Limited Group Therapy One truth we have found in leading groups with involuntary members is that it is quite unpredictable what will engage them and get their interest flowing. Previous researchers have discussed the problem of assuming that groups can be readily facilitated by clinicians without specific training in group therapy (American Group Psychotherapy Association, 2007; Center for Substance Abuse Treatment, 2005; Sobell & Sobell, 2011; Yalom & Leszcz, 2005). In a recent survey of group therapy SUD specialty clinicians in the United States, 69% reported that all of their facilitated groups were open-enrolling groups, with only 10% reporting that none of their groups were open (Author, 2017). Encourage the client to self-evaluate. He's not alone. Perhaps the biggest issue is not so much the clients objections, but their potential invisibility. "It lets you explore what they've done to put off other people," says Brodsky. Members may have been caught drinking and driving or misusing alcohol at a school or university or in the community. Accept them exactly as they are. Deal With Difficult Don't engage. In. Let your manager know that you are constantly being challenged by your co-workers difficult behaviors and ask them to intervene.. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. The client may be behaving in a way that signals complete disengagement from the group. Observing and navigating resistance may require changing approaches and interventions. Dealing With Difficult People in Specific Situations . In Psychologist's Desk Reference: Third Edition, 2013. Now I want you to think about your personal goals. Even reluctant members will usually at least pick a fuse, which indicates they are thinking about what is being said. Leader: How long is your anger fuse? (Throws pieces of string, measuring various lengths and representing fuses, in the center of the group.). The Unfocused One. It is important to recognize that not all participants 2. Her book, There Is No Heartbeat: From Miscarriage to Depression to Hope, is authentic, transparent, and provides hope to many. There are several distinct types of 'difficult behaviour' which can occur in group situations. Use open-ended questions to help the client explore their personal experience without influence. Dealing with difficult group members Clinicians discussed several challenges and barriers with providing group therapy in SUD treatment. In certain ways, this flexibility was embedded into clinics' existing group programming; in other ways, clinicians needed to make adaptations and accommodations based on individual and group needs. The following therapy questions bring the exercise to life (and are less confrontational), potentially avoiding the triggering of resistance mechanisms: The questions help create a picture of how life could look and may feel less contentious and pressuring than direct questions. the contents by NLM or the National Institutes of Health. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Nonetheless, this focus is clearly a mismatch for SUD specialty treatment settings. 204 CONDUCTING AND MANAGING GROUPS While some clients may have unconscious (also known as transferential) resistance to therapy, others have conscious, deliberate opposition to therapeutic initiatives that they fail to understand or accept (Austin & Johnson, 2017). Therapeutic alliance rupture as a therapy event for empirical investigation. These group dynamics were sometimes complicated by frequent changes in enrollment, beyond the clinician's control, that influenced or impaired group cohesion. If you can get someone else thinking of something else and that helps them calm down physiologically, that is great, notes Dr. Galasso. The way you communicate with [difficulty] is imperative as well. One form of departure (reported by eight clinicians, including five New Day clinicians) was through impromptu accommodations, with clinicians changing course based on what is happening in the current session. Following that, the leader focused on the purpose of the group, which was to discuss the members use of marijuana at school. If not, then refrain from looking for scapegoats to blame for group disharmony and conflict. Sullivan, M.J. This helps immensely because mandated members are notorious for not volunteering to talk. For example, in a review of clinical trials for alcohol use disorder treatment, didactic educational groups were the least effective of 48 treatment methods, including confrontational approaches (Miller & Wilbourne, 2002; cf. Think of times when you have attended a mandatory meeting and that meeting was somewhat boring. I read their feedback sheets that they give after every group. I thought, Hmm, this sounds like Ed Jacobs Impact stuff. At any rate, remarkably little research exists concerning what SUD clinicians do in group therapy, and thus the extent to which a treatment modality mismatch is a barrier in EBT implementation is unknown. Dr. Sabrina Romanoff, PsyD, is a licensed clinical psychologist and a professor at Yeshiva Universitys clinical psychology doctoral program. Joe Biden has defended the difficult decision to send widely banned cluster munitions to Ukraine, after he was condemned by human rights groups and a fellow Three approaches to qualitative content analysis. Leader (shaking a bottle filled with Coke): Can I get a volunteer to point this at themselves and open it?. As a therapist, it can help to remember that you are there to bear the burden of your clients pain. Broad