 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. So I'd like to welcome everybody to today's presentation on group therapy. This is a continuation of the series of group therapy based on treatment improvement protocol 41 from SAMHSA. If you're interested in group therapy, if you like doing group therapy, it's a great introductory tip. There's a lot of stuff they don't cover in it, but there's a lot of stuff that they do. And this is going over chapters six and seven of that treatment improvement protocol, covering leadership skills and common errors. So over the course of today's presentation, we're going to discuss the characteristics of group leaders and describe concepts and techniques for conducting substance abuse and mental health treatment group therapy. So one of the things that I kind of like about being a group leader is that you have a lot of ability, if you will, to choose how much leadership to exercise and how much not. I tend to liken it to being a parent and having eight or 10 kids. And if you're still saying after that, you want to let the kids learn to work it out at a certain point. There are going to be times where you feel you need to step in. There are going to be times when you need to set structure. So think of it as creating sort of a family. And I don't want to say a mini-family because sometimes our groups are 12, 15 people. But it's a family sort of situation or a community. So you have the ability to choose how much leadership to exercise and you don't have to maintain that same level of control, if you will, the whole time. One of the things that you'll find in, if you remember back to counseling graduate school when you took group therapy, there's the forming, storming, and norming. So in the forming phase, people are kind of trying to figure out where everything is. The storming phase, people are pushing limits. Like when you have a new teacher or a substitute teacher, you're pushing boundaries to see what you can get away with. And norming is when everything kind of levels out. And people figure out what's expected, what they can do, what they can't do. So as you go through those phases, you're going to exercise different amounts of leadership. Hopefully starting with more leadership and gradually being able to kind of turn the reins over to the group itself. Just like you hope you're able to do with your family, with your kids, with your classroom, or with your subordinates, if you're a supervisor. One of the things my supervisor always told me when managing people, he said, you want to start out tough. It's much easier to loosen your control than to try to take control back if you never had it in the first place. And that's really true. And in order to create a situation where people understand what the boundaries are, you're consistent in the boundaries, and you have enough structure, it's usually better to start out a little bit more controlled and structured and gradually loosen up. You can choose when to intervene. Now, I've worked as a co-facilitator with a lot of different clinicians. Some people intervene almost immediately because they don't want to see emotional upset distress. They want to keep it on a skills academic level. And if you're doing a psycho-ed group or a skills group, sure, that's totally justifiable and reasonable. On the other hand, especially if you're getting into the skills group a little bit, people are practicing, you may not intervene right away because you want to see if they can work it out and apply their skills and actually benefit from what they're learning in groups. So you have a lot of leeway in terms of when to intervene, and it's based on your clinical judgment, what is best for the group, what is best for the individual. You will know your group, so you'll be able to affect a successful intervention, whereas somebody who's coming in, who's never worked with that group before, they don't know the hot buttons and the group doesn't trust them. I remember there were a couple of times where I had to step in and facilitate a group because we had a group member leave group in crisis. The group facilitator went out with them and I would come in and take over. And we'll talk about drop back and punts later. But going into that group, they knew me as the director, but as far as my clinical style, as far as me knowing what their individual issues were, we were complete strangers. So figuring out how to approach that group at that particular point in time and de-escalate was a little bit more challenging. And obviously I went in taking over as a new facilitator, if you will, because I hadn't worked with that group before, went in with more control. And I said, all right, this is what's going to happen. You know, we're going to process what just happened, but here's how it's going to be. So they knew what to expect from me and they weren't kind of guessing. You want to be able to manage the group's collective anxiety. They're looking to you for structure. They're looking to you for leadership. And basically, if you think back to Erickson's stages, you know, think about child development, they're trying to develop these new skills, become independent with these new skills, but they want to be able to come back to a safe place, which is the group, which is the group leader. So it's up to us to be able to figure out, in order to manage the group's anxiety, how much can we let this one person escalate in order to help him or her work through this particular issue? And if the group itself has a high level of anxiety, how do we handle it? And at what point do we need to intervene versus encouraging them to figure out which skills? It's a whole lot more effective for people to learn skills and learn to apply skills when they're under a little bit of stress. Not that I'm saying we want to freak our clients out because that's not what I'm saying, but I want to know that when they're out there in the real world, not in the comfort of the therapeutic environment and they're under stress, when they're feeling distressed, they can actually access those skills and apply them effectively. So I don't want to necessarily jump in right away to intervene and diffuse the group's anxiety. I want to see how they kind of work together. And then I'll figure out based on the development of the group and the presenting issues and all that other stuff, when to intervene and how to resolve other issues that may come up, relationship