How to Avoid 5 Group Therapy Leadership Mistakes

Foreign like to welcome everybody to today's presentation on group therapy, leadership skills and common errors. I'm your host, Dr. Donnelly Snipes. In this video, we're going to discuss the characteristics of group leaders, describe concepts and techniques for conducting group therapy, and hopefully get a better understanding of really what we're trying to accomplish by through group therapy. One of the first things to remember is that you as a leader are in the driver's seat, especially at the beginning when the group is forming. You know, you have forming, storming, norming, all those different stages of group development. So it's important to remember that you are in the driver's seat and you have the ability to mold how that group operates. How much leadership do you exercise? Do you come in? Do you give them a topic to talk about and then let them run with it? You know, that's pretty loosey goosey. Or are you engaging in active dialogue and activities throughout the entire group, which is more of a psycho educational type of thing? How do you structure the group? Again, that kind of goes with how much leadership you're exercising. Do you have a lot of activities? Do you engage the in the group like in a psycho educational group? Or is it going to be more of a therapy group like a trauma processing group? When do you intervene? You know what you feel comfortable with and you know your population. Sometimes it's better to let a process play out a little bit so people can start using skills that they're developing in treatment, like listening without defensiveness and assertiveness and respecting boundaries and all that stuff. Obviously you want to make sure it is a safe and empowering environment for everybody there. That doesn't mean you have to jump on everything as soon as it happens. Part of the beauty of group is that it basically recreates on a small scale the outside in the group room. How people behave with one another in the group room often resembles. It doesn't mimic totally, but it resembles how they interact with others on the outside. What triggers them in group is probably what triggers them out there so you get an idea of what might be going on. You start seeing behavior as communication and then you can start helping people develop more effective tools in order to be more responsive themselves so you're not intervening. They develop the skills so they know how to respond when they start feeling dysregulated and that helps them feel safer and more empowered in their own skin. You choose how to affect a successful intervention. How are you going to do it? How do you manage the group's collective anxiety, especially in the beginning, there is a lot of anxiety during the forming, storming and norming phases when people are getting to know each other, trying to figure out who can I trust. All of their transference issues are kind of just exploding, floating around them and there can be a lot of anxiety. It's important to figure out how are you going to help group members deal with it? Are you going to encourage them to openly communicate in group to support one another? That's typically what I do. But you will have your own techniques based on your population. If you're doing groups with fifth graders, it's going to look a lot different than if you're working with teenagers versus if you're working with people with cognitive disabilities like dementia or people who just got out of detox. Four very different groups of people that you're going to be dealing with and different issues related to how that anxiety comes out and, and how you're going to deal with it. And you have to choose or you have the ability to choose how to resolve other issues. We're going to talk about a lot of those personal qualities of leaders. Consistency or constancy. Show up when you're supposed to show up. Be present when you're there if you are. I always use this term because most people know what it means. If you are Jekyll, always show up to group as Jekyll. Don't be Jekyll one day and hide the next day because that's really confusing for the people in, in your group. If you're having an off day, that's the time to be authentic and say, y', all, I'm here for you. But you know, my kid was up throwing up all night long. I didn't get much sleep. So I'm feeling like I'm not having an A day today. But being authentic and letting them know it's not that I'm disinterested. If I seem a little flat today, I have something going on. How awesome is that for them to be able to hear that? Because a lot of people in our groups do a lot of personalizing and they are very hyper vigilant to signs of rejection or criticism. You are able to actively listen. You have a firm identity of who you are as a person and as a clinician. It doesn't mean that you're going to convert everybody in your group. I am in large part a integrative trauma informed cognitive behavioral therapist. But it doesn't mean that everybody in my group is going to embrace those techniques that everybody in my group is Going to see issues as being the result of trauma, necessarily, that's fine. You know, I know how I conceptualize the world and I'm willing to hear other people's perspectives. I may morph mine over time. I know I have as I've learned more about trauma. But I respect their point of view and they respect mine. You have to have confidence when you're standing up there in front of 10, 15 people, sometimes more. You have to know that you belong, you know what you're talking about. And if you get asked a question that you don't know, just like an individual, you say, I don't know. Let me get back to you on that. That's okay. But having confidence that you can facilitate the group, having confidence that, all right, I'm going to go in here and I'm going to provide people with some tools that they can use and they're going to walk out having something useful. You need a little spontaneity every once