empirical support has been documented for principles of group therapy (e.g., group cohesion; American Group Psychotherapy Association, 2007; Yalom & Leszcz, 2005), suggesting the importance of fully capitalizing on these principles if group therapy is to be utilized. They hire people with group experience sometimes. This wall represents I can change, and this wall represents I cant change this is who I am. On the count of three, Im going to have you move to where you see yourself. Is problem impossible? First, clinicians' reported experiences at the three clinics for this study may have limited generalizability to other SUD treatment clinics and clinicians. Group therapy for substance use disorders: What do we know? in Therapy Doing so, he says, helps clients see that their therapists understand them. Leader: Everyone stand up behind Carl. (Carl is in the center of the room at the front; members line up behind him.) You probably got fidgety or sleepy, or even started talking or sending notes to the person next to you. Be assertive and set clear expectations about what a respectful relationship looks like. WebGroup therapy offers the members opportunities to provide assistance and insight to one another. Substance abuse treatment and the stages of change. Understand the thinking behind how they are responding, and share your assessment with the client. Sharing stories (confidentially) can remove feelings of isolation, lead to positive suggestions, and identify valuable techniques. The value of rounds is that everyone speaks, even if only to give a number for a rating (such as Rate how the week was on a scale of 1 to 10). In a large group, one person can kind of take over, and the rest of the group members can kind of hide. This dynamic reportedly resulted in more quiet or withdrawn clients receiving considerably less attention and care than they would have through individual therapy. This leads to a discussion about their anger and the consequences of spewing it everywhere. This approach makes sense for a developmental training process but only if observed clinicians and supervisors are themselves skilled in group facilitation. Well, I am responding to your comment. All of these ineffective learned reactions can be worked on and resolved in Dealing with anger and conflict For New Day and Recovery Services, flexibility was further integrated into group structure through check-in periods at the beginning of each session, in which each client would briefly report their emotional state and recent relapses, cravings, stressors, and/or victories. Calm yourself. Characteristics of participants are summarized in Table 1. Reduce or stop excessive questioning. We hope you enjoyed reading this article. Although the mother stepped in to defend Honda and they eventually repaired their therapeutic relationship, the experience left him shaken. The American Institute of Stress. Putting firm boundaries in place is also a good way to handle difficult relationships with friends and in social settings. Because of the stigma associated with mental illness, many didn't want me to disclose my diagnosis because they feared what would happen to my career or how people would perceive them as someone closely related to me. Client resistance may take different forms, including (Miller, 1999): Enhance wellbeing with these free, science-based exercises that draw on the latest insights from positive psychology. These group dynamics were sometimes complicated by frequent changes in enrollment, beyond the clinician's control, that influenced or impaired group cohesion. First, New Day had four progressive 10-week phases of group programming, designed in terms of client motivation and readiness for change; each phase was 10 weeks long and consisted of 90-minute weekly sessions. And I think it is easier in that way to become disengaged and sort of just like mind drift off. (Taylor, New Day). In spite of the high prevalence of group therapy for SUDs in real world settings, research efforts have focused primarily on individual therapy. WebSo people may have only three reactions in the face of anger and conflict: withdraw, attack, or avoid. Those who subscribe to more of a facilitator model of group leading, where much of the responsibility for the flow of the session is given to the members, will likely find leading mandated groups to be frustrating, to say the least. Joe Biden defends difficult decision to send cluster munitions to The Challenger. And so again, it's meeting the clients where they are at. Participants varied in whether they were concerned about the amount of education in groups. The 1-10 rating round is also helpful for getting a sense of how the members feel about something. Psychologists can feel a lot of shame when they're having trouble with clients, says Honda. In most cases, interviews were completed in one visit (two participants required two visits). This is now the fifth session. Bring the group conversation back to the topic, and become aware when avoidance tactics are evident. The counselor knew she needed to do something out of the ordinary to get the group off to a good start and to convince members to participate. In working with groups, it is important to realize that groups differ in form and function. One of the most engaging activities involves having members do various written exercises. I wanted to teach them how to except who they were, and coping skills to work through what was so tough for them. Although each clinic operated within organizations that offered