Well, welcome everyone. I'm Dr. David Stifler on behalf of the American Academy of Addiction Psychiatry. I want to welcome you to today's webinar in our series called Advanced Addiction Psychotherapy, which is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. And this is hosted in partnership with Oregon Health and Science University and New York University. We're excited you could join us today and that we can offer you these live trainings that will be held on the second Wednesday of each month from 530 to 7 Eastern time. Today's presentation will focus on group psychotherapy for trauma survivors. Our next presentation will be in September and Dr. Eric Garland will talk about Mindfulness Oriented Recovery Enhancement, which is an evidence-based neuroscience-informed psychotherapeutic approach that can be used for both addiction or chronic pain. You can check out the AAAP website for updates and listings of further speakers this year. Thanks everybody. And again, I'm Chris Blazes from OHSU, and we're very lucky today to have Dr. Christine Berkman with us, who's an associate clinical professor at the University of California, San Francisco. She specializes in the assessment and treatment of substance use disorders and traumatic stress with a focus on developmental and complex trauma, as well as moral injury. Dr. Berkman uses an integrated approach with both individual and group psychotherapies, often pulling on psychodynamic theories to inform her conceptualization, and flexibly applies evidence-based psychotherapies to best meet the needs of the veterans she treats in the substance use disorder and PTSD clinic at the San Francisco VA. Her research interests have focused primarily on developing a novel treatment to address moral injury among combat veterans who have killed in war and the impact of killing. She's also currently examining whether race-based stress and trauma are adequately addressed in existing EBP or for PTSD. Dr. Berkman has supervised dozens of psychology, psychiatry, and social work trainees, and was recently awarded the American Psychological Association's Division 18 Award for Excellence in Mentoring. She recently published a book called Group Approaches to Treating Traumatic Stress, a clinical handbook. And on a more personal note, I was lucky enough to be a trainee working with Dr. Berkman when I was at UCSF, and I can't quantify the amount that I learned from that experience with her. She's one of the true masters that you'll come across every now and then, and that's why one of the reasons we invited her back for her second contribution to our curriculum, and I'll pass it on to Dr. Berkman. Thank you so much. I'm so happy to be back, and if anybody was here last time, you'll know I do really encourage participation, even more so because we're talking about groups, so it feels very strange to kind of carry something totally by yourself when you're talking about groups because that's not what it's about. So I'm going to go ahead and start sharing slides, but I'm really going to encourage you to raise your hand or throw something in the chat. I might ask questions, and if you can speak to any of it, I'd really encourage you to unmute yourself and speak or just write responses so that we can try to have a more interactive discussion about groups. All right, so I'm going to try with the time that we have, if I were to take away three things, I really just want to try to have a conversation about the benefits and risks of really skill-based groups, which are pretty much primarily based in CBT versus more process-oriented groups, which tend to be influenced by psychodynamic thought, interpersonal, and more system-centered theories. They kind of all get lumped together in this term of process-oriented group. I would argue that there's a lot of overlap between the two depending on who's leading it, but for the sake of discussion and how I think groups show up in most places, I want to really talk about kind of the differences and why you might want to put a client in one versus the other. I want to also talk about core group skills needed to maintain psychological safety in group settings. This is particularly important when we're working with trauma survivors who are reluctant to be in a room with other people to begin with, so really kind of slowing down and looking at what are the core functions of the facilitator to try to keep that as safe as possible, and then just talk about some dynamics that we see show up when we're working with trauma survivors. So we'll talk a little bit about the history and background of groups and why things like enactments and splits can happen in groups, and it's something to really pay attention to, particularly if somebody's had, you know, a lot of our folks have had interpersonal trauma, but if there's been elements of betrayal or really kind of gnarly boundaries, that's all stuff you want to pay attention to when you're working in a group setting with trauma. Okay, so I, you know, as mentioned, I work at a VA. I think a lot of people train through a VA, and I think most group therapy gets developed, researched, and understood through VA settings, and so it's not really surprising that so much of the development of group therapy is closely tied to the history of war. So a lot of group therapy really came out of World War I and World War II, especially World War II, but thinking at the time was very psychodynamic, and Freud's initial thought about group or having any kind of therapy or analysis in a group is that a group of people generally have the same instinctual or libidinal drive impulses, right? So they have the same kind of id. They have the same ethical standards or superego and the same reasoning capacity or ego. So, you know, the thought was in any sort of collection of people, there's this universal shared set of drives that kind of drive how people interact. Bion took that further. I'm not sure if folks have heard of Bion, but very important in the development of groups. He was actually an officer in the British forces in World War I, and he was treating World War II soldiers in like psychiatric wards, and these are folks that were called psychiatric casualties. So terms like shell shock were more commonly used then, but what Bion really contributed is this idea as a group of a whole. So he's watching people kind of on a milieu setting, he's working with these soldiers, and some of the goal was to get them back to the front line, actually. But what he really kind of teased out was this idea that there is shared impulses, wishes, and other psychological phenomenon that are interacting with the group in a way where it's not like universally the same forces, it's how they interact with each other. And so he really kind of developed the first three ideas of group formation or group forces that are at play, and his were dependency, pairing, and fight or flight. So this idea that there's a lot of sense of camaraderie, or you need each other, there's split factions, like how people separate and how they identify differences, and then what happens when there's conflict. Do people kind of escape, or do they engage? And if you think about this in the context of like war, or coming out of war, wounds of war. Oh, great. Yes, definitely ask questions or clarifications in the chat. Thank you, Dr. Blazes. You can imagine there could be a lot of like already, we didn't have a PTSD diagnosis at the time, but there could be a lot of symptoms that made fight flight really prominent in terms of the observation. So post Vietnam, and the accompanying cultural revolution, I think there was a lot of work to kind of develop group formation, but the old model of kind of the very detached facilitator that was observing in a very kind of authoritarian way, in some ways, wasn't going to fly. There was so much distrust of authority, there was so much conflict, that the idea of having a group leader that was kind of not part of became really problematic, just in terms of the culture at the time. So there was a lot of work, there were rap groups, encounter groups, where people were really like letting organic interactions happen, which allowed people to really think of group facilitation, or the group leader as a participant observer, that you can't actually observe a group without being part of a group, and that you carry different weight in the group when you recognize that you're part of the ecosystem, basically. So that's where that really changed radically, kind of the role of the facilitator. And Yalom shifted the focus, and I think folks have heard of Yalom, I can't see you all, so I don't know if people are nodding, but I think a lot of people have heard of Yalom, you know, the theory and