in a while. You're going to get a heckler or something's not going to go how you anticipate. Go figure. And you got to roll with it. Being spontaneous can be helpful. I remember doing groups very early on and I was too much lecture, not enough, you know, activity, and people would start getting a little bored and I would have to drop back and punt and change what we were doing, not what we were talking about, but change how I was approaching what we were talking about sort of on a dime in order to re engage the group. Otherwise it was going to be a really long 90 minutes. You have to have integrity. Do what you say, say what you mean. You have to be trustworthy and trusting. That doesn't mean you're going to believe everything that comes out of everybody's mouth. That's. You have to be smart about what's going on. But we need to trust people to do the best that they can with the tools that they have at any given time. I need to trust that they're doing that. And you got to have a sense of humor. Sometimes something's going to fall flat or you're going to burp in the middle of giving a. Talking about something. I don't know, things happen and sometimes you just gotta laugh. You, if you can laugh at yourself, that goes a long way. I used to tell my clients in group, I don't care if you're laughing with me or laughing at me. If you're laughing, that's a good thing. And you need to have empathy because that communicates respect and Acceptance of the person. I hear where you're coming from. I may not have the same experiences, but I hear where you're coming from and I'm trying to put myself in your shoes. Empathy encourages people to talk if they feel like they're being validated, if they feel like you're not shutting them down, telling them they're overreacting, that's wonderful. A. A good group leader compliments people on progress they're making and tells less and listens more. When I do psycho educational groups, for example, I try to limit how much I talk. In the very beginning, I do. We go around the group and I have everybody do a check in, tell me, you know, how they're doing, and I have the topic for the group up on the board. Anything they want to share about that particular topic. Then I'll summarize what I heard from everybody, try to, you know, make it, make it all congeal or coalesce, find a common thread, whatever you want to say, and then I will provide the psycho educational content for about 10 minutes and that's it. And then we have activities where I say, okay, how do you apply this information to this situation? Or what do you think are three strategies that you would use to handle this situation? And we start. I start having people, everybody in the group share. Everybody in the group talk. Not everybody's comfortable with sharing initially. Hopefully they get there. If they're not sharing, I want them writing it down. I want them at least taking notes about what they would do so they're applying it even if they're not sharing with the whole group. And then again, eventually, once they feel safe, once they see other people have shared, once they hear other people sharing the things that they've written down, they start feeling more confident about being able to share. Not only that what they have to say is worthwhile, because it is, but they start believing that. But they also start feeling comfortable enough that if they share and it's something other people don't agree with, that they're not going to get chastised for it. And we want to gently persuade people to consider different perspectives. They don't have to accept them. That's where that boundary goes. But gently persuade them to be able to listen and at least consider other perspectives. As far as the group, the interpersonal qualities we really want to foster are the same as we foster for secure attachment, consistency in your presence, but also among group members. And nobody's going to be 100% consistent. But because we all have bad days, we all have good Days, Some days we're going to be more distracted than others, but trying to be consistent. When you're in groups, you're in group, and you're going to focus on group, being attentive to one another and what people are saying, not playing on your phone or going to sleep, being responsive to each other, not just sitting there like a bump on a log, but if somebody asks a question or posits a something that they want feedback for, providing feedback, in my experience, this has worked. Or even just empathizing with the person if they're having a bad time. But being responsive to your fellow group members, it goes a long way to helping people develop these characteristics in a way that they can implement them out there, helping them develop empathy for one another. A lot of times in substance abuse, at least, my groups have started out where we've had people that have tried to one up each other. My life is worth worse because. And I hear that everybody has had challenges and traumas and distress. And instead of comparing and saying, well, my situation's worse than yours, empathizing this person may not have had your experiences. So what they're going through right now feels pretty dagum awful. And minimizing their experience is very invalidating. So teaching group members how to empathize, even if they don't agree, empathy is a way of saying, hey, I can imagine what it might be like in your shoes. And then providing safety. One of the things I love about group is the sense of safety. I started out my career doing group for people who were on felony probation and parole. And it was an interesting group of people. And I remember, you know, it was me in this big building at night, and I was the only staff person there, which technically wasn't supposed to be happening, but it was what it was. But I never for a minute felt unsafe because I had allegiances, if you will. The people that were there knew I was there to help them, and they were generally there to try to get