a range of SUD services (including residential programs, housing, and detoxification), this study is limited in scope to the specialty adult outpatient services of the specific clinics. Written from the perspective of intersubjective theory, this article addresses how the leader and group members co-construct the difficult patient. Hogue A, Henderson CE, Ozechowski TJ, Robbins MS. For example, three clinicians gauged the success of group sessions in terms of whether clients were learning and retaining educational content. There are several distinct types of 'difficult behaviour' which can occur in group situations. Connors GJ, DiClemente CC, Velasquez MM, Donovan DM. Using the 'I' statement avoids accusing or blaming a person but expresses how their feelings affect you, states Bowman. Patience and Self-Renewal The therapist can then gently raise concerns regarding either what is being avoided or the tensions that arise. But knowing the background story can give you effective tools for coping. A person can become irritable, aggressive, intolerant, and noncommunicative for a number of both internal and external reasons, including: Author Natasha Bowman, JD, SPHR, noticed that her behavior changed as she dealt with the responses of family members and friends to her bipolar diagnosis. Although there are many signs of resistance, here are some: Resistance refers to the act of opposing or fighting against change, while resilience refers to the ability to adapt and recover from change or adversity. This article investigates the obstacles to participation in group therapy. Experience with group process might also be enhanced through discussion or, better yet, role play during clinical meetings and/or between co-facilitators. Many times, leaders worry about the topic or content of the group and fail to pay attention to the elephant in the room the members just dont want to be there. The students had been referred to the program as part of the punishment for getting caught. "You can touch base with them when you're feeling rattled or insecure about something you've done," he says. You have people that are not willing to speak up, won't give you eye contact, maybe just sort of nod their head. All mental health professionals have challenging clients. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. Be assertive and ask for exactly what you want.. Group motivational interviewing for homeless young adults: Associations of change talk with substance use and sexual risk behavior. If there is something that I feel like they really cannot hear today, based on where the group is at, I will skip ahead to the next one and then come back and do that one. Carroll KM, Ball SA, Jackson R, Martino S, Petry NM, Stitzer ML, et al.Weiss RD. Sharing tales of challenging clients with other mental health professionals while respecting confidentiality can not only help end that isolation but also lead to constructive suggestions about how to deal with such challenges. I think I observed five or six groups and then a therapist observed me do one group. When faced with a challenging client or situation, you don't want to escalate the situation by reacting to it in kind, says Honda. (Karlie, SUD Intensive Clinic), A lot of what happens in the group is really based upon where the [clients] are at. Communicating in an understanding, compassionate way also helps. Behaviorists may not like the term resistance, but they recognize that clients often fail to comply with therapeutic instructions (Leahy, 2003). In like manner, a common practice (reported by seven clinicians) was individualized planning at the end of groups, in which clients would briefly discuss their goals and activities from now until the next session; these plans were reported to be especially important prior to weekends and holidays. and yet therapists dont ask themselves about their method, stance, personal skills, personality, real success of their personal therapy Based on facts it is just as possible to say there is no resistant clients, just incompetent therapists. Evidence-based treatments (EBTs) often are not utilized in treatment settings or lag years behind in their uptake, resulting in clients receiving compromised or potentially harmful care (Carroll & Rounsaville, 2007; Manuel et al., 2011). Well, what if three people say yes and four say no? When the father and daughter started yelling at him, for example, Honda put his head in his hands and asked them to stop talking for a few minutes so he could calm down. Unless confronted, the therapist risks strengthening the clients need for nurturance rather than growth (Safran et al., 1990). What strategies would you apply when dealing with difficult group Might apply it at some point. Several participants, especially clinicians from New Day and SUD Intensive Clinic, had minimal group therapy training and experience at the time they were hired. (Meagan, SUD Intensive Clinic). Brodsky, S.L., &, Titcomb, C.R. As the therapist becomes more experienced with handling resistance, it becomes less threatening. Funny, therapists talk about clients blaming others (I hope we all know who is responsible for child abuse or rape, or it was childs responsibility and than an adult blame perpetrator for? ) A vision of the next generation of behavioral therapies research in the addictions. Journal of Clinical Child and Adolescent Psychology. Some group members are voluntary and some are involuntary. I think [clients] would enjoy it more, instead of necessarily just sitting there and just talking again and again about the negative consequences of their substance use. The publisher's final edited version of this article is available at. Discuss with the client that you are sensing some distancing (from you or the group) or that you are concerned you are not on the same page. These situations can be most helpful. The use of the inner circle-outer circle technique allows those who want to gain something to be able to do so without those on the outside being given the opportunity to sabotage the group. That may be coping with a specific medical condition, This field is for validation purposes and should be left unchanged. 