issues, dynamics, transference, counter transference stuff we'll get to in a minute. So personal qualities of group leaders. If you are a clinical supervisor, you will notice, and even being a clinician, you will notice that a lot of these are reflective. I mean, we're not really presenting all that much difference in terms of what kind of qualities make us effective in these situations. Constancy, being dependable, being predictable is important for our group. It's important for an individual client if you're doing one on one. But if you're working with a whole group of people, it's even more important to be present and to be predictable in what you say, what you do, how you're going to react. Active listening, oh, that's a no-brainer. And a firm identity, knowing who you are and knowing what skills you use, what interventions you use, what you believe in. It doesn't necessarily mean that they have to believe in the same thing that you do, but being able to model your identity and how you set your boundaries and you can accept people with differing opinions and how you create, run your group and how you're willing to hear other people's, how other people run group, but this is kind of your group. So this is your identity as a group leader as well. This is something that people come to expect. When I worked at my long-time job where I was for 14 years, when I would walk in to do a group, people knew what to expect. It wasn't a surprise. I didn't vacillate. I was not very different between groups. They knew how I ran group and it gave them a sense of stability and comfort. Now, they may not have loved the way I did it, but they knew what to expect, which gave them confidence that, A, I kind of had a clue what I was doing, but it also gave them confidence that they knew how to act and react and participate in a way that was going to be productive. Now, I say all of that talking about stability and constancy and yada, yada. And then I come to spontaneity. Well, you know, every once in a while, the group or life is going to throw you a curveball. So how do you deal with it? I remember there was one group I was in and it was, it was a psycho-ed group, thankfully. I wouldn't have wanted to be in a therapy group for it, but we had a fire alarm and so everybody had to evacuate. We're like right in the middle of group and there's a fire alarm, um, which through the whole group off kilter, but being able to gather them up outside and, you know, we made the best of the situation as it was and use the skills that we were working on in group to apply to that situation and dealing with the frustration of getting interrupted and having to be out in the Florida heat in August. So being able to kind of drop back and punt sometimes if something unexpected happens, staying within the boundaries, if you will, of what's expected, which is kind of behaving with integrity, being true to yourself and your clients. It'll help them develop a sense of trust in you. So they're not always, you know, wondering if I say this, is it going to keep me from graduating on time? And when I do things, what is the repercussion going to be? If I'm honest about something, um, so they want to be able to trust that the group leader is going to be there is going to be compassionate is going to be predictable, all that stuff. Everything you would expect and want out of a friend, out of a clinician, out of a supervisor, you know, things that you want in a relationship with anyone. And humor, you know, sometimes you just got to laugh at yourself. Uh, and I did that frequently when I used to teach at UF, thankfully, in the, in the clinic that I worked in, we had dry erase boards, but when I taught at UF, we still had the old fashioned, um, chalkboards and my family could always tell when I would come home if I had been teaching that day, because I would have a chalk handprint on my butt every single day because I would, you know, clean the blackboard off and then I'd wipe my hands on my pants. And I never realized this. And then they finally pointed it out to me and I became much more aware of it after that. And sometimes I'd forget and I'd have a handprint and somebody pointed out and I'd be like, yep, guess I was teaching today. You know, it's all about being able to laugh at yourself, um, and laugh with the clients, being able to show some humor, sometimes starting a group, if it seems particularly tense that day, sometimes starting a group with some humor before you actually launch into your typical routine can help kind of break the ice if people seem to feel a little bit, um, agitated and empathy. You know, again, goes kind of without saying because empathy communicates that respect and acceptance. We want to be empathetic, not only to the individual, but to the group as a whole. You want to think kind of of the group as a unique entity and how they are feeling as a whole, but then you also want to look at each individual. So you're a little bit busy. We want to be encouraging and knowledgeable and complimentary. So again, making sure, like I said last time, making sure that clients don't feel like they're just a number or a butt in a seat. Being very, um, true to, um, yourself, being very true to the group process is going to be really important and doing a lot of listening. It is possible to have structure and be constant and firm identity and all of this other stuff we've talked about without really saying a lot. Um, when I would do group, I would start out asking a question and then going around the room, letting people talk, and then I would tie it together, find common threads. So do a summary statement. Then I would give like a 10 to 15 minute psycho educational or skills kind of presentation and an activity we would do on the board. And then we would again, go around and have people apply it and talk about how it could be effective in their recovery. I wanted to hear more about how they were using it. I wanted to hear their questions. I wanted to hear them try to explain it to me more than I wanted to talk because they can only take in any of us really can only take in chunks of information at a time. Um, so it's helpful to listen and also try to elicit from them the answers that you're looking for instead of telling them. Cause if think about having kids, if your child comes up to you and says, what's 63 plus 24 and you automatically give them the answer, they're not going to learn how to add. If