practice of group psychotherapy is a book that many, many people have, and kind of uses like the group bible, and not only does he talk about kind of group formation and development, and we'll go into that in the next slide, but he really contributed this idea that the focus for, you know, like beyonds era, it was group as a whole, so it's looking at the entire like unit, and what was happening as the group as a whole. That was still important to Yalom, but he really brought the focus back to the individual, and understanding that the individual, and how the individual is acting, often was shaped by previous experiences. So what was happening in the room, and in the group process, each individual was bringing like preconceived patterns with them, or pre-established patterns with them, and then they would act it out in the group. So the group members were both contributing to the responses, but weren't necessarily solely responsible for the responses, so it was really trying to understand individuals reactivity, interactions, knowing that every person was kind of like bringing, if you can picture it, they're all bringing like this whole world of parents, and coaches, and sergeants that contributed to likely their trauma, but also how they relate to, and how they view themselves. So I'm just going to pause there to see if there's any questions from just, or as quickly as I could. Oh thank you, yes, that's the reference for Yalom, in terms of kind of how we got here, and this is really going over the history that brought us to group process, process-oriented groups, not necessarily the skills-based, but let's, any questions? I'm seeing none, okay. One thing I will say is that Dr. Berkman is good at creating uncomfortable and comfortable silences, so we're going to be a little bit pushy to try to encourage participation today. And if I had to like put money on which slides, I'm really going to sit in the silence, it won't be this one, but just in case there's any questions about history, I want to know, but let's, let's jump into, trust me, the later slides, I'm going to insist we get people's reactions, because I also am just curious about your experiences running groups, and, and, or potentially being in groups. Okay, so this is a kind of summary of, there's some variation, depending, there's multiple sources down there, there's a little bit of variation depending on who you're, who you're looking at in terms of group development, but this is generally agreed upon when we're talking about how any group that works together with any length of time is going, like, it's given they're going to go through these phases, is, is the theory, right? So the first stage is this idea of formation and engagement, and that has a lot of focus on issues of belonging or inclusion. There's a lot of kind of referencing with each other, there's a lot of testing of what can be shared or not shared. You'll see a lot of, in groups, you might see a lot of people, like, for example, in the VA, they're going to talk about which branch of service they were in, they're going to talk about which deployment they went to, or where they were, they're going to look for commonalities, they're going to talk about how dumb civilians can be, they're going to find things that they can all agree, make them similar, there's a lot of focus on, are these my people, right? And so there can be some phrases or some early kind of disclosures that really test the boundaries of whether this is a safe place or whether these people are close enough to them that they're willing to stick it out and try a little bit more. When that happens, and people actually start to engage, so if people never engage, you're not going to have a lot of fighting, right? Like, if people never actually show up as their full self, if people never take risks, you're going to probably have a fairly superficial but smooth group. So I still remember an early supervisor to me said, if it's going too smoothly, like you're not getting into the work you need to do, it needs to be a little rocky to know that you're getting into something meaningful. So that's where conflict and rebellion show up. And this can be with each other. And it's really important when we're thinking about trauma, power and control, especially if there was some sort of, and I'm thinking about veterans here, if there was some sort of betrayal by authority, some sense that somebody in charge let them down, somebody in charge led them astray. And I think especially for our Vietnam vets, that was a really prominent theme. There's going to be a lot of focus on, is the leader competent? Do they know what they're doing? And we're going to test them to make sure we know what they're doing because they need to have control of the room. So that's where inappropriate behavior might show up, showing up intoxicated, breaking the group rules about kind of language or how we talk to each other. And is the facilitator going to step in and kind of stop it and enforce the rules? There's also going to be conflict with each other. So that's where the differences start showing up. When we think about engagement, we're thinking about a lot of focus on how they're the same. The differences start to show up when people start to kind of separate a little bit. And that can lead to some subgrouping, that can lead to ways in which there's kind of factions in the group. So in some groups, that might be people who have stopped using or drinking and people who haven't. And you start to see them organize around how they're different versus how they're all the same in that situation. But part of what you're really trying to do is get genuine connection, not this superficial, oh, we all served or, oh, we all have addiction. You're trying to have them understand that they're not the same, but they still have something in common and they can still be beneficial towards each other. So if you can get past the fight stage, and this is usually the most stressful for the leader, because you're constantly worried about people dropping out or getting into a fight in some situations. But if you can get past it and actually get people to stay in the room, feel the feelings and resolve the conflict as best as possible, you move into a really cool area of work. And that's where you start to establish trust and cohesion. There's more self-disclosure, there's more vulnerable self-disclosure. They're modeling conflict resolution. So in that moment, they're starting to like, you see the language change. It's like they're fighting, but they're fighting nicely. They're able to have more conversations about differences in a way that doesn't feel as kind of intense, feels a lot more productive. So you really start to see that increasing of vulnerability. The integration and kind of working phase is kind of like an even deeper layer of that, where the focus is on differentiation. So more nuanced differences in each other's experiences. And it's, again, you're kind of almost craving other people's opinions, because it's not that you need to be told who you are. You're more curious about why you're reacting to another member the way that you are. You can get defenses down and get people curious. You're working in this phase. And that can come with a lot of disillusionment and disappointment. So learning things about yourself does not always feel good or relieving. So there can be a lot of kind of heaviness in this phase, because people are like, oh my God, I've been doing the same thing in my life for 40 years. And that's why I continue to have this problem. So even when it's like a successful intervention, it's heavy. It's a heavy part of the work. And then finally, termination. And we'll talk about this. It's a big deal. If it's a time-limited group, there's a very clear termination. If it's an open-ended group with process, and a lot of the more process-oriented groups were designed to be very long-term or open-ended, when do you end? How do you end? How do you talk about ending? And if you get to a place where members are deeply attached to each other, where they feel like they've been able to be vulnerable with each other and work through some things, and remember, if these are trauma survivors, that's a huge deal that they're having kind of a corrective emotional experience of people who aren't hurting them, people who aren't violating them or taking them for granted, the idea of it ending can bring in a ton of fear. And so in a lot of avoidance, because we know that's like a hallmark of PTSD, right? So to have to lose a member or to have to have the group itself close and end, in the best-case scenario, you want to discuss it. You want to talk about how much sadness there is, how much anxiety there