety. And that can include microaggressions, that can include everything. We want to make sure that people are not Actively using substances while they're in group. And we want to ensure boundaries and physical contact is appropriate. Sometimes it's appropriate for one group member to give another group member a hug. Most of the time, I would have to say probably not. So those kinds of comfort sort of things may happen. And I've had a couple of groups where we've been processing something that was pretty emotionally charged and someone felt very vulnerable and was very upset. And the group members chose to gather around and support that person with appropriate physical contact. You know, patting her on the back. And I think one of her roommate actually gave her a hug and it was appropriate. It wasn't overwhelming in any sort of way. And it seemed to help her feel supported. But that what is appropriate for physical contact is going to vary between groups and between settings. Leaders help cool down affect in groups. So if somebody starts getting really emotional or really angry, we are able to help de escalate. If a group and sometimes a group will just kind of go off on its own, they start talking about something. For example, in substance abuse groups, if the topic of medication assisted therapy comes up, that can trigger a lot of people and there can be some very demonstrative reactions to that. And a good group leader is able to bring down the tone of that group to something that's respectful and or switch the topic if it's not something that is appropriate or helpful for that group and table it for another time. Leaders encourage communication within the group. We want people to talk to each other. Go figure. I don't want to have 12 people sitting there talking to me. So I'm basically having 12 individual sessions in a room. That's not what group therapy is. I want people and they can make eye contact with me when they're talking if that's what makes them feel safer. But I want them to talk among themselves. So if somebody shares, going to say, I'm going to put it out to the group and ask who has something that they want to offer in response to what Sally just shared. In order to encourage group members to recognize again, they have experience, strength and hope. As we talk about in substance abuse groups, a lot of people have tools and strengths that they don't give credit to. They think, oh, well, I don't have anything to offer because I'm a client too. Well, no, that's not true. You have a lot of stuff to offer because everybody has their different skills. Yes, we all may be here because everybody in this room has a diagnosis of clinical depression, but each person in this room probably has different tools that they've used in the past that have worked for them or different, similar experiences that they can share so Sally doesn't feel so isolated. Interventions we want to help people connect with one another. Groups help people connect and feel less isolated. We want to help people discover the connections between their addiction or their mood issue and their thoughts and feelings. And we can do this gently in each session of group by pointing out, you know, if somebody comes in and they're in a negative headspace, we might be able to help point out the connection between those things. We want to understand attempts to regulate feelings and relationships and help people understand why they do what they do. Why did they scream at their significant other this morning? Why did they lose their temper with the bus driver that was late getting them to. To group or whatever. Help them understand where that's coming from, why they act that way with particular people and learn skills to deal with it. We want to help them build coping skills and perceive the effect, understand the effect of mental illness or addictive behaviors on their life. That way they stay motivated to want to change. They see, okay, my depression is impacting my relationships with my kids and my significant other this way, it's impacting my health this way, it's impacting my work productivity this way. Yeah, I really, I want to. I don't want to do that anymore. I want to improve those areas. So I understand that I've got to work on my depression in order to make those things improve. And as group leaders, as well as group members, we want to notice inconsistencies among thoughts, feelings, and behaviors. And this is one place where I think groups really shine, because instead of being one on one, it's 12 on one. So you've got 11 other people that can notice when there's an inconsistency between thoughts, feelings, and behaviors. And when you're running a group, you know, and if you've run a group before, you know this to be true. You have the person that's talking and they are communicating verbally and non verbally what's going on with them. But then you've got 11 other people who are giving off nonverbal signals, and, you know, they may be rolling their eyes or sighing or nodding their head in agreement. That's all communication. And it's hard for one person, a group leader, to be aware of all of those things that bring it in and not miss something. So it's good if the group is working together because, you know, after Sally quits talking, then Jane can share how she felt or Jane can say, you know what, it seems like Tammy didn't agree with what Sally was saying. I'd like to know more about what Tammy was thinking. Okay, great. So then we can start talking among the group about what was going on and what everybody's reactions were. We want to avoid a leader centered group by building skills