help. Now, they may not have wanted help for their substance use, most of them didn't, as a matter of fact, but they wanted help getting off probation, and that's where we started. And group members will tend to protect one another, but making it an environment where people feel not only physically safe, but cognitively and emotionally safe. I can share what I'm thinking and feeling, and you're not going to attack me for it. Leaders need to vary therapeutic styles to meet the needs of clients and the needs of the different group. My style in psychoeducational groups is very different than my style. In issue processing groups. One tends to be a lot more gregarious than the other one, but both are intended to engage and inspire. We need to model appropriate behavior. If we tell people that they need to be consistent and attentive and empathetic, we. Well, darn it, we need to be too. We need to be sensitive to ethical issues overriding a group agreement. If the group agrees that this is not going well, we need to be really careful about saying, well, I disagree with you and I'm going to, you know, trump what you have to say. We also need to pay attention. For example, if a group gets together and decides, hey, this person is really disruptive, if you override that and say, I don't care, they're staying in anyway, what does that do to the sense of safety and the sense of empowerment that people have in that group? Sometimes it has to be done, don't get me wrong. But it is important to try it. All costs. If you have to dissent from what the group wants to give them a voice in, all right, this. That can't happen. We can't completely kick this person out, but let's make it. Figure out how we can make it work so everybody feels safe. We need to inform clients of options if they don't want to go to group. Not everybody is willing to go to group. What are their other options? We want to prevent enmeshment. It's not up to us to tell them how to think or tell them how to feel or to create a dependency. We also don't want them to get enmeshed with each other where they are basically being codependent with one another. And we want to make sure that we are acting in each person's best interest in the group. If somebody is not benefiting from group, then we don't want to just say, well, you're a billable hour, so you're going to stay in group. We need to figure out how to make it work for them or refer them somewhere else. I had one client that I worked with who had really high levels of social anxiety and a tic disorder. And when he would start to get stressed out because of his social anxiety, his ticks would get really bad. It was not productive for him to be in group. It was disruptive because he felt, you know, anxious. He would start having ticks and then that would draw attention to him. It was. It was a whole thing. You could see it was not ethical or even, well, it was not ethical to keep him in that group. So it was important for me to advocate with the supervisors at that time and say, you know what? This, yes, we run a basically group program, but that's not going to work for this person. Let's talk about how to create a situation where he can benefit from being here. We improve as leaders improve motivation. When members are engaged at the appropriate stage of change, if they're in pre contemplation, then we need to engage them there. And a lot of my people who were in coming into my group from probation, they were pre contemplative. They didn't want to be there. They were involuntary. They didn't see the problem. They may have tried to get clean before and had failed, so they felt like it wasn't going to help. They may have felt overwhelmed by the possibility of change. There are a lot of reasons people, people may be in pre contemplation and you can watch the, the video on motivational interviewing to learn more about that. But if somebody is not buying in to your mission, if you will, and we'll stick with substance abuse because that's the most obvious one. If they're not willing to get clean, they don't see a problem with it. Okay, so what do you want? Let's create a win win here. What is it that you are motivated to change? And for all of the people there, without fail, it was to get off probation. Okay, well, to get off probation, you got to stay clean for the next 16 weeks. So. And you've got to come to group and participate. Those are the three things I need you to do. How can we make that happen? Instead of lecturing them for 16 weeks about how to quit using, well, that's no good. They had no intention of quitting using. So lecturing them about how to do it was just a waste of my breath and everybody's time. So we started talking about what is it that would help you stay clean and stay out of trouble while you're on probation? You know, basically we're talking about the same stuff, but they see it towards a different end. Members receive support for change efforts even if they're not totally successful. Any effort to change gets a kudos because change is hard and change often doesn't take the first time. You have a few steps forward, a couple steps back. Hopefully a few steps forward and a couple steps back. So you're always inching forward. But it's not a linear process. We want to make sure that people know that and we are providing them support. Choices and consequences are explored with group members. If somebody Makes a choice to skip group for two days or two sessions. We want to explore that with them. Hey, we really missed you here. We were worried about you. Explore that because it does have an impact on your group. If. Whether you believe it or not, I want you to think about it and actually explore it with your group. When somebody has been there and that's part of the consistency of the group, and all of a sudden they're not there anymore for a day or two days or more, people start feeling like they were either rejected or. And that can open old trauma wounds. Or they start wondering if