is, or even anger at whatever the force is that's making the group end, to try to make sure that you're internalizing the gains, that you can be sad, you can grieve the loss, but that there's a recognition that this experience that they had is something that they can take with them and hopefully generalize to life outside of the group therapy room. Can I bring up- Can I pause again? Any questions? Yeah, go ahead. So it may have even been you, but someone in the past mentioned that this isn't just in like, you know, a clinical setting that if you, 10 people got stuck in an elevator for four hours, that they would likely go through a lot of, you know, these processes. Yes, yes. Thank you. That's a really good point. And I think that also kind of reflects the contribution of the encounter groups that when you took kind of all the constraints of a clinical setting of a shared goal, a shared focus, that's part of where they noticed that this is what people do, right? This is the pattern that a lot of people hold. And that's not necessarily what we as group leaders, depending on your training, we're taught should happen, right? It's like, we have a goal, we have an agenda, we move through this. But I think this is to remind us, like if allowed to just organically develop, this is what groups of people will do. And one other thing is like, I find it interesting that a lot of these principles apply also with just individual patient interactions. Like I find that if I don't have some conflict at the beginning, you kind of have to stir up the elements in order for to get to the more deeper later stages of, you know, therapy and therapeutic alliance. Absolutely. And I think with, especially with a complex and developmental trauma, you wanna be really cautious of trust that isn't earned. So what can happen is just like we're familiar with trauma survivors who are extra skeptical or not trusting and don't open up, I'm actually more nervous for and pay more attention to the ones who are like very quick to attach and trust, because that's not genuine. If they're skipping some of these steps, if they're not going through conflict, if they're open too soon, like it's a counter reaction to actually being truly vulnerable and it can set them up to feel violated immediately. So that's where, you know, it sounds like a very cynical person to say this. I'm like, but if they trust you right away, it's too good to be true. It's too good to be true. You're not that good. You didn't earn it. So take a step back. I'm sure you're great, but take a step back and try to help keep them safe by like trying to make sure you're tracking the tentative tests of can I trust you are much healthier. So you're actually gonna try to encourage them to get to a place where ideally you can even disappoint them, piss them off, irritate them in some way, because that's where you're gonna start to build the trust, the true trust that lets them do much deeper work later. If that makes sense. Okay. Any questions here? Anybody looking at that and going, that is ridiculous. That's not how people develop or communicate. I'm not seeing anything. So I'm gonna keep moving. If PowerPoint lets me. There we go. So let's talk a little bit. I didn't wanna go into too much detail on this because I wanna get really focused on kind of the nitty gritty of which groups, what skills, but I can kind of summarize it in a slide. There's not great evidence for group psychotherapy. And I think there's a lot of good reasons for that. The majority of studies that actually are showing kind of differences between group and individual, a lot of it's CBT based. So then you're really asking yourself kind of what's getting studied. Is it individual psychotherapy that you would get otherwise in a room, just kind of in a room with more people like a group CPT or group PE, or is there something about the dynamic of the group that's actually enhancing and somehow making the work better or worse? That gets tricky to try to break apart. So one thing that some of the researchers have found is that when you analyze clients together in a group setting there's statistical dependency based on clustering. So for example, if there's a highly cohesive group and you're looking at how well they do with PE in a group setting, if there's trust, if there's engagement, if there's a lot of things we just talked about in the last slide, they may push themselves to do more exposure. They may push themselves because they have each other to do more work. So you're getting this sense of like, wow, this group is way more effective than if somebody had it individually, but what if there's a disrupted member? What if there's just one person that kind of spoils the safety of the group or interrupts like how much somebody can focus or concentrate, you're gonna see much less robust outcomes. And so you're really trying to tease apart, like, is it the material of the group? Is it the process of the group? Is it group membership? Like what actually is happening? And I think statistically, you know, when we're doing research design that gets really tricky. And I think people haven't figured out a way that consistently can show what they are thinking they wanna show. So this is my pitch. We need more research. So especially with process groups because we're really trying to find out like what are the factors that actually create change? What are the factors that make people get better? And what gets better? Is it symptom reduction alone? And what I would argue is particularly in process groups and really well-run skills groups, it's not just symptom reduction. You're looking for qualitatively different experiences in how people relate to each other, qualitatively different experiences in how people can sit with themselves. So their self-view and their ability to regulate their own emotions, identify them, name them, express them. You're looking for how much that generalizes. Like, can they have better relationships outside of the group therapy session that they're in? We wanna understand that. So I think we know there's a lot of groups, especially as the demand for psychotherapy gets higher and staffing issues become more prominent, there's gonna be more and more push to have psychotherapy happen in group settings. And we don't exactly know what or why a good group is good and a bad group is bad. So there is this kind of idea in the group of folks, small community of folks that are researching group therapy is that it feels like science chasing practice. Like we're trying to create questions and create frameworks that try to capture a thing that people can experience and try to describe, but we don't have a great framework for it yet to show it in a scientific way. That kind of leads me into, I think that creates a lot of disparity in how people are trained. So I don't know about the rest of you. I'd love to hear it. This is a slide where I'm willing to sit in silence because I really wanna know, like what kind of training do you get? I did not get any didactics. I didn't get any formal coursework on, this is how groups are, this is group development. This is how they run. This is how you do it outside of, until I got to my internship, it was maybe a lecture and a seminar, but I didn't have like a course. I didn't have consistent training of how to do group therapy the way I did individual. So even when I was running groups in like early practicums, supervisors were really focusing on training us on individual way more than group therapy. And in some models, you're not even in the room with your supervisor. You're running a group solo and they're kind of checking in with you about how you report it, which can be really challenging to get meaningful feedback about what you're doing and why. There's messages like, oh, group therapy is individual therapy, just with more people. And that's really problematic because then you're not understanding like what your role is when you have 10 people in a room and they're interacting with each other. So I think for those of us who are lucky, we get to co-facilitate with somebody who knows what they're doing. And almost everything I learned about groups, I learned with a co-facilitator who was senior to me and knew how to look for the things that we're gonna talk about in the next several slides. And importantly, not just run it with them, but have post-tache. So really stressing, and that's really hard in systems that feel like there's no time to do anything, but having 20 minutes even to talk about what just happened, what did you see, what did you do? That's what's gonna help people really understand group process. And without that, there's diminishing returns in terms of even sharing a group with somebody