in members and avoid doing for the group what it can do for itself. So that example that I just gave of, I call it moderation. If Jane over here notices that Tammy is indicating agreement or disagreement or whatever and feels like it might be helpful to bring that out into the open, then encouraging Tammy to do that, encouraging Tammy to ask questions appropriately instead of. And it is a matter of teaching them how to ask the person appropriately. It's important to ask the person, you know, it seems like, Jane, you're disagreeing with what Sally was saying. I'd like to know what you were thinking so maybe the rest of us can learn from it or whatever. We need to encourage group members to learn the skills necessary to support and encourage one another. And that's active listening first and foremost and empathy and learning how to set emotional boundaries. And emotional boundaries are so key. And we've talked about this before in group, but I'm going to go over it one more time. A mentor of mine in graduate school communicated the difference between sympathy and empathy. He said, imagine somebody is stuck down in a well and it's cold and it's wet and it's dark. Sympathy is standing up at the top of the well going, sucks to be you down there. You know, I'll stay here until help comes along. You can kind of imagine what it's like for the person down there, but you're really not experiencing it the same way. Empathy is strapping on rappelling gear and going down the well and experiencing that coldness, that darkness, that dampness with them. And to a certain extent, the apprehension. The difference is with good boundaries, the rappelling gear are your boundaries. With good boundaries, you can pull yourself back up out of that well when it's time to go. The person who's stuck in the well is still stuck in the well. That repelling gear, that ability for clients to not take on somebody else's problems and take them home with them is really important to teach in group. We want to refrain from over responsibility for clients. Clients should be allowed to struggle with what is facing them. Again, not jumping in as soon as somebody starts to get upset, not providing a solution as soon as that happens. Using a lot of socratic questioning, you know, what do you think your options are? You know, I hear this is a really terrible situation that you're in right now. What do you think your options are for solutions? Let's talk about it. And y' all know I'm a fan of a whiteboard. So in my group I'll turn around and I'll write on the whiteboard, let's list the options that you've got right now and then I might put it out to the rest of the group. Does anybody else, can anybody else think of any other options that Sally might have to handle this situation? If so, I'll add those to the board. If not, then that's fine. We'll move on and start talking about how to implement those. I want to encourage Sally to start using her problem solving skills in terms of relationships outside of group. In substance abuse group, it is really difficult if not impossible to prevent that from happening in most cases. Most of the places that I've worked with, worked for, worked with have either been, well, have been primarily 12 step. And yes, there are celebrate recovery groups and in small sections you can find some smart recovery groups. But the preponderance of people go to 12 step groups and the preponderance of people end up going to the same 12 step groups. I can't tell them which group to go to outside of outside of therapy. So they are going to be engaging with one another outside of group. So I would rather have that be a topic we can discuss in group and a topic we can discuss an individual than prohibiting it knowing good and well it's going to happen because then it starts talking, setting up a dynamic where people are keeping secrets. In mental health groups it's a little easier to say it's better to not have relationships outside of group. But again, once they walk out of your group, they're going to do what they're going to do. So encouraging them to process if they start having some sort of friendship with someone in the group outside of group, encouraging them to process it with their primary therapist at the very least to make sure that they are engaging in a healthy relationship as opposed to an unhealthy one. And I agree with Daniel. One of the things that I do, and I don't usually go back and forth between psychoed and group dynamics because I just don't have enough time, usually structure my groups. So the first five to 10 minutes is our go around and our check in and you know, rapport building because I run open groups. So we typically have new people coming in and we need to re establish that, you know, forming and norming and all that kind of stuff. First 10 minutes is the check. In the next 15 minutes at most is the psycho educational part. And I present that visually. You know, I give them handouts, we talk about it, we do some activities. Then I go around the group and I have people apply it. You know, how could you apply it to a situation you experienced last week? And, you know, we talk about that and how it might have worked. And then at the end of group, again, we go around and we talk about how they might apply something that they learned from group to their recovery in order for next week. You know, in the next week, how do you see applying something that we talked about today? So that encourages them to not only think about, yes, I have this tool now, but they're translating that into sort of imaginary action they see in their mind's eye themselves. Using that