something bad happened to the person that may open old trauma wounds or anx. There's a lot of stuff that happens when one of your. One of your group suddenly disappears. Same thing is true if you're doing a substance abuse group and somebody relapses. All right, it happened. So let's talk about that. How do you feel now that you're out of detox and back with the group? Members feel safe, cared for, and empowered. As leaders, we need to point out their competencies. You're really good at this, so how can we build on that to help you move toward your rich and meaningful life? A lot of people that I've worked with in all different types of groups have been extremely. Hyper aware. But I turn that into empathy. You're extremely aware of how others are feeling because of your traumas. It wasn't safe, you know, past experiences. It wasn't safe to be, you know, within yourself. So you became hyper vigilant to what other people were feeling. Now that hyper vigilance is exhausting, but it did give you a tool of empathy. So let's talk about how we can reign that in. So it's a useful tool instead of an overwhelming drain. And positive changes are noted in group and encouraged by the group. We want to make sure that we're celebrating successes, whether it is 30 days sober or. Or whatever. Leaders work with and not against resistance. We're going to talk about resistance more in a minute. Leaders protect against boundary violations. And remember, boundaries come in five different flavors, if you will. Physical boundaries. People aren't getting up in each other's space. Likewise, physical boundaries can be violated by glaring at one another. If you don't agree with somebody or something else is going on, just sitting there glaring at them. Even if you're not physically in their space, it's still a physical boundary violation. So we need to protect that. Interpersonal boundaries, who's friends with whom outside the group. Everybody has a right to their friendships. And inside the group, we don't want to have strong alliances that start forming factions, emotional boundaries. How I feel. If I feel angry about something, okay, that's my feeling. Everybody else doesn't have to agree with it, but they need to respect my right to have my feeling. Same thing with thoughts. You may have a thought about something. Like, in substance abuse treatment, there can be very passionate beliefs about medication, assisted therapy. All right, well, that's fine. That's your belief, whether you're for it or against it. And I will respect your right to that belief. It doesn't mean that I have to take on that belief. And that's so important that we start teaching unconditional positive regard. I value you as a person. And. And we can disagree. Oh, my gosh. We maintain a safe therapeutic setting with emotional aspects of safety, an absence of substance use, and again, with boundaries and physical contact. In some groups, there is a prayer at the end of the group, which is not comfortable for everybody. We want to be sensitive to that. And if we have people that don't feel comfortable, allowing them to opt out of it or not doing that prayer. In some groups, the opening and or closing is done with everybody holding hands. Not everybody's cool with that. We need to allow people the ability to not join in by holding hands and to let the group know, hey, it's not that I'm rejecting you. I just. I'm not a touchy person. I. That's not me, and that's okay. We respect their physical boundaries. Leaders help with cool down, cooling down, affect when things start to get riled, and it will. Sometimes we need to help bring it back down and acknowledge. Validate everybody's frustrations or anxieties. Here. There's a lot of tension in the room. Let's talk about that. Because frustrations and anxieties tell me that people are not feeling safe, and I want to know what that's about. So we can create an environment in which you do feel safe. And we encourage communication within the group. It's not a legal proceeding where everybody needs to go through the judge. I want people to talk to one another, not over one another, but if they've got something to say to a group member, then in an orderly fashion, saying that interventions you can use in group encourage people to connect with one another. Icebreakers. I know it sounds childish or whatever, but doing an icebreaker in your first group can be really helpful. Discover connections between physical and mental health, addictions, thoughts and feelings. Cognitive behavioral therapy says that our thoughts impact Our feelings and impact our behaviors. And I will also add on, they impact our health. If you're feeling sick, how does that affect your mood, your thinking and, and your behaviors? If you are feeling angry, even if it's not about the group, but you've just had a God awful day, how's that going to affect your reactions in group and the way you interpret what people say and the events of group? You know there's, we can help people start looking at what I call the diamond because I include that physical aspect of it. We want to help people recognize behavior is communication. If I am getting angry, then it is communicating that I feel unsafe. And I'm obviously not doing that with my words, but I'm doing it through my actions. If I am falling asleep in group, it may be communicating hey, I'm really bored with what's going on. Or it may be communicating I'm not getting my basic needs met and this is the only place that I feel safe enough to go to sleep or I'm working three jobs and I gotta catch a cat nap where I can. So we need to understand behaviors, communication and not assume we know what the person is actually trying to say. We need to ask, you know, tell me what this is about. We need to build coping skills. How do you tolerate distress? How do you down regulate when you start feeling dysregulated? We want to recognize the effect of the person's illnesses and experiences on their life. If they have