204 CONDUCTING AND MANAGING GROUPS - Nova I graduated from West Virginia Graduate College in the mid 1990s and was exposed to your Impact Counseling work during my courses with Bob Rubenstein. Dealing with difficult members is a very tough situation. By encouraging controlled talking through the use of a round, a leader can hear from everyone and also better manage any negativity by having the round be in the form of a word or phrase. dealing with difficult group Continue trying a variety of unique and unexpected activities. We interviewed clinicians concerning complexities of group therapy facilitation. Therefore, clinicians ought to be wary about relying too heavily on educational groups, even when teaching content derived from EBTs. Second, Recovery Services had a five-week intensive outpatient program as well as standard weekly outpatient groups. Implementing evidence-based psychosocial treatment in specialty substance use disorder care. Even though Seattle-area private practitioner Kirk Honda, PsyD, had been a psychotherapist for 15 years, it only took a hostile client a few minutes to make him question his own competence. group therapy - These vignettes suggest that clinicians attempt to check the pulse of entire groupswhere the group is atand adjust accordingly. Group therapy for substance use disorders: A motivational cognitive-behavioral approach. Not just one thing, and this is the only perspective. WebAbstract Client resistance to psychotherapeutic efforts often has a demoralizing effect on the nurse therapist, especially when the resistance crops up in a group therapy setting. Leaders have told us, however, that members have reported to them that they do look forward to attending as a result of the first two sessions going well. If a client is frustrating you, remember the bigger picture that therapy is helping to bear the burden of another person's pain, says Schnitker. Taking a course on group therapy or group dynamics provides essential background on group development, conflict and how to address it in groups, as well as how to foster group cohesion, identify and repair ruptures, and deal with diversity in A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Dealing with difficult group members - Spokane Community They are speaking with their feet as demonstrated by where they place themselves on the continuum. Web . Intensive groups met for three hours (half process-oriented and half educational) three times weekly; standard outpatient group sessions lasted 90 minutes and these groups did not have a fixed duration for a given client. The toughest kinds of groups Members usually laugh or say theyll open it while pointing it at others. I asked them what would make this group better, and they gave me all kinds of suggestions. A major conclusion from this study concerns the wide chasm between real-world group facilitation and the use of EBTs or manualized therapies. Clinical versus actuarial judgment. The importance of flexible group facilitation was evident from clinicians stressing the importance of incorporating multiple topics and activities, in order to reach the most individuals. How has your week gone? I would say groups are my weakest point. So I scrolled up and thats exactly what I saw. The following results include a presentation of major interpretive themeslimited to those that cut across the three clinicsas a result of systematic coding and thematic content analysis of qualitative data. Cultivate patience. Clinicians also discussed problems with the inflexibility of some manualized/structured therapies in the context of group therapy. For average therapist, primary profession doesnt matter, any STEM problem is resistant if they try to solve it, even most simple cases which can go from paper to something that works in afternoon. This digest examines two representative problems in groups and Family conflicts present a different dynamic. Structure is really good, but I think there's got to be some flexibility in there too. Keep in mind that their attendance is due to being mandated, not because they look forward to attending. It can also be helpful to get a second opinion by consulting on specific cases with colleagues who are "outside the fray," says Matthew J. Sullivan, PhD, a private practitioner in Palo Alto, California. (Kris, New Day). Clinicians from each clinic reported that their clinics would like to begin instituting formal outcome monitoring but that they had not yet done so. The leader can then ask members to comment on their anger fuse and whether they think it can be lengthened. These recommendations are primarily geared for open groups, in light of the prevalence of open groups as well as the practical barriers in providing closed groups within SUD specialty clinics. Client Resistance in Therapy: How to Help Difficult Clients An effectiveness trial of group cognitive behavioral therapy