tool in the future, transference clients project important past relationships into present relationships, which again, your group forms a microcosm. It may be reflective of their family or their social situation. We want to be aware of that and help clients recognize transference reactions and help them recognize how those transference reactions may be occurring in the outside world. You know, so if somebody reminds them of their mother, you know, and they don't have a good relationship with her, then, you know, helping them recognize that feeling they get and get down to facts and identify, what is it about this person that is rubbing me the wrong way? Is it something about this person, or is it because this person reminds me of my mother? And then they can start identifying that while they're dealing with their mother issues in group or in individual countertransference, the other person projects emotional response to a group member's transference. So you may have one person recognizing you, the group leader, you, you remind them of their mother, and they become hostile towards you. And then you have another group member who may see that interaction and it reminds them of their family of origin. And then they start having a reaction. So you've got to look at all the interactions and the dynamics. Countertransference can come up. When somebody has a feeling of having been there before, it's like, oh, I don't like this. I remember this. This reminds me of a time feelings of helplessness when the leader is more invested in the treatment than the clients are. And this can be a countertransference feeling that we have because we want them to get better and they're looking at us to, quote, fix them a lot of times so we can have a sense of helplessness that we need to pay attention to. And sometimes we as leaders can have feelings of incompetence because of unfamiliarity with culture and jargon. In substance abuse, this is really common because new drugs come out and there's new jargon that comes out. So we can feel inept sometimes. And it's important to be real with clients. Resistance arises to protect the client from pain of change. Resistance is difficult. And resistance, remember, reflects the fact that in the client's mind, the old behavior is more rewarding or less painful than the change that you're asking them to make. Resistance is an opportunity to understand something important for the client or the group. So we need to ask that question, why? Why is this, what we're talking about here, more threatening or more painful than the alternative? Resistant indicates the proposed solution is less rewarding than the old behaviors, or there's a fear that the new behaviors will become more painful or less rewarding. So efforts need to really be made to understand the problem instead of just going, okay, well you guys aren't into this, so let's switch topics. I'm curious as to why you guys aren't into this. Let's talk about it. In what way is this not useful to you? Or what do you think would be more useful in this situation? Strict adherence to confidentiality regulations builds trust. You need to encourage clients to maintain confidentiality. Not only is not just something that we as clinicians have to do, but in groups. You know, I don't want them going to a even out to break and discussing what's going on in group, out in the open, if you will, because there's too much possibility for other people to hear and I certainly don't want them discussing it. At support group meetings, leaders should explain how information from sources may and may not be used in group. If we get information from probation officer or a doctor or something, how it might be used in group, or if we get information from another group member, how will that be used? And a lot. I prefer not to take information that's come in and use it in group. I generally prefer to talk to the person individually, but that's a leader's decision. Violations of confidentiality should be managed in the same way as other boundary violations. Professionals in the healthcare network need to be aware of the role of group therapy and how it integrates with the multidisciplinary team. It can create such cost effective and efficient access to services. Because I can see 15 people in a 90 minute session or I can see one person in a 60 minute session and then, you know, maybe half of another session. So it allows more people to be in treatment. Now, not everything is appropriate for group. However, the lion's share of issues that people present with can benefit at least to some extent, from involvement in group therapy. Clinicians should coordinate the treatment plan, keeping important interpersonal issues alive in both settings. So recognizing that if Sally is having issues with anger management, you know, discussing that in individuals, obviously what she's there for, but then paying attention to anger triggers when you're in group. We also need to have a medication knowledge base and be aware of medication needs of clients, the types of medications prescribed, and side effects. Because sometimes clients will start on, for example, an atypical antipsychotic, and if they're taking it before group, they may be dozing off in group. That's triggering to people who may be recovering from opiate addiction. Being aware of the side effects of medication, what patients might need in order to address those side effects is important. Conflict is normal in group. It's healthy and unavoidable. People are going to have their own opinions. So we want to help clients learn how to handle anger, develop empathy, you know, manage emotions