without that post-tache, you don't fully, I think, get why something went terribly wrong or something went really well. And we can talk more about group facilitation if it's of interest. But I would also say for people who didn't get a lot of opportunities to train like hands-on experiential training, I mean, you can certainly look for it. I listed a couple of, if you Google those things, you can find folks that do like separate day long, week long, weekend long trainings for people, but they're really having to look kind of outside of their institutions or outside of their training programs. So with that said, like what kind of training did you all have? And you can either put it in the chat or if anybody's willing to talk about it, I'd love to hear it. And I'd really love to hear if somebody's like, I got great training because that would make me really happy. But what does your training for groups look like? Oh, good, we have hands. Oh, hi. My initial trainings, this is Reverend Robin. My initial trainings were based on doing clinical pastoral education when I was in seminary. And the model was for the first couple of weeks, we had group therapy with our peers in the training process for clinical pastoral education. There was at the first time, there was like 11 people and we would have 90 minutes, three times a week of group therapy with our clinical supervisor and a co-facilitator. And this is 90 minutes, three times a week, with our peers. And I thought at the beginning, oh God, three times a week, we're just gonna hash over the same things all over again. But at first month, it was kind of confusing as to what we were doing. But then the clinical supervisor started to bring up things that similarities and differences between different group members. And then when it got into like the second month, we were working as chaplains in a hospital in New York City and we would take verbatims. You're not in the room, you don't write down anything you say to a patient in the hospital. But when you got home, you did verbatims of what you remember because it was important for you to remember what hit you that may not have hit another chaplain if they were in that room 10 minutes later. And it was from those verbatims that the group would really start to form either identifying with what you felt with that patient. A very quick example, I was stunned that the very first patient I had in the process, I just wanted to get out of the room. As soon as I was in that room with this lady, I wanted to get the hell out. I mean, like I really felt like I wanted to run out. I didn't wanna talk to this gal. And when I wrote the verbatim and people had already been getting to know me, somebody said, hey, that was your mother in the bed. I almost fell on the floor because there was something very similar with when my mom died many years ago. And to be able to see that and stand with it and touch it and say, oh, wow, this is part of who I am. That was very powerful. But the verbatims helped certainly the three times a week therapy group with my peers. And the verbatims helped immensely because you remember what was important to you from that encounter is what speaks to you about how you're dealing with the group and what you as a person are taking from that. Am I making sense? You're making perfect sense. I'm just incredibly impressed that you got three times a week, 90 minutes and then willing to create enough safety where people were that vulnerable and able to share that much. I mean, that sounds really from my perspective, very unique. These are all students that were in seminary. So we were in that process toward ordination, but it was the most powerful thing I ever did in my life. It was called CPE, clinical pastoral education. And some denominations require it if you're gonna be ordained and some don't. I think one thing I love so much, thank you so much for sharing that. And one thing that sticks out to me that's so important as a provider, as a clinician, but I think as a human being that group does so well is this recognition that we can have all the information. We can be training in it professionally, right? But it takes someone else seeing us. We have to be immersed in the process. Yeah, and having someone else really see us helps us see ourselves. So it's this humility around, we will not see ourselves the most clearly. And I think you can understand that intellectually, but until you have some sort of kind of experiential knowledge of that, there's a shift, right? There's a shift in really appreciating and understanding that. It was the best thing I ever did, not just for seminary, but for my own personal life. Wow. Yeah, absolutely. Well, thank you so much. I think, is there another hand? Or did I imagine that? I'm gonna lower that. That hand is gone. So I don't think I see. Okay. Anybody else? Is anybody else waiting for the next opportunity? Oh, okay, great. Well, I see some comments. I see one question that sounds like a processing group and not a group psychotherapy. Are they the same? So are we talking about the seminary training, just to get clarification, to get a thumbs up? This clinical pastoral education did not happen in the seminary. You had to be in a hospital with a clinical supervisor and someone who was your own personal supervisor. And once a week, you had to have therapy with a therapist and you had to pay for it. Okay. All those things put together. Yeah. Yeah. Well, I think it's a good, I mean, in terms of like training, I know there's peer processing groups. So it sounds like this was different. This was like psychotherapy that you were all required. But I think the thing that's a little unique is that it was with your peers, where when I think of like personal psychotherapy, you're usually not necessarily with your peers. So I think this is, again, a bit unique, but it sounds like it was formal group psychotherapy. I think that the difference, the distinction we're trying to make is, especially when there's dual roles, it's very hard for doing group therapy with your peers or with people that you're working with to necessarily be the same way that it would be if you were with strangers, right? Or with something that's more formal, because you're gonna be more inhibited. You may not be able to share as much. So there's just that added layer. So I think when we think about group psychotherapy, there's an explicit agreement that you are a group member and that there is a therapist and that you're agreeing to that relationship. And I think with some of the processing groups I've heard from folks who are learning together, it's not as formal, if that makes sense. Yeah, yeah. Okay, thank you, Belvina, for the question. Okay, next one. My closest experience to a group activity was when my residency program wanted us to run groups on an involuntary inpatient psych ward for one hour each week. The goal was to answer any questions patients had, especially those regarding medications and legal issues. But my co-residents and I quickly discovered was that floridly manic and psychotic patients would either not participate, perseverate on exact details about their individual treatment plan and discharge, and thus dominate the hour with a high patient turnover average stay of 14 days. The group cohesiveness was poor. Well, my goodness, Zachary, you couldn't just figure that out and make it happen? That's crazy to me. I'm just joking. That sounds like an incredibly steep learning curve. And I think part of what you're highlighting, there's so many things that I take issue with a little bit in terms of this being kind of a learning experience, one of your first learning experience, is how much buy-in do your group members have? And there has to be some sort of consent or willingness, some sort of consent or willingness to engage. So I think off the bat, you're gonna have minimal engagement in terms of, and when we think about the phases of group, right? I mean, just involuntary in and of itself, you're gonna have minimal engagement. We see that a lot with like court mandated folks that initially it might take a long time to get any sort of meaningful buy-in. I don't think you have that kind of time when it's an inpatient setting. And yeah, there's about patient stability, right? And so we're gonna talk about that in I think the next slide, like what type of group would be helpful, the less structure that you have, or the more kind of open-ended question and answer, or what do you guys wanna talk about today? There's a lot more room for kind of psychotic or manic or severe trauma reactions to kind of interrupt and take the space because less structure raises anxiety in the room. So not having like an agenda, skills, a lot of containment