been struggling with substance abuse and depression for most of their life and they had a traumatic upbringing, lots of adverse childhood experiences, we need to recognize how that influences the way they perceive the world and the way they react and the tools that they actually were able to develop. It impacts everything. We want to notice inconsistencies among thoughts, feelings and behaviors. If somebody says I want to get clean and I want or let's choose a relationship, I want this relationship to work out and, and I think it's really important to me and I feel passionate about making this work. And they come to group, they sit in group therapy, family therapy, and then they go home and they don't do anything that we talked about in group. Well, we need to see what's going on. You say you're going to do all these things and then you walk out and it's like, you know, you forgot everything we talked about. So what's the disconnect? Are you motivated to do it and then. But you start to do it and you don't feel like you've got the ability to actually implement it or are you just talking a lot of talk? So hopefully you get praise in, in session. What's motivating that behavior? We want to avoid a leader centered group. It's exhausting to do a leader centered group where you are performing. Basically we want to build skills and members and avoid doing for the group what it can do for itself. I will start out with a question and I will say when you get into an argument with your significant other, what is that about? Or what are the best ways to respond? And then I will have the group share. I love my whiteboard or chalkboard if I'm in an old fashioned area because that's a place where I can write down what they say. They have a lot of knowledge that they don't even realize that they have. And we start putting this stuff up and all of a sudden what Jim Bob offered as an answer, Sally sue, over here goes. Oh yeah, I forgot about that one. That one too. So they start creating these connections among themselves and they start recognizing that they actually do have. They have some skills. They may just not have figured out how to effectively apply them yet. We want to encourage group members to learn the skills necessary to support and encourage each other. Like listening without defensiveness, assertiveness and boundaries. And refrain from over responsibility for the people in your group. Allow them to struggle a little bit with what's facing them. If they are getting ready to go to court for something and they're terrified about it, all right, well, that's not your responsibility how they feel. But we can support them in and empathize with them about how scary it must be. And we can encourage the group to provide suggestions when they've had to go to court or do something that was really terrifying. What helped them tolerate the distress confrontation can have an adverse effect on the therapeutic alliance and process. We don't want to directly call out somebody unless, you know, that's like a last resort effort. If you're going to call somebody out, literally call them out and say, Jim Bob, I need to talk to you outside for a second. But that really is not very effective in group work because then everybody in groups like, ooh, you're going to get in trouble. It's not. We want to be able to handle it in group as much as we can. And we want to allow the group to facilitate as much as they can if somebody starts becoming rambunctious. All right, I hear that you're feeling really frustrated about having to be here right now. Does anybody in the group want to Share what they're feeling like at the moment. So bring it. Acknowledge that person's situation, try to de escalate it a little bit and then allow the group to work, allow them to address it in a way that feels comfortable for them. Confrontation can point out inconsistencies such as disconnects between behaviors and stated goals. But we want to do it gently. I typically focus on, hey, you're here, you're trying to get clean, and I know it is really hard and that relapse must feel like a huge step backwards. And I am so glad you came back and you are trying again. So you can point that out. If somebody's falling asleep in group, they say they want to be there and you know, they want to get the knowledge and you really believe that they want to be there, but they're falling asleep. Then you know, I might pull them aside or call them off to the side after group and say, I hear you wanting to be here and you were so excited when you started, but your enthusiasm seems to have kind of waned and you're falling asleep in group. Let's talk about that. But I do it off to the side. Transference is when clients project parts of important past relationships into present relationships. If Jim Bob walks into the classroom and he sees Tommy over there, that reminds him of the bully that beat him up all through elementary school. He may have a transference reaction. It's not because that actually is the kid that beat him up all through elementary school, but his brain, Jim Bob's brain says, this reminds me of a very unpleasant, unsafe situation in the past. So Jim Bob's anxiety is going to go up and we need to recognize that. We need to help people recognize how common transference is in life. And I share with my group, you know, different experiences of transference. I've had both good and bad counter. Transference is when the other person projects an emotional response onto the group members transference. So Jim Bob walks in, he automatically starts feeling stressed out and oppositional towards Tommy. Tommy perceives that as hostility and rejection. So he starts reacting accordingly. And we're all reacting in this situation based on something that's not even occurring in the present moment. It's based on a past traumatic event. We need to recognize that these things can happen because of schema memories that people have of things they've been through before. Typically