they say, what's 63 plus 24 and you go, well, let's figure out how to work that out. And what would you do first? You know, walk them through writing it down on paper, um, and adding it. There's no carrying any of the one of those. So it's a pretty simple addition problem. But walking them through it, instead of giving them the answer, ingrains it, it helps form those neural pathways. So they are more effective with the information that they're getting. We do want to be able to gently persuade clients to be open to the stuff we're providing. Now, some of it is not going to work for them. And I'm not saying persuade them that you are right. I'm more encouraging you in group to persuade them to be open to possibilities, figure out what works for them, keep what's useful, leave the rest. And in that, we can provide support. And that's another thing that I really like about groups, because you have the ability for people to go, that works for me and other people to go, really that I've tried that before and it didn't do diddly squat. And that's okay. And both people can be validated because they're unique individuals with their own experiences, which teaches everyone else in the room that you know, we're all unique individuals and not everything's going to work for everyone. So let me try, let me be open to new experiences. In individual counseling, it's a little bit harder because, you know, as a therapist, I may say, why don't you try this? And they may try it and they think I want them to say, yeah, it worked great. And that's not necessarily what I want to hear. And I always try to couch that when they come back in an individual with, tell me how it went, you know, again, if it didn't seem to fit, if it felt weird, let's talk about it, it may not be a good fit. But the nice thing with group is you've got everybody supporting each other, giving alternating or alternate opinions. Okay, where did my mouse go? Leaders have varying therapeutic styles to meet the needs of clients. I can be loud. There's just not a nice way to say it. I can get really excited and be very demonstrative in group and be kind of high strung, if you will. But that's not appropriate for all groups and even the same self-esteem group, I may have different clients in those groups that have differing needs, so I may need to tone it down in some groups. I may need to use altering or alternate therapeutic styles. So one may be heavy on cognitive behavioral, while another is much more focused on rogerian, client-centered, something that's, you know, less confrontational, less confrontive, if you will. With that, we want to model behavior, whatever we're doing in that group. If I'm modeling CBT or teaching CBT, then I want to model that. But I also want to model how you're supposed to interact in an ideal world, in a microcosm with other people. So I want to be accepting. I want to be validating to other people. I want to show how it's okay to have differing opinions and to agree to disagree, if you will. I avoid that phrase most of the time because it makes some people kind of get the heebie-jeebies because they've heard that before in a passive aggressive manner. So I tend to avoid that phrase myself. But, you know, it may work for you. What we want to do is show clients how do we set boundaries? How are we authentic with ourselves? How can they be authentic in group and with one another and be okay with it, even if not everybody likes their opinion? We need to be sensitive to ethical issues. So if there is an overriding a group agreement that something needs to change, let's talk about it. In what way is this beneficial to the group? In what way is making this change beneficial? In what way is not making the change potentially harmful? We want to look at, you know, above all, do no harm, be, you know, be faithful to your clients and all those other ethical principles. What are we doing that's in the best interest of our clients? We want to make sure to inform them of options when we're in group, if they're feeling like they need to take a time out, if they're feeling like they don't want to speak, if they're, again, going back to those basic ethical principles, fidelity, non-malphysense, beneficence, well, those are the big ones for me. Being true to what we got into this profession for, making sure clients know that they have options for how to stay safe in group. If we tell them, you know, you really aren't supposed to leave group in the middle. You can't just get up and bolt. Well, what are your options? If you start to get upset, how do we handle this? We do want to prevent enmeshment. So making sure people learn how to set appropriate boundaries, encouraging them to articulate their points of view and be open, not getting their feelings completely smushed if somebody disagrees with them and not feeling controlled by one another. And we want to make sure that we are acting in each client's best interest. Remember, I said we've got the group as a whole. We want to make sure that functions well. But within that whole, there are individual parts. Just kind of think of a machine and we want to make sure every single part is functioning effectively. Because if one starts to go a little wonky, then the whole system could potentially break down. So we want to make sure if there are particular issues that are present, post-traumatic stress, something like that. And that issue comes up. How are we going to handle that? It's not uncommon to be in a group teaching something benign like self-esteem and a topic such as prior sexual assault come up because a lot of people, if they've been sexually assaulted, it takes an effect, has an effect on their self-esteem because they feel broken. They feel damaged. They feel, you know, feel in the blank. So, you know, it can come up that way. So how do we act in that client's best interest? If we have one client in there who has been a, who is a survivor of sexual assault, if that topic comes up, what do we need to do to make sure that that client feels safe and doesn't feel attacked or whatever. And we can still attend to that particular issue. Leaders improve motivation when members are engaged at the appropriate stage of change. So if clients are in pre-contemplation, for example, they are not wanting to be there. My, my first job working with involuntary clients, my clients didn't want to be there. So 80 percent of my job was to increase their motivation to be there. They