for patients with persistent depressive symptoms in substance abuse treatment. The problem is you. All eligible clinicians from the three clinics were recruited, and six from New Day (100%), four from Recovery Services (57%), and three from SUD Intensive Clinic (100%) participated (81% total participation rate). See Also: Building Group Cohesiveness. Compassion for the client should also be accompanied by consequences, adds Abblett. And both of those methods can Participants are identified by pseudonyms, along with their respective clinics. I felt unprepared. Instead, accept, embrace, and empathize with them rather than fighting the response. According to the behavioral model, the failure of the patient to comply with therapy may be the result of inappropriate reinforcers or reinforcement contingencies (Leahy, 2003). All Rights Reserved. New York State Office of Mental Health. Denial or disbelief about the need for change, Passive resistance, such as being uncooperative or not putting in effort towards the change, Active resistance, such as openly speaking out against the need for change, Not following through with the action plan. Do they have a long commute or stressful meetings once they arrive at work? They told me all kinds of good things that I should do, so thats what I have planned for this group. Remember to prioritize your well-being, set boundaries, seek support, and stay centered, and you'll be better equipped to handle difficult behavior healthily and productively, Bowman concludes. Ungreatful bricks! One of the biggest obstacles with mandated members is their negative mindset and determination not to talk. Take five minutes and get it all out here. "I talk about how it seems like we're not on the same page about our expectations of the work and our mutual responsibilities," he says. Although most clinicians endorsed the use of MI (especially for New Day and SUD Intensive Clinic), six expressed difficulties with facilitating MI in groups, in terms of limited experience or difficulty balancing the needs of individuals with groups. Tell them you are sorry for doing something that has made them angry or that they feel is not helpful. Always realize that one or more members of the group are most likely benefiting from what you are doing. Disseminating evidence-based practices in substance abuse treatment: A review with suggestions. Accept them exactly as they are. Miller, W. R. (1999). The Dominator. One of the best approaches is to wait or gesture for an opening or pause. (Rosemary, Recovery Services). - Positive psychology uses science to uncover, understand, and share what allows individuals and communities to thrive or flourish (Boniwell & Tunariu, 2019; Seligman, 2011). It examines clinical data to illustrate various ways a client can monopolize a group and how other group members react to this behavior. If it is a rainy, gloomy day like this, I would not show a video. (Becky, SUD Intensive Clinic). In other cases, clinicians had minimal training and then felt unprepared when they were expected to facilitate groups on their own. The others can be on the outside, sitting quietly and just listening.. This is a big plus because silence is one of the hardest things to overcome with mandated members. First sentence from abstract of paper Resistance or Rationalization?, Lazarus, 1982: The concept of resistance is probably the most elaborate rationalization that therapists employ to explain their treatment failures.. Some members will get the point that drinking may interfere with successfully reaching their goals. Additionally, moving around is more engaging for the members than just talking about how they feel about their ability to change. And even if it doesn't feel fair, says Honda, apologize, telling the client you're sorry that something you did has made them angry or that they feel you're not competent to provide the services they need. However, clinicians also had challenges with group therapy facilitation, as evidenced by their reported difficulty in managing complex group dynamics, their limited group therapy experience and training, and their reliance on educational groups. A randomized controlled trial of a group motivational interviewing intervention for adolescents with a first time alcohol or drug offense. Santa Ana EJ, Wulfert E, Nietert PJ. All three clinics provided extensive group therapy programming, all of which was in open-enrolling format. Do they feel like their job is threatened by you or another coworker? Read our. In this study, several clinicians reported having limited experience prior to being hired, as well as minimal oversight and supervision on the job. [], In 1998, positive organizational psychology at work gained legitimacy when the father of the movement, Martin Seligman, chose it as the theme for his term [], Validation means that you understand where the other person is coming from, even if you disagree with what they say or do (Rather & Miller, [], Chamber of Commerce (KvK) Registration Number: 64733564, 6229 HN Maastricht. "Some clients say they really want to change, then fight every inch of the way to make sure they don't," says Fred J. Hanna, PhD, who directs the counselor education and supervision program at Adler University in Chicago and is also a faculty associate at Johns Hopkins University. Rather than do the expected, disrupt the typical (often anticipated) pattern of thinking, questioning, and answering with alternative questions and approaches.
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