traumatic events, feelings of helplessness when the leader or the other person is more invested in the treatment than the clients are. And we can really experience a lot of countertransference if they're coming in and they're not doing what we think they should do, we can start having some emotional reactions. And people in group can feel incompetent when they're in group. If you start throwing around a lot of culture and jargon or jargon and things that are not culturally responsive because they're walking in and they're like, okay, this is another situation where it's just the system against me. In resistance, we want to recognize that it arises to protect the client or the group from the pain of change. Sometimes groups become very connected and they don't want to change. They don't want to take a different direction, and we want to respect that. We may have to talk about where that's coming from and what they're fearful is going to happen. Sometimes people are resistant because they don't understand why they need to make the change. So this is an opportunity to understand something that's important for the client or for the group. What's going on that is causing this energetic reaction, this energetic pushback. You know, something is eliciting that response, and efforts need to be made to understand the problem. You can't just ignore resistance. You need to recognize it as communication. Resistance indicates that the proposed solutions are less rewarding or appealing. Why would I, you know, do this when I know that this works and it works really fast? Well, let's look at why you might want to make this other choice. The person does not have the skills to cope without the target behavior or with the change in group. Sharing in group is very scary to a lot of people, and they may be very resistant to it because they don't have the skills to cope with sharing. If I share, I'm vulnerable and I don't get vulnerable. That's. It just doesn't happen. We want to recognize that and respect that that person has felt unsafe when they've been vulnerable in the past or they may try to do if they can't cope without the target behavior. If I don't have the skills to address an issue, if I don't have good assertiveness skills to address an issue, then I am going to default to anger. I'm going to default to what works. We need to make sure that if we say, all right, responding by yelling and screaming and causing a scene, that's not really helpful. Well, the person may realize that we also need to make sure they understand and have the skills to do something different. We can't just say, well, don't do that. We, without saying, do this Instead, if the person has resigned, they've tried group therapy before, they've shared before, it hasn't helped. They have gone to residential before, it hasn't helped. They've tried to exercise, to lose weight before, it hasn't helped. Whatever it is you're asking them to do, if they've tried before and it hasn't helped, they may feel defeated. It's like, why should I do it again? It hasn't helped the last three times. You know, it's the definition of insanity. We want to understand what is it about this? Have you tried before and why didn't it work for you? Help me understand what about it was not a good fit and maybe we can find something else to do instead. Sometimes people are resistant because they feel overwhelmed by the prospect of making a change. It's like, I just, yeah, I know I need to do it, but omg, I just don't have the energy to do one more thing. Or they may be resistant because they feel controlled or disempowered. They feel like you're making them do something and that triggers trauma memories for them, that triggers that contr those control issues. In group, we need to make sure that people feel like they've got confidentiality. A strict adherence by everyone to confident confidentiality regulations builds trust. Leaders need to explain how information from sources may and may not be used in group. If you know something about what your group mate was doing outside of group, that may not be appropriate to bring into group. And likewise, definitely nothing that was shared in group leaves group. Violations of confidentiality should be managed in the same way as other boundary violations because it's a violation of safety. Professionals in the healthcare network need to be aware of the role of group therapy and how it integrates with the multidisciplinary team. We do not use groups enough and there are unfortunately too many examples of poorly run groups. So there is a lack of faith in the group process. Clinicians should coordinate the treatment plan, keeping important interpersonal issues alive in both settings. If one of the things that somebody's dealing with is developing self esteem, let's keep it alive in both settings. If they're working on assertiveness, you can do it individual, you can do it in group. Let's keep it alive in both settings. We also, as leaders, need to have a knowledge base of medication, be aware of the medication needs of clients, the types of medications prescribed, and side effects. Why? Well, if you've got somebody that suddenly starts becoming very hyperactive or, or is dozing off in group, it's important to not automatically assume, hey, they're intoxicated or withdrawing and maybe consider doc just increased their dose of Seroquel. So it's not a surprise that they're having a hard time staying awake. That can go a long way in the group if you've got somebody who's falling asleep talking with them about what's going on with their meds and and allowing them the opportunity, if they want to, to share with the group what's going on with them. Conflict in group is normal and it's necessary. If everybody gets along all the time, somebody is faking it, so it is normal, healthy and unavoidable. We need to help people in group learn how to handle anger. Anger is a response to a perception of a threat. Notice it, acknowledge it