didn't think they had a problem or if they did, they weren't willing to admit it. Beating them over the head with it and going, you have an addiction, you need to learn about this was going to get nowhere and they weren't going to hear me. They weren't going to be engaged, probably weren't going to show up. So some of the things that I did to help engage them was create agreements, if you will. They had to complete treatment. They had to do what they wanted to, what they needed to do to get off papers. So it's important to remember that not everybody is in the same stage of change. So things that you can do at pre-contemplation, for example, is find mutually agreeable goals. I needed them to stay clean. They needed to stay clean to get off papers because they wanted to get off papers. So ultimately, we both needed them to stay clean at least for 12 weeks. So we would start talking about that. This is one of the things. I needed them to stay clean and come to group in order to get off papers. They had to come to group. Okay. Well, you can either come to group and sit through it and hate me or we can talk about what is it since. And, you know, I was pretty frank with them. I'm like, the state is paying for you to have therapy for 12 weeks. So what is it that you want to work on to improve in your life while you're having state-funded counseling? And they would generally identify something sort of benign like blood pressure or stop smoking or something. But that was okay. That gave me something to work with. So engage them by helping develop mutually agreeable goals. Encourage members to support each other's change efforts. So, you know, with my first groups, like I said, I don't think I ever had a single person in there who thought they had an addiction during that group period. And, you know, that was okay. But I did want them to stay clean for the 12 weeks and encourage each other to figure out how to stay clean and sober and get to group for the 12 weeks. So those were the things that we focused on, not as much of self-identification with an addiction. If people are in anxiety or depression, mental health type recovery groups, they're not going to change everything overnight. So encourage each encourage each group member to listen for positive changes from other group members and provide feedback and support on that. Reinforce the positive. And as leaders, we want to model that too, not always picking up on the, well, you know, what could you have done differently? I want to be able to say, wow, that was awesome. You did look what you did two weeks ago versus what you did yesterday. What awesome progress is that and reinforce what they're doing and encourage group members to focus on positive steps forward. We can explore choices and consequences with members. I like doing this in terms of putting a whiteboard up and writing up there. What was your choice? What was the situation? What was your choice? And what were your potential consequences if you chose A versus B? You can do a decisional balance chart that gets a little bit cumbersome. Generally, if you have two or three choices and you put them all up on the board and you write down the potential consequences of each and then talk about why you chose or why the person chose one over the others. It gives people a chance to start articulating their thoughts. But when you've got 15 people suggesting consequences, it often opens up some of those blind spots that one person would have. One person may come up with five consequences for their choice. 15 people may come up with 15 consequences for the choice. So you've got a whole a much broader range, wider range and greater depth of answers to give the person something to think about. Throughout all this, we do want to communicate care and concern because we don't want to be calling somebody out. People won't share. They won't become vulnerable if they feel like they're attacked and called out every time. So it's important that we couch this in care and concern, again, validating the positive and pointing out each person's competencies and how much better they're doing, what steps they're making, even if they're small steps. Hey, I'm actually super thrilled with small steps because those are often some of the most constant, sustainable changes people make. People can make huge changes. Think about if you decided one day that you were going to go on a diet and you were going to start eating healthy. And I've had a lot of friends that have gone on Atkins or Paleo or one of those others or it's a huge dietary change and they maintain it for a little while. But then they quickly fall back into their old habits where if they start making small changes over time and building on those small changes, those small changes tend to last a lot longer, such as starting to drink more water and then starting to cut down on processed carbs and gradually working up to where they want to go. Maybe they do want to get to Paleo eating or Atkins or whatever it is. But if they do it gradually, it tends to stick and be more become more of a lifestyle than a change that doesn't stay and positive changes are noted in and encouraged by the group. So always reinforcing we want to work with not against resistance. So if somebody says, I can't, I won't or yes, but those are my three favorites. OK, what are you going to do instead? Or and that's obviously what I come back with. I can't go to meetings or I can't get a job. All right. I'm not going to tell you, you can't. I want to hear what why you can't help me understand because then I can help you figure out how to come work around those barriers. And we can talk about, you know, the differences in transportation issues, childcare issues versus fear issues. And all of those can potentially come out. I'm not going to argue with them. If they tell me they can't, you know, I may roll with the resistance, but I want to understand their point of view because resistance is telling me that I don't understand. If they're not willing to hear, if they're not willing to act, if they're not willing to do, then clearly I'm missing something because the current behavior is far more rewarding than whatever I'm suggesting. So I want to work with it. I want to hear it. I want to understand what are the challenges if they say I won't. That means I choose not to. OK, why not? Or, you know, sometimes it's obvious why they don't want to and you can go on to what are