around what you're doing, which I think more of our colleagues who work with severe mental illness groups, there's more structure. There's a lot more structure to kind of help contain the anxiety that gets raised when you're asking people to kind of develop a conversation on their own. So that's intense. And I hope you get a chance to do another group that has a little bit more room to see what that would look like, because that's a really, really tough, tough group. And I think there's people that can do a really good job of getting people to engage, creating as much safety as you can in the room. That's just a pretty steep, steep ask, if you ask me as a group therapist. Thank you for saying that and for validating our efforts on the inpatient unit. Yeah, it was tough to kind of run groups. And a lot of times the materials that we would talk about in one week wouldn't necessarily carry over to the next week. And we found ourselves kind of repeating over and over the same thing. It's a challenge. Yeah, let alone like how much are people encoding? So when I think of some of our most severe trauma presentations, they're not hearing you. And an individual, you can be like, did you catch any of that? And they're like, no. But we intentionally have a lot of repetition in some of our early phase groups, because one, how sober or altered are they? How long ago did they use something? How anxious are they? Are they taking anything in? And when you're thinking about, inpatient is so hard. I think groups are so hard in short-term inpatient groups, because the rotating, we're gonna talk about this too, the rotating nature of like different people every day or every week, you're starting over. Every single group is a new group when you have a new member, every single one. So that's the other thing to keep in mind. And like, you can run a drop-in and you can run an open door group, but there's a lot of work that has to happen every single week, because it's not the same group. And we can talk about that a little bit more later, but good for you for trying, but please don't evaluate your group skills based on that example. Thank you. Yeah, of course. Okay, let's keep going. I don't know why, I'm going backwards now. Okay, structure and process. So I think this slide applies to both groups trauma survivors, our clients with PTSD and clinicians. So I developed this slide because I think it applies to all of us, honestly. I think that there's a lot of folks who avoid running groups, let alone joining them. I think for our clients, especially with PTSD, avoidance is core to their presentation. So of course they don't wanna go be around a bunch of other people, let alone, and if it's a physical group, right, let alone in a room where there's only one door, maybe two. And there's a lot of fear of rejection and alienation. Like, am I gonna fit in? Am I so messed up that if I share, people are gonna just confirm what I believe to be true, which is I am deeply broken. I am deeply toxic. I am deeply wrong in some way, which are some of the core beliefs our trauma survivors have. Obviously lack of trust in self and others. I think the lack of trust in self is probably the biggest barrier for me. I think the lack of trust in others, people can overcome more quickly if it's a well-run group, but the lack of trust in self often is what takes people so long to be truly vulnerable. And it's not just, can I trust somebody else with what I'm saying? It's, can I trust myself to have an emotion and survive it and not lose my composure or not like lose my mind by feeling something intensely? I think there's also this perception that individual is always more valuable than group. And I think that's unfortunate, but it's a very common belief. So there's this real sense of like, you're just sending me there because you don't have time for me individually, or you're just sending me there because your hospital can't afford to see us individually. And there's lots of flexibility, right? Like if it's a group, it is gonna be the same day and time, depending. So those are some of the big hurdles people have to get through. There's lots of benefits, exposure being one of them. So just showing up is addressing a core feature of trauma, and that's huge. What I see to be one of the most beautiful things that happen in group is a reduction of shame, stigma and alienation. I think some of the most harmful consequences of PTSD, when I think about the most severe folks with addiction or suicidality is that they are their own judge, jury and executioner, right? Like everything they think about what they have done or what happened to them, the shame is crippling. And so if you can actually get them in a room where somebody else had a similar experience or somebody else could just validate how messed up something was, or that they too don't sleep at night, or that, oh yeah, I also kind of zone out at an intersection. There's immediately this like, you can see chests start to actually get oxygen again, right? Like you can see people start to breathe again and realize like, oh, it's not just me. I think actually the participant Reverend Robin who shared the experiential learning of self in context, that there are things that people learn about themselves that other people who've gotten to know them can see that they can't see. And that maybe their individual therapist wouldn't have even seen, right? And so then there's also this collective knowledge. The group starts to hold kind of a group mind. So there's things we've learned together in a group. And if you've, even in my early phase groups, like you have enough really bad relapses, you have enough really bad fights with a partner, like the group starts to understand the warning signs. They start to understand the phrases that get them there. And there's this kind of like strength in a collective knowledge of what's dangerous, what's helpful. And they also get to see each other try. They get to see each other practice and whether it's successful or not, it can be really inspiring. And I remember one that I loved his phrase. He's like, what keeps me sober might get you drunk. And so I think there's a lot of recognition that it's not a one size fits all. So to be a valued member of the group, you don't have to conform and be exactly what everybody else is. But the shared sense of we're gonna collectively explore the world and figure out what's helpful to us and share it with each other can be incredibly powerful. And this whole sense of like to fight the alienation that I'm not alone in this, that somebody else is giving me suggestions. And I promise you, if a veteran encourages a coping skill that I've spent like three years trying to get somebody to do, and all of a sudden they're like, that's a great idea. I'm like, yeah, what a great idea. If you only ever heard that from somebody before, but there's power in having it come from a peer. There's power in having it come with somebody who's lived through what they have or something very similar. So I'll take it, any day of the week, I'll take it if they hear it from a veteran, even if they couldn't hear it from me. And again, there's the support, the development of safer relationships. So I don't wanna paint this with too like Pollyanna of a brush. There are problems. We'll talk about the problems in future slides, but the idea is you don't wanna reenactment. You don't want somebody who is going to hurt you or violate you be in the group because even if they let you down, they don't return the phone call. If you start exchanging numbers and stuff, or they didn't get something you said in group, you can still be disappointed, but that's very different than the level of violation that somebody may have had prior to coming into that group. And in the best case scenario, you have people in group and an individual so that you can fine tune and figure out like what are you reacting to? Why do you not wanna go back and help somebody understand their experience? Yeah, okay. Any questions about that? Okay, poor Clifford. He's the fear that our folks often have. This is kind of a logistics slide, but I think it's really important. And I think when hospitals and institutions are trying to figure out like what kind of groups do we need, you're constantly thinking through like the needs of the population with the capacity of what we have to work with, right? So one of the biggest questions is, is your group gonna be drop-in or closed? And rolling admission, like when it's drop-in and rolling admission, we think of that as the lowest threshold. So if you have somebody who's really on the fence and isn't willing to kind of make a commitment to come to a group, having a drop-in group is awesome because