and disagree respectfully, basically agreeing to disagree and being able to take the other person's point of view, even if they don't agree with it, to sort of try to understand where they're coming from. And obviously managing emotions, you've got your distress tolerance skills that come up here to help people prevent dysregulation. The leader facilitates a call to attention to unhealthful patterns. If we see undercurrents of irritability, or for example, like I suggested earlier, if somebody sharing and somebody else closes their posture and rolls their eyes, that is an aggressive nonverbal. So calling attention to that and having the person put words to what their nonverbal said, so we can start getting that out in the open. Conflicts that appear to be a scapegoat, a group member may be misplaced that a member feel toward the leader. So if there is a conflict that's going on, or if the group is angry at you and you feel like you're the scapegoat, well, it could be you're the scapegoat because they don't want to talk about whatever that issue is that's going on, or it could be that you really deserve it, so you need to be willing to check and go, did I do something that may have triggered the anger in my group, or is there Something else going on that I basically serve as the representative target for. And conflicts can be a transference issue. Subgroups are going to inevitably form in group therapy. You're going to have cliques, you're going to have people who go to the same 12 step meeting or recovery support meeting. You may have groups forum where people's kids go to school together, or whatever those subgroups are going to form. These can provoke anxiety, especially when a therapy group comprises individuals that are acquainted before becoming group members. So if you already know somebody when you're walking into group, then you've got a leg up on everybody else in group who doesn't know that person, and it creates a power dynamic. It's important to remember, though, that subgroups are not always negative because subgroups exist in real life. We need to help people learn how to deal with subgroups and not feel angry or suspicious or dysphoric in any way if they're not part of a particular subgroup. Just because you don't have kids that go to their same school, you know, it doesn't mean they don't like you. It just means you don't have that in common. When we respond to disruptive behavior, especially clients who can't stop talking, you know, you may have a client is going on and it's been time. You may stop the client when it's appropriate and say, okay, you know, you're getting way ahead of me here. Let me see if I understand what you're saying right now. Summarize what's going on and then ask other people in the group. Because sometimes if that client just has to stop long enough to get a breath, then everybody else can participate. Sometimes it's important to discuss it outside of group. If this person habitually cannot stop talking and tries to dominate the group, it's important to discuss the purpose of group and each person's role in group and the expectations. Ideally, you do that before group even starts, but it may need to be reminded. Some people may need to be reminded of it. And if clients can't stop talking, we also want to explore their motivations. And sometimes they want to do this because they're afraid of what other people might say. So if they keep talking, they don't have to hear anybody else or they want to appear smarter or healthier than they really are for some reason. So we want to explore the motivations, and there can be a lot of them. If you have clients who interrupt, you can use something called a talking stick or icon, have something that clients hold when they're talking. Then when it's time for somebody else to talk, they hold. We call it the talking stick. And that shows that that is the person who has the floor at that period of time. Clients who flee a session, and it happens. This is when it's really helpful to have a co facilitator. So one person can stay in the room and manage the group, and another person can go after the client who walked out or a backup plan. You know, if somebody leaves, what is the group supposed to do? Hopefully in your facility, you have at least one other person on duty that can go in and at least supervise the group while you're handling the client in crisis. Sometimes clients are unable to participate in ways consistent with group agreements. Removing people from group is serious, and it is, you know, does have its consequences for their psyche as well as the group. The leader makes the decision to remove an individual from the group, and members are allotted time to work through their responses, how they feel about this person being removed. Some people will be all for it because they were tired of that person dominating the group. Other people might feel bad because they. They think, well, that person just had was so much needier than the rest of us or whatever. If people are coming in late or missing sessions, if they're silent, if they tune out or participate only around the issues of others, they just want to talk about everybody else's stuff, not their own. If they fear losing control or if they are in a fragile psychological state, it's important to pay attention to those things. Discuss them with the client, encourage them to appropriately participate, and encourage them to do whatever they need. Especially with clients, you know, maybe one who just had a suicide attempt, it's important to make sure that you've got a plan of action before group. So if that client starts feeling