you going to do instead? One of my tag lines, if you will, is always OK, that's that's fine. If you won't do that, I'm not going to argue with you, but I want to know what you're going to do instead. If you're not going to go to 12 step meetings, if you're not going to take medication, if you're not going to fill in the blank, whatever it is that your clients need to do, that this issue or this intervention has been prescribed, if you will, for your current presenting issues, depression, anxiety, addiction, yada, yada. For this particular reason, how are you going to address that reason if you're not going to do this? And they may have a very well thought out alternative. Great, that's awesome. You know, let's try that if you think that's going to work for you because they're motivated to try that and let's support them in using their strengths and going with something they're motivated on. On the other hand, if they don't have a plan, they're like, I won't do that. I don't know what I'm going to do, but I won't do that. That's the beauty of groups because then we can throw it out to the group. What are some alternatives besides, you know, taking antidepressant medication? If Sally doesn't want to do that, have any of you chosen, had made a similar choice. We're not doctors. We're just presenting our experiences and hearing. The concerns that this person has about this intervention and trying to help him or her come to some sort of decision or plan about what they're going to do instead. It's our job as leaders. And I think this is one of our main jobs as group leaders to protect against boundary violations, protect against the bullies in group, protect the clients who have weak or no boundaries, which goes back to that whole investment thing, to make sure that everybody feels like their opinion and their points of view are valid and important because they are. Help people realize that it's OK to have differences of opinion. But this is goes beyond verbal boundaries. It goes beyond emotional boundaries to also physical boundaries. And I shared with you in the last presentation, I think that when I first started working in substance abuse treatment, that's a real touchy feely group. They do a lot of handholding when they say the Lord's Prayer at the end, lots of hugging, which I'm not used to. Not what I grew up with in my family, not definitely not what I was taught in graduate school. So it took me a little while to kind of understand where this was coming from. But it gave me a lot of empathy for clients who weren't comfortable with that. So it's important to be able to help clients who don't feel comfortable with other people touching them or holding hands or saying the Lord's Prayer or whatever it is. To know how they can safely confidently and respectfully assert their own boundaries. And as leaders, hopefully we get to a point in the group where we don't have to step in and stand up for that person. The group is respectful of that person's boundaries and preferences. We maintain a safe therapeutic setting, making sure to pay attention to the emotional aspects of safety. We want to make sure that people aren't using more than once. I've done a group where somebody has come in and then smelled like a brewery. I mean, there's just no other way to say it. They weren't necessarily presenting or acting drunk, but they smelled like alcohol. So creating an environment of safety where they're not triggering other people in the group. If someone is in a group for people who self-injure or who are clinically depressed, there may be other triggering cues that you need to watch out for. So being aware of those. And we already talked about physical contact. We have the ability to help clients learn how to de-escalate. We can help the group de-escalate. And a lot of our clients, if you want to go back to dialectical behavior therapy 101, a lot of our clients have emotional dysregulation issues. So we want to be able to help the group as well as each individual learn how to tolerate the distress, ride that wave and cool down. On top of that, we need to encourage people to communicate. If we're going to have an open and effective group, people need to feel free to share their opinions, their issues, their comments in a respectful sort of way. So we want to encourage open communication as much as possible. We want to help people connect with others that have similar issues and have had similar experiences, help them discover connections between their substance use or their depression or anxiety and their current thoughts and feelings. I mean, somebody who's depressed probably has thoughts that are more depressive and probably feels increasingly depressed. And what do they notice? Do they notice that it's a beautiful sunny day outside? Or do they notice that it's a sunny day and gee, I still feel like crap. There's a difference there. So we want to help them notice the difference and the interaction between their thoughts, feelings and behaviors. We want to help them learn how to regulate feelings and deal with interpersonal distress. We want to help them build coping skills in group because sometimes stuff's going to happen. Sometimes it's distress tolerance. Sometimes it's learning to be patient. There's a variety of very seemingly basic skills that we end up communicating in group. We want to help them understand the effect of their substance abuse or mental health issues on their life. You know, if you're depressed and you're having difficulty getting out of bed, what are the effects on the rest of your life? We know it sucks inside your own head right now. How is it affecting your family? How is it affecting your work product? How is it affecting your health? So they start to understand which increases motivation for change. We can also point out inconsistencies among thoughts, feelings and behaviors. I prefer to try to focus on positive inconsistencies. So if they they're telling you they're still feeling awful all the time, then if I have an example of how there was an exception there, or if I don't, I'll ask for have there been any exceptions, any glimmers throughout the week to point out some of their all or nothing thinking. We do want to avoid a leader centered group. So we want to build skills and our members and avoid doing things for them that they can do for themselves. If there's a conflict, you know, initially we're probably going to intervene a lot more than later. We