then if they show up even once every two, three months, you're like, cool, we've got their like pinky toe in the door. Closed groups are where you're really gonna be able to kind of see, ideally see that group formation that we reviewed earlier with the different phases where you're gonna really be able to start to develop meaningful trust and intimacy that's gonna let people do really deep work and really vulnerable work. That is very hard to do in a drop-in group. And some groups are kind of semi, somewhere in between. So a group I did with a colleague for years, we had a lot of regular members who would join the group, but it was our entry group, right? And so anybody coming into the clinic would join that group and most folks were ambivalent about changing their substance use or they're trying to get sober or not use. So we had a mix of people who were sober, people who are trying to get sober and then people who weren't even sure they wanted to. What can happen is that the more established members, the members who have been there longer can then start to kind of develop this almost mentor role, which boosts their own confidence and self-esteem in a way that's actually pretty cool. But it's still different. It's still different than a closed group where everybody's kind of on the same level. Because when you have that kind of mixed phase or that somewhere between drop-in and closed, avoidance being kind of so key in all groups, your further along patients get to kind of be, they start to move into this like pseudo therapist role. They wanna counsel, they wanna focus, they make the new people like identified patient and that way they can hide and that way they can kind of stop developing. So that's when we wanna move them into probably a closed group with other people where they're really gonna get challenged again. But that's just something to think about. Time-limited versus open-ended. Time-limited is easier. It makes sense. It is what a lot of hospitals like because then you can tell them you did a course of treatment, check, right? And I think for a lot of folks who are really skeptical of group or avoidant, I think this is a better buy-in for them. It's like, look, it's only 10 weeks. Just give it a shot for 10 weeks. And it can be a way that it makes it more palatable for folks who are really avoidant of groups if they know it's only gonna be for a short period of time versus some people have really dug their heels in at this idea of I'm gonna join a group that I'm gonna be in for a really long time. But when you do get a group of folks who are together for years, even decades, how do you say goodbye? And do you say goodbye? So do you graduate? Do you leave if you're a member and you've been in a group for six years and you decide it's, you feel like you've gotten a lot out of it but you don't wanna go anymore? That is a really challenging situation for the individual client and the group as a whole because you're gonna have to work through all the feelings of like abandonment and it's a differentiation. You're kind of breaking up the cohesion. And what you're really introducing is that the group you had will die. The group you had will end. And whether a new person comes in or the group is just one less member, you're starting all over again. And whether people consciously know that or not, it's felt. And so any group that loses members, they feel that. They feel that they kind of have to completely recreate that sense of safety and intimacy and work through all of the conflict again. And that can be really hard. So, I mean, as harsh as this sounds, like in some ways it's easier for members who've been together forever to have someone die or move out of state than it is for them to just decide not to attend anymore. So as a group facilitator, you're gonna have to think through, like, when do I end a group? How do I end a group? So I inherited a very long, well, actually we developed one. It was two longstanding groups that we merged together. And it's one I had to end. It's the one that Dr. Blazes and I did together. And it's one I had to end over a year ago at this point because we had three group members die within like a year, year and a half. And the health was really, really poor of our remaining members, except for one. And so then you have this fear of the lone survivor. You don't want there to be one group member that has watched every member of their group die. So we, as a group, myself as a facilitator had to make a choice to end the group. And that process took like eight months, but it's hard to do. Virtual, in-person or hybrid. I would just say like, I've done them all and I think they all have value. I like in-person the best. I think I feel like I feel the most confident in it, but that's also because that's the one I learned in, I think, and I think there's something really powerful about all of the body language and non-verbals that you get to have in the room. But I've seen some really powerful groups online. I have. The thing that I often talk to trainees about now is like one of the hardest things I find about group psychotherapy online is like people are very obviously doing other things. And that creates a lot of challenges in actually developing full engagement and intimacy. So there's like new group rules or there's insisting on, can you be fully present? It's definitely a huge challenge. And with trauma survivors, like even in the room, you've got to encourage them to get off their phone. You've got to encourage them to like engage. It's just a lot harder when they're at home, in my opinion. And then co-facilitation. Are you gonna have a co-leader? I hope so. I really, really hope so. I know that there are so many places where facilitators just have to run the group solo because they don't have the staff to have two staff members in a group at one time. It's possible. I've done it. I've done groups solo. You can do it. It's just draining. It's not as I think dynamic or enlivening. And I don't think I'm as good as one person as I am with another person in the room. Because you see different things. You have different reactions to patients. You see different patterns. You pick up on an eye roll that you didn't miss but your co-facilitator saw. You have two sets of eyes that are really being able to observe that many people all at once. And that's what you're doing. You're not just watching what the person who's sharing is saying. You're watching the reactivity of everybody else in the room, whether it's verbal or not, to try to understand what's happening. That's tough ask when it's just you. So if you are running a group solo, I wanna validate it's hard, number one. And number two, I'm gonna really encourage, try to find a consultation group. And if it's not formal, just ask somebody else who's running a group solo to have lunch with you once a month or something and talk through reactions. Because a mentor of mine once talked about, groups are very powerful, but because of that, groups are very powerful. So a tough session individually, like if you have a lot of tension between you and a client in an individual session, that can be hard. You can feel a little drained or a little beat up, depending on whatever you're working through. When it happens in a group setting, especially if the group is challenging authority or really working through, you've failed me in some way, the intensity of 10 people being disappointed with you feels very different than a single person. And it's just having some compassion for the facilitator of you're holding a lot of, to borrow Freud, libidinal energy, right? You're holding a lot of energy of that group when you're the sole leader. So downloading, decompressing, processing, having strong reactions about, I hated that, that was fine. There are these two people in group I wish wouldn't come back. Like you need to get that out instead of pulling it in, or it's very likely to come out sideways in your interventions. Cause it's just a lot to ask of yourself to manage all of that by yourself. However, if you have a terrible relationship with your co-facilitator, you can do more harm than good in your group. So it's really important that the co-facilitators have a decent working relationship. Don't have to be best friends, don't have to love each other, but you have to be on the same page about how you're going to interact with each other. You don't even have to have the same style, but there has to be an agreement that you can work together in a way where you respect each other and you can show the group that it's okay to have different styles or different opinions or different questions. But that modeling of communication with each other is critical to keep the room