overwhelmed, they have strategies to manage that and they don't become completely dysregulated. Common errors, impatience with clients, slow pace of dealing with changes. You know, sometimes it takes clients three or four sessions in order to implement a strategy or be willing, be open to even considering strategies. Sometimes we are unable to drop that professional mask. And that's where the humor comes in. There's a failure to recognize countertransference issues. We do need to understand what the dynamics of the room are doing, which is one reason co facilitators are so helpful. But also, if you can record your group, that's really helpful to go back and watch it. We need to clarify group rules at the beginning and every time somebody new starts, make sure that you're not conducting individual therapy in a group setting and make sure to integrate those new members effectively into group and I just did a class on facilitating open ended groups that we talked a lot about how a clinician can effectively integrate a new person very quickly into group staff development theories and techniques, the traditional psychodynamic methods, cognitive behavioral and systems theory, all of those are helpful background for people to have. It's really helpful for group leaders to sit in on other groups or study tapes of other groups in order to learn different techniques and even study tapes of their own groups to identify things that they may have missed. Experiential learning by participating in a training group or being a member of personal therapy can help people become better groups. Facilitators and ongoing training and supervision is also helpful at improving group facilitation skills. Essential leaders skills for supervision include group training, cultural competence, awareness of co occurring disorders and the knowledge and signs of intoxication and withdrawal. So a supervisor needs to be aware of all these and communicate it to the supervisees. A supervisory alliance is required to teach skills needed to lead groups and ensure that the group accomplishes its purpose. So yeah, you do need supervision for group therapy, even psychoeducational groups as well as individual therapy. Clinical skills. You need to use your clinical skills in selecting appropriate group members, designing treatment strategies and planning and managing termination of the group. If it's an open ended group, you may have people coming and going at different times. If it's a closed group, then you're going to have opening and termination for everybody concurrently. You need to have comprehensive knowledge of co occurring disorders and knowledge of your agency's preferred approach. If you are leading a group, it's important to have diagnostic skills for determining co occurring disorders so if something starts to pop up, you're aware of it and you can refer for further assessment. You have to have the capacity for self reflection and recognize your own vulnerability and ability to monitor your reactions in groups. Group it's important to have consultation skills in order to provide feedback to referring therapists and to get information from them. And we all need to have the capacity to be supervised and openness to constructive feedback. Leading group is very different than individual therapy. Group dynamics can give insight into how the client reacts in social situations outside of the group. Group facilitators have an obligation to continue to enhance their skills even though you may have already gotten your license, especially if you just started doing group. But even then you know ongoing professional development is always helpful. I learn new group techniques pretty much on the weekly as Far as selecting appropriate group members, it depends on the type of group you're doing. And you know, not to be evasive, but you want somebody who has the ego strength to participate in group. Someone who is floridly psychotic is probably not going to be able to adequately participate in group. Someone who is starting new medications may not be able to participate in group. Someone who is overly aggressive. You know, look at the dynamics of people who may not be conducive to a collegial type of group. That's the first level that you want to look at. Then you also want to look at their diagnosis. Like I said, if they've got social anxiety, they may not feel comfortable in a group of 15 or 20 people or whatever you're doing that may be overwhelming. So looking to put them, if you're going to put them in group, put them in smaller groups. And that's another thing that is important to consider looking at their diagnoses. If they are in early recovery from substance abuse, you know, they're just out of detox or they're in detox, you're going to be doing different types of groups. So you're not going to want to refer them to an in depth therapy group if they're still coming out of the fog. Likewise, you know, you've got to consider if you're referring somebody to a trauma group, for example, they have to have the skills to be able to handle that intensity when they're outside of group. So you want to make sure that they have the coping skills to deal with group and the support system to deal with group in, out, in the outside before you start putting them in a group where they may be dealing with some really potentially traumatic stuff. So it all comes down to what group is going to be best for this person and which people are going to best benefit from this type of group. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcast CEUs to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com sponsor. Thank you.