want to encourage them to practice those skills, just like a parent at home. I've got two teenagers and when they were younger, you know, I would intervene and, you know, help them figure out empathy. And, you know, how do you think Haley felt when you did that? And yada yada. But as you get through the group, as the group develops their coping skills and their communication skills and ability to set boundaries, hopefully it's not necessary to intervene as quickly. So we want to encourage them to try to work it out for themselves. And we may need to, you know, call a timeout and ask them to take a pause and think about what what is the next best step in this situation to get them to get out of that emotional mind and into their into their wise mind. But, you know, it's still, we're still not telling them what to do. We're asking them to take a timeout and think about what they think they should do. And we want to refrain from over-responsibility for clients. So, client's struggling. It's not up to us to fix it. Untrue in individual and group. We want to encourage them to struggle with it a little bit and figure out what they need, figure out if they need to ask for help or if they've got it on their own. And, you know, sometimes it's appropriate to step in. But making sure that we're not taking away their power by doing too much for them. Confrontation can have an adverse effect on the therapeutic alliance and process. So, we want to be careful about how much we call people out. Now, our clients may call us out too. So, we do want to be aware of that and how we respond to confrontation if a client calls us out on something that they don't like. Maybe they don't like the way you're running group that day or they don't like a administrative decision that you made. But confrontation can also be used to point out inconsistencies such as disconnects between behaviors and stated goals. So, if the goal for the group is to become, to deal with anxiety and develop more effective communication skills, but they're not effectively communicating, this might be a point for confrontation for the group where we can bring it up and say, you know, I notice that these are your stated goals, yet when you communicate with one another, this is what I'm seeing and this is what I'm hearing. Being objective, just like we would encourage them to be of one another. Objective about what you're seeing that is not effective at helping them achieve their goals. Confrontation in this way, when it's done gently, objectively, appropriately, can help clients see and accept reality so they can change accordingly. If they realize that, yeah, you know what, I have been harboring resentments and not stating my opinions and then getting angry at others because they don't read my mind. Well, if we kind of gently start pointing that out, then they can start seeing and making changes. Transference is when a client projects parts of important past relationships into present relationships, not just client counselor, but onto the group. So we want to be aware of transference, counter transference. The other person projects an emotional response to the group members transference. This happens a lot in groups. You've got people that remind you of family members of people from your past. If you had, for an example, a sullen, abusive, verbally abusive person in your family of origin and somebody in the group is sullen and somewhat antagonistic, maybe not verbally abusive, that might provoke a transference reaction from another client. All right. Now, so Sally starts getting anxious and nervous and somewhat defensive every time Tom talks because she's having that transference reaction on Tom, then Jane over here sees her family of origin. She sees mom and dad and she starts having a counter transference reaction to what's going on between the first two. So just being aware of is this person reacting fully reacting to what's going on in the group or is this brought on more likely from stuff in the past. And this is a repeat manifestation. So you're getting into some interpersonal process stuff, but it's important to be aware of it. Resistance arises to protect the client from the pain of change and also to identify that whatever I was doing is more effective than what you're suggesting. So as clinicians, we need to figure out how to switch the balance on that scale. So we need to understand what is rewarding about being depressed. And a lot of people scratch their heads and they're like, well, there's nothing rewarding about being depressed. It sucks. Not so much. I mean, there's a lot of it that really stinks. But change is scary as heck. And it takes a lot of energy that the person with depression may think I ain't got that kind of energy. I just can't do it. And it also sets them up for the potential of a fall. So if they start feeling better, what happens if they relapse and how horrible is that going to be? That's terrifying. So understanding the negative or the drawbacks to recovery is just as important to understanding the benefits of benefits of change. So thinking about it from their perspective and groups again can kind of start brainstorming and spit balling, if you will. Why are some what are some reasons somebody might not want to get happy, might not want to be undepressed? You know, maybe every time in their life they've started to get happy, the other shoe is dropped. So they don't want to experience that again, they prefer just to stay down here. So they're never let down. They're never disappointed. Okay, that's something we can talk about. But we need to understand why the person isn't motivated to work forward to walk forward before we can provide effective interventions. Confidentiality in groups is huge. We can't hold them to HIPAA guidelines because they're other clients. But it's important for clients to realize that if you don't maintain one another's confidentiality, then nobody's going to trust anybody and we're not going to get anything done. Trust built over time. So it's a matter of letting clients learn to develop trust in one another. And if somebody violates confidentiality, we do need to make sure to address it individually with that person, but also in group reiterate confidentiality guidelines, why it's important to maintain confidentiality and the purpose of confidentiality. Everybody on the healthcare team needs to be aware of the role of group therapy and how it in integrates in the team. What's the benefit to this? It's cost effective, but it also gives a greater breadth and depth of experience for people working on developing new skills. So we need to be cognizant and coordinate treatment plans. If you're doing group therapy and a person has a individual therapist, not unheard of, not unusual at all, but it's important to be kept in the loop. What goes on in group, we need to share with the individual therapist with respect to that person. And if somebody's going through something huge in individual therapy or is developing a new skill, the group therapist needs to know about that in order to integrate it and be sensitive to it. I've had more than one occasion where a client's been working on intense trauma issues in individual. And it was important for me to know that to understand why that person was behaving differently in group being more withdrawn, solemn, tearful, et cetera. We also need to have a medication knowledge base. So we understand the side effects what clients are on, how it might affect them. If they start taking Sarah Quill, for example, that they might be more sleepy and nonattentive in group. It's important that we know what medications our clients are on, even if they just start taking like cold medicine because they're not feeling well. Just give me a heads up. Let me know that you're on that. So if your behavior seems a little bit different, I get it. Conflict is normal, healthy and unavoidable in groups. So it's important for us as clinicians to just sit in our chair and brace for it. We know it's going to happen. We need to know ahead of time, though, how do we handle anger? How do we help clients who are angry, develop empathy, manage emotions and disagree respectfully? And, you know, obviously the first thing is to teach them how to practice the pause, take a breath, take a break, get out of their emotional mind. So then they can have a rational discussion about what's going on. But you need to know this ahead of time with my groups, especially therapy groups. This is something we start out with when we start the group, you know, session one. If you get angry, if you get upset, let's talk about what steps you need to take or what it's going to look like so you can, you know, effectively handle that. And we'll just role play a few situations. So people get kind of a preview of what they need to do when they get upset, not if because there are going to be buttons that we're going to push. We want to subtly call attention to unhelpful patterns, again, not calling people out. But maybe if we see a trend in our group that people are starting to become less attentive or talk in group or write notes or that aren't you know, taking notes, we might bring that out in group, you know, I noticed that people seem to be coming more and more disengaged. Let's talk about what's going on with that and what we need to do to get back on track. Conflicts appear to be that appear to be scapegoat, using a group member, maybe misplaced anger that the group that the group feels towards the group leader. So somebody may start calling another client, you know, teacher's pet, which indicates that they may be angry or feeling that the group leader is displaying favoritism. Sometimes if the group is acting out, you can't put it back on them. It is you. And too often we want to say, all right, you know, the people in the group are struggling. So it must be something with them. Sometimes it's you. So being willing to step back, either during group, sometimes you have to do it right then. But definitely after each group, just spend a moment to three minutes and thoughtful reflection of how the group went, making sure that you're being authentic, you're being true to the group and you're doing things that are everything's in their best interest. Because anger tends to indicate somebody feels disempowered. So, you know, I would always think to myself, was there anything that I did that might have made someone feel disempowered, anxious, self conscious, you know, I tried to avoid that at all costs. But, you know, if I said something that I think struck a nerve with someone, I might go to them individually and pull them aside and go, you know, let's talk about this. But being aware that conflicts and disagreements that clients have with you as the group leader, the person in power, you may not be a safe target to get angry at. So they may redirect or misdirect their anger at someone who is a safer target. Subgroups are going to inevitably form. So just kind of be prepared for them. They can provoke anxiety, especially when a therapy group comprises individuals acquainted before becoming group members. This is especially true in substance abuse groups. If you've got people who knew each other from 12 step meetings, then they can kind of click together. And other people may have difficulty penetrating that click. Just because people are in sub groups isn't always negative. So you can use that and use the 12 step group to share their experiences and their points of view. And you may have this other group over here that's anti 12 step. All right. So let's have a healthy discussion and let's share and appreciate both people's points of view. If the clients are disruptive, though, one of the things that you can do if you have a client who's constantly interrupting or somebody starts talking and talking and talking, just say, okay, you know, let me stop you right there and make sure that I understand where what you're telling me. So you can stop them, paraphrase what's going on, summarize what's going on to try to, you know, wrap it up in a bow for the group. And then what I usually do is I'll paraphrase, find something to ask the group about what's going on, and then throw it back to the group or a particular other group member. And I might say, Sally, what what is your take on what you hear John saying? Have you experienced something similar? So I'm taking the floor, if you will, away from John and letting Sally have it for a minute. So John can hear and I'm balancing out that that time a little bit. If they're still being disruptive, when you have a break, sometimes you need to take a break right then, pull the client aside, discuss it outside of group and explore the motivations. Why do they feel they need to dominate in group or be disruptive in group? What's the benefit to them? And how can we help them be more comfortable and follow the rules a little bit more? If you have clients who interrupt, you can use a talking stick or whatever you want to use, whoever has the talking stick has the floor. If you've got a client that likes to go on, that doesn't always work because they're going to hold on to that. And clients who flee a session, really important to have a backup plan if somebody flees because they get upset. Does the primary therapist go after them? Who takes over the group? You can't just abandon the group because they're going to be in their own set of crisis. So make sure you have a plan. If you've got a co-facilitator, know which one of you is going to go and which one of you is going to stay. Sometimes clients are unable to participate in ways that are consistent with the group agreement. If you have to remove someone or if they discharge AMA, it's important to process that with the group because it's going to be a group loss. It's going to affect the group dynamics. So we want to let people work through, say what they've got to say about their experiences with that client or with that client's behavior. If people are coming late or missing sessions, it's important to address that because that's disruptive and disrespectful, not only to the group, but also to themselves. They're not talking at all. It could be a social anxiety issue. We can talk about that. If they're just being passive or passive aggressive, we want to deal with that. If they participate only around the issues of others, they never share anything of their own. Other people may start to feel uncomfortable or feel like that person is trying to be better than them. So it's important to encourage mutual sharing, equal amounts of sharing. If they're always sharing about somebody else or providing experiences, you might occasionally call on that person and ask them what their experience is or what's one challenge you faced this week. So it doesn't seem like they are always the know it all. Some clients fear losing control. So we want to be able to make sure that they feel like they're safe. And they have a backup plan if they start to get upset. So they know when group starts that, okay, it could get intense. But if that happens, I know what to do. And the same thing is true if clients have anxiety and resistance after self disclosure, they kind of regret putting it out there. Normalizing that, being compassionate, being empathetic to the client and encouraging the group to be supportive of, you know, Jane, that took a whole lot of courage to share with us. So the person doesn't feel like they just exposed themselves and people are staring at them. We don't want to be impatient with clients if they're slow in dealing with changes, everybody has their own pace. So let clients move at their own pace. If they seem to stall out, then you might want to talk with them before or after group or work with their individual therapist. Be sure to recognize counter transference issues and make sure group rules are clear. It's important, especially in therapy groups, I've seen too often where therapists will conduct individual therapy in a group setting. So it's just the therapist and John talking for 80% of the group. That's not group counseling. That's individual counseling in a group setting. So make sure to involve the group. Make sure that they have input, they have say, they have equal time, and it doesn't revolve just around one particular person. If that person brings an issue that they are distraught about, it's possible to ask other people if they've experienced similar things so they can share support and provide empathy for that client. It's important for us as staff members to know where we're coming from, but be familiar with different techniques that we can use in group. And that's great for continuing ed. It's awesome if you can sit in on groups, study tapes of other people's groups or your own tapes, and watch groups. Again, if you can watch somebody else's tapes in addition to your own, to see dynamics, to pick up on things, to hone in your skills, to learn different techniques. You can participate in a training group or be a member of a personal therapy group to get an experience from kind of the other side of the chair. And it's important not only for individual counseling, but for group therapy or group therapists to get ongoing training and supervision on group therapy, not just how to handle John Smith's problem. In supervision, it's essential that we make sure that our group leaders have training in group counseling, understand the stages. They're culturally competent. They're aware of co-occurring disorders, mental health, substance abuse, and their knowledge of signs of intoxication and withdrawal. Even if you're not doing a substance abuse group, you need to be aware of those signs so you can address any issues as they might arise. A supervisory alliance is required to teach skills needed to lead groups and ensure that the group accomplishes its purposes. So in order to assess leader skills, we want to make sure that the clinician knows how to select prospective group members, design treatment strategies, and plan and manage termination of the individual client as well as the group. Because sometimes individuals will terminate sooner than the entire group ends. They need knowledge of co-occurring disorders, knowledge of their preferred theoretical approach, and the institutions prefer theoretical approach. Diagnostic skills for determining co-occurring disorders are important because if one starts to develop while the client's in-group, you need to be able to refer out or handle appropriately. Leaders need the capacity for self-reflection to be aware of your own vulnerabilities to things that are going on, any trigger points you have, and monitor your own reactions to things. Leaders also need consultation skills so they can consult with the referring therapist, provide the feedback, coordinate with other members of the multidisciplinary team, and we need the ability to be supervised, including openness to corrective feedback and to supervision. Ultimately, in group, we want to make sure that clients feel safe, and we are doing our best to enhance their ability to effectively communicate, set boundaries, and get their needs met. Are there any questions? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com, providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists, and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.