safe. Think about a family where like, your parents are fighting and it's very obvious there's tension in the room and it's obvious there's disdain and you're supposed to pretend like everything's normal and nothing's wrong. Don't ask group members to do that. It creates problems. So it's really important that that relationship isn't ignored and it's actually given some space so that you can coordinate and communicate with your providers. Some of the most common conflicts I see, especially when two staff are working together, it's easier when there's a trainee because there's a power differential, I think. So it's very clear kind of who's in charge and who's learning usually. It's the two staff where I think things can get really sticky and usually a trainee isn't there long-term. So if you're running a group with somebody long-term, who's staff, like that's where it's really important to get things running smoothly. So one would be like, is somebody chronically late? Is somebody chronically feeling like they have to be the bad cop? I mentioned that in like addiction because if one group facilitator is like, so-and-so, it smells like there's some alcohol in your breath, have you been drinking? And one facilitator never wants to be that confrontational person, that's gonna, you're gonna build resentment over time if you're constantly the one who has to confront and you're not sharing some of those harder responsibilities that we'll get into in a future slide. Any questions about that? Anybody wanna share anything about co-facilitating a group, whether it was a peer, a supervisor, somebody you loved running a group with, somebody that you were so grateful when the group ended because you did not wanna run the group with? Anybody willing to share about that? Oh, we had a hand. Looks like Carla, I will unmute you. Thank you. Yeah, there you go. Yeah, I have one question. Isn't me. I'm, oh, I'm sorry. I'm not. I'm not Carla Marienfeld, I'm her new fellow. I'm sorry, I'm just good. Yeah, that's great. Yeah, you're welcome to this welcome to speak nice to have you here. Yeah. Yes. So I'm wondering, before the running the group. So, I just assume that co facilitators, they might have some plan or kind of discussion about what kind of role. Each co facilitators might take, for example, one person, take the lead and then the one person, take the kind of a assistant, something like that. So I'm wondering about that kind of thing. Do they plan some kind of strategy, or something like that. I think that's absolutely the right thing to do. I think if you are starting a group from scratch with a colleague, you want to have multiple meetings, you want to, you want to understand what their style is what they think about group how they like to run group and then share your own. You want to have those conversations about like what kind of roles do we want to have. I feel like I'm kind of good cop bad cop that's just one that popped into mind of when I've seen it go wrong. But you want to be really clear about what the group goals are what you hope for your group members, who's doing what down to the nitty gritty of like phone calls and notes right you want to you want to have a conversation and make that explicit. I think what can happen in practice is a new hire comes on and they're told they're going to run a group with this other person, and the other person might have already started the group. And in the best case scenario they meet with that that new colleague and they have a conversation very similar to if you were developing the group from scratch, because people are so overextended and busy and you know their schedules are filled to every minute of the day, my what I think often can happen is that there's no protected time to have these conversations that that leadership doesn't always necessarily value the importance of pre hash and post hash. And that's, that's a problem like I think that that diminishes the effectiveness of the facilitators in the group for the patients, if they don't have protected time to get on board with each other and have a strategy. And you'll see weird stuff play out when co facilitators are super burned out and overburdened and they're not kind of practicing what they preach right like they're a subgroup within that group and they're not talking about what's going well and what's not going well. And I was fortunate enough to have, you know, someone I think of as my group guru, a social worker in our clinic her name is Susan Carpengo and I think she's brilliant. And I got to work with her for like 10 years, and she taught me so much about a safe co facilitation relationship. You can say like, I didn't sleep last night, I'm going to be kind of dead weight today, and the other facilitators like gotcha. And it's a really awful interaction. Like you make an intervention and it flops horribly. And the more that happens where your co facilitator kind of picks it up and helps it work or helps make it easier for you to be like wow that really failed that there's, you're going to take more risks the safer you feel with your co facilitator as a group leader, you're going to take more risks with your group members, you're going to be more vulnerable and that's going to push the group forward. So it's an incredibly privileged position where I got to work with somebody who I thought was, you know, so good at this. But I've also done groups of people where that was not the case, where we did not have that relationship. We didn't, you know, we did not have time to talk we didn't have time to pre hash or post hash and it went okay. It was nothing like a cohesive intentional co facilitation relationship and I think if you're going to train people. This is my opinion, like you owe it to them to have at least a post hash, because if you don't explain what you're doing and why and how did you react to that or did you have a different opinion about how you would have done that you're not modeling what you're hoping they're going to get to do somewhere else like if you're modeling you don't talk about it you don't think about it. That's considered the norm, and I think that that can be risky for our group members. Any follow up questions about that before we move on to my think, Robin Yeah, I just unmute you again Robin. Can you hear me. Hello. Okay. I was just going to enhance what you just said. I recall that when I was a newbie. I mean, newbie newbie new from nothing. And I was the co person in the room who had no background or education and group therapy what's a group meetings whatsoever. And it was mandatory that right after the group finished that the facilitator, with a capital F would with the two of us would go into a room and talk about what just happened. You see when Donald said to Maria right next to him, that little statement, and she almost went through the roof with anger, what do you think happened there. Or what do you see was happening, or what, what part of the group, did you feel something wasn't clicking that something wasn't happening, and for instance one time, it was a gal in the group who in the middle of the group she took off her sandals, and she started to cut her toenails. And I said, well, it didn't seem like many people in the group were offended by that so, or even acknowledged it but I said but I thought that was one of the most beautiful horrible things to take away from the person that was speaking at the time that she was starting to clip her toenails in the middle of growth is an aggressive move. But it was a good, it was usually 15 or 20 minutes or half an hour most of the time, and we just talk about certain peoples in the group, and what do you think happened to so and so, when this person said it to her. And part of that part of that, you know, download that exchanging what was that about. I think part of what that helps us do is we get to have an understanding of what happened, right, we get to even if we're wrong, we get to have some sort of framework or understanding of what just happened in that room and I think that allows us to go in the next week, with the feeling that like we've got we've got this I think as a group facilitator you need to have some sense of I can keep this room safe. I can make sense of even the most bizarre things that happened like somebody pulling off their sandals and clipping their toenails, while somebody else is speaking. And I think that's really really important in all groups but especially with our trauma survivors because I think they are more sensitive to an anxious leader than than others and so I think it's really important that that that postage happens about you, you get you get more competent and what's happening what you're doing and why. And I like this