down, regulate, and address. We need to help them develop empathy for one another. A lot of people that I've worked with really have never experienced a lot of really genuine empathy from anybody else. They so they never learned how to give it to other people. They know how to sympathize and go, oh, that, that must really suck. Empathy is having an example of somebody stuck in a well and instead of looking down the well going, huh, sucks to be you. They actually strap on repelling gear and go down there and experience it to a certain degree the way that person's experiencing it walking a mile in their shoes. You're not just saying, oh, wow, that sounds really awful, but you're trying to understand what it feels like to be in their shoes. Managing emotions, super important. Distress, tolerance, super important, and how to disagree respectfully. That is, again, again, respecting those cognitive and emotional boundaries. When there's conflict, the leader calls attention to the subtle, unhelpful patterns, whether it is dismissive nonverbals or overt verbal communication. Conflicts that appear to scapegoat a group member may be misplaced anger that a member feels towards the leader. If they're feeling dissatisfied with group then or the way a group's being run, then they may pick on everybody that is seems to be keeping it from running the right way. When in reality their anger is about the fact that they don't feel like they're getting anything out of the group because they don't like how it's being handled. So sometimes they may be angry at you, but they're afraid to tell you, hey, this ain't working for me. Conflicts also can be a transference or countertransference issue. We need to recognize that a conflict is going on. Somebody feels unsafe in the present moment and help them recognize based on the facts in context. Is there an actual conflict going on right now? And if so, let's talk about it. Or is this a reaction to transference or countertransference? And again, let's talk about it. Subgroups are inevitably going to form. Subgroups can provoke anxiety, especially when a therapy group comprises individuals acquainted before becoming group members. This is really common in substance abuse when people may be coming from the same 12 step meetings, so they know each other from out there, from outside, and they come in and they've already got inside jokes and they've already got an element of rapport with one another. Then the, the new people may feel like they're being ostracized. Subgroups are not always negative though. We can recognize in, in outside life that there are always subgroups and, and that's okay. How do you deal with them? How do you mesh with them? Just because these three people knew each other from a 12 step meeting doesn't mean they're rejecting you. It just means they have history. Now you can build history together, helping people recognize that a subgroup's not necessarily exclusive in terms of disruptive behavior. For clients who can't stop talking, stop and summarize what's going on, call them aside outside a group and discuss it with them that how disruptive their side talking or talking over is and explore their motivations. I have had experiences, lots of them unfortunately, of people with undiagnosed ADHD or bipolar disorder who truly were trying to be respectful, but they were just having difficulty with that impulse control because they were in a hypomanic episode or something else. Sometimes people will talk and be disruptive when the group itself is triggering things in them and they're like, oh, this feels really awful. So I'm just going to check out and I'm going to talk to my friend over here. So being disruptive in group could be an indication that you're, you're striking a nerve. If we have people who interrupt a lot in group, I've had therapists use a talking stick. So the only one who's talking is the one who holds the talking stick. I don't like that approach, but some people do. Sometimes you'll have clients who just flee a session. It's important to be, be prepared for when this happens, not if it'll happen, but when it happens. If they get up and leave, how do you handle that? And ideally there's a co facilitator or some sort of backup plan. Sometimes clients are unable to Participate in ways consistent with the group agreements. Removing someone from group is serious. When the leader makes the decision to remove an individual from the group, members need to be allowed time to work through their response to that. Some will think it's totally unfair. Some will be relieved that that person's not there. Some people will think it's unfair and feel relieved all at the same time. I mean, there's a range of emotions and sometimes there's a grieving process. And it's going to be important to allow the group members to really explore how they feel and what this brings up for them. You know, what similar situations have they experienced in the past? If somebody is coming late or missing sessions, let's talk with them. What is that behavior saying? Maybe they ride the bus and they can't help it. Okay. Maybe they've got childcare issues. Okay. You know, we just need to not assume, but we need to also not let it go unaddressed. If they're silent or tuning out. I've already discussed some possible reasons for that, Bringing it up with them, talking with them about how that's protecting them in some way and how it may be preventing them from getting the most out of group, participating only around the issues of others. Oh, it is really easy to be everybody else's shrink and not look at your own self. And it's important to help people recognize that they've got a lot of valuable information, but they're also in there to get help for themselves. And it's important that they take some of that in and get some support for themselves if they have a fear of losing control. All right, let's talk about how to prevent that. If you have fragile clients with psychological emergencies, if you're doing a group in a crisis stabilization unit, it's going to be important to recognize what potential issues could happen and have a plan. And some people may have anxiety and become very resistant after self disclosure. They feel vulnerable, so they get stressed out and all of a sudden they start pushing everybody away. That's normal. And we want to recognize that as a response to feeling unsafe and vulnerable and respond with compassion. If we become impatient with clients, slow pace of dealing with changes, then they're going to feel like they're failing. They're going to feel like they're being rejected. And that is the antithesis of what we want in group. Every change, every move forward is a move forward, no matter how small. If people relapse or regress, that doesn't indicate a failure. It indicates we missed something. They weren't didn't have the skills and tools they needed to keep going forward, so they got pulled back in. If we have an inability to drop the mask of professionalism, it can come off as feeling very cold. We need to be human in group. If we have a failure to recognize transference and counter transference issues and blame clients for what's going on right now, that's also an issue. We need to make sure that we clarify group rules and conduct group effectively. This is not individual therapy with, with an audience. It's group therapy. And we need, if you're, especially if you're running an open group where people can join at any point. We need to integrate new members effectively into the group. Not just be like, hey, this is John, he's joining us today. And start group. You know, who is John? Let people introduce themselves for a second. In terms of staff development, group leaders need to know traditional theories and techniques like psychodynamic methods, cognitive behavioral models and systems theory. We need to have observation. We need to observe others doing group and have others observe us doing group. We need to study our own tapes just like we did for individual counseling. We need to have the benefit of experiential learning, participating in a training group or being a member of a personal therapy group. This is super helpful. We did this in my group therapy class when I was in college where we basically ran a group among ourselves and got used to what those different dynamics might feel like. And it's important that we have ongoing training with groups. Under the supervision of an experienced leader, we can evolve. Essential leader skills include group training, cultural competence, awareness of co occurring disorders and trauma and how those will impact group participation and group issues, knowledge and signs of intoxication and withdrawal. A supervisory alliance is required to teach skills needed to lead groups and ensure that the group accomplishes its purposes. In terms of assessing leader skills for clinical skills, we need to look and make sure that somebody is able to to select effective groups of people. Can they select a good group and put a good group together? Can they effectively design treatment strategies to meet the needs of that group? And can they effectively plan how to do the group and manage termination? Do they have a comprehensive knowledge of co occurring disorders? Do they have a knowledge of their preferred theoretical approach and a knowledge of the institution's preferred theoretical approach? Do they have the diagnostic skills for determining co occurring disorders and referring when necessary? Do they have the capacity for self reflection, recognizing their own vulnerability and ability to monitor their own reactions in group? Do they have the ability to consult with referring therapists Provide feedback and and coordinate both individual and group treatment. It's you're not out there on an island if somebody's also seeing an individual therapist. Make it work. If in residential, if they're seeing other group therapists, you need to collaborate, not just, you know, be out there in la la land. And they have to have the capacity to be supervised, including openness to supervision, setting goals for training and discussing one's learning style and preferences. Groups often form a replication of the members outside world. Members behaviors are based on doing what they know will help them stay safe or sometimes just get them the most reward. We need to recognize behaviors as communication and work with the client to understand what they're communicating and maybe help them communicate in a more appropriate way for group. And we need to work to create a group that's consistent, attentive, responsive, empathetic and safe. I got everything done within that hour. I'm pretty proud of myself. Thank you for being here today. Okay, for those of you who are still with me, and I even made it without coughing, what questions do you have? You're right, Nikki. Group members can come up with some awesome questions too. If you just put up their anger management or frustrations and say what do you want to talk about in relation to this today? People will have some ideas. Space ride and Mars. I guess you're one of the people that got smacked by that snowpocalypse like we did. I don't think in the 15 years we've lived here we have ever gotten 8 1/2 inches of snow, but we are literally knee deep in it right now. Okay, I'm not seeing any particular questions about group therapy, so I am going to. Oh, Nikki comes up with, is there an ideal therapeutic group size depends on the type of group you're doing. If you're doing a processing group, then typically the recommendation is 8 to 12. If you are doing a psycho educational group, you can go as high as 15. But most insurance, including Medicaid and Medicare, set limits on the number of people that can be in your group. And generally the limit is 15 for a psycho educational group. So that's a great question. Alrighty everybody, have a wonderful day and I will see you at the next counselor education webinar.