slide because I don't want anybody to leave here thinking that I'm like poo pooing highly structured groups, I love highly structured groups I think they serve an incredibly valuable function, like especially when we're working with PTSD, right. So, with more structure what I mean by that is, is that there's more containment so there's usually more protocols or rules or things that you're doing. There's always time limited. You're looking at like, does the PCL go down. There's often worksheets there's things that people are holding on to so I think about seeking safety I think about how you get like you get a handout every week there's something tangible that you get. There's just a lot of help in teaching people how to be in a group, we're going to do a check in we're going to do it this way. For somebody who is excessively anxious, that level of kind of, they know how to how to react or they know what's expected of them can bring the anxiety down, and that can be really helpful. It can also be a place where people can kind of hide out. If they're past that and they actually have the tolerance to endure more anxiety, and you know, you can start a group that's very skills based and you're really focused on your agenda and you're getting through everything and as the group starts to get more comfortable with each other, depending on the dynamics of that group, you can start to bring in more process you can start to bring in more vulnerability if you choose to as a leader you can start to see a lot of people integrate aspects of more process oriented groups into their skills groups. Based on clinical judgment of is this group ready to do that because there's a specific function for why we use a highly structured group with certain patients I will say the other thing that we have used it for is when when I'm shared and that's last slide that I'll hopefully try to get to relatively soon in terms of challenges or dynamics that show up with trauma survivors enactments happen so there are ways in which people can kind of recreate vulnerable situations or recreate trauma there's there's also sometimes you get group members that are kind of antisocial. That's part of their illness that's part of what's showing up so we've had group members that have sold drugs we've had group members that have taken money and not paid it back we've had group members that have been, you know, sexually inappropriate. You have to recognize that with less structure there's more room for that kind of behavior to happen with more structure you're helping people stay a little bit more contained and on point. So if somebody is super problematic and toxic we're not going to put them in a group anyway and toxic is a rough word but in the context of a group member. We're not going to put them in a group because they're not safe to be in a group, but if it's somebody who just gets flustered every time you try to redirect or every time you're trying to get other people's voices in the room, a structured group might just be more helpful because they have more of like a roadmap of how they need to be. So there's a lot of reasons to use the highly structured groups groups with less structure. I mean there's still a sense of like how do you, how do you check in what do you do, how do you take turns speaking, but there's a lot less, you know, like you don't have a topic necessarily every week you're letting it organically come up from what people bring into the room, it's going to make things more anxious, you're going to have a lot more silences. If nobody wants to talk that day you're going to figure out what are you gonna do with that. They tend to be ongoing so they tend to not be time limited. You're really looking at interpersonal outcomes, I think a lot of them are process oriented groups one of their tracking and they want to see kind of qualitatively different ways of relating to people, less written material, it tends to be more verbal. And there's not often in between session assignments and members are asked to take on a role. So, you know, when I think about a skills group like if nobody's talking you're probably going to teach something you're going to move them into the next thing. And a process group of nobody's talking, you're going to remind them that this is their opportunity to get something out of the group and that what they bring into it is what makes the group, because what can often happen is people are so used to being like you, you're the leader make this happen. And you can, and you can give them choices about Oh well I've noticed several people when they checked in use let's talk about relapse or. Oh, I noticed that when somebody checked in like, you know, it seems like people are having trouble with sleep you can give people options to get a conversation going. But what you're trying to convey is this is your group. So you as a member have a responsibility to make this group work because you're a very important valuable active member of why this is going to work. And the woman I told you about who I feel like taught me everything I know about groups would always say to group members like you're only responsible for what you don't bring in. Once you once you bring it into a group once you hand it over. You've got a team to help you. You've got other people to side with you to argue with you like you're no longer the only person responsible for it when you bring material into a room, because you have the choice and you have the ability to do so. So many of our veterans because of shame because of avoidance for all the reasons they won't. And so, helping people and teaching people how to empower themselves to recognize that and to believe that and have enough experiences where it's true, is I think one of the most beautiful things that can happen in a group where they really feel like it's their group it's not your group as a facilitator it's their group. Any questions about that. Do you have any questions in the chat that I can I can answer. Okay. No, that was just a comment. Okay. Just out of curiosity and you guys are welcome to just throw an answer in the chat. With the group that I have here do people feel like they've had more experience with highly structured or minimal structure, like skills groups or process groups, I'm just trying to get a sense of the audience, if you guys wouldn't mind. Or you're welcome to unmute and actually verbally say it. I'm not seeing any responses yet. Maybe the better question is, people who are here, have you done groups? My question is, is there any orientation or instruction to start a group? For example, about confidentiality or kind of do not blame each other or something like that. Yeah, definitely. There's so much more nitty gritty we can go into. That's a great question. But whether you establish a group from the ground up, you're going to repeat those rules. And depending on the type of group, you're going to have a conversation for shared agreement on the rules. So confidentiality being one, what language is allowed? What are you going to do if somebody's more than 10 minutes late? There's a lot of group norms that have to get established. And depending on the group and depending on the facilitator, it can be a very facilitator driven set of group rules. Or it can be a group, you know, especially in a closed group, you can have the first couple groups are going to be the group deciding what their norms are going to be. And when you have that kind of buy in as a facilitator, I feel like it's easier to enforce because it's a shared agreement of how we're going to operate and how we're going to work. I'm just trying to see if there's. But enrolling groups like where you have, you know, people may have been in there for several weeks and new members are coming. What I love about that is that it gives you an opportunity to re-say the rules, re-say the norms, re-say the goals of the group. And I think that's really helpful for a lot of reasons. I just talked about, like, if members are highly anxious, if they just finished drinking, they're not encoding, they're not paying attention. And repetition is very, very helpful, especially in early phase treatments where you need to say it over and over and over and over again. So that part of a rolling group, I think, is great. Usually what can happen in a closed group after that initial orientation, that initial agreement is you're usually only bringing it up when there's a violation. And that's not always great. It would be great if we could bring it up in more of a celebratory or orienting way in closed groups. But that's usually easier to do in a drop in or a rolling group. Does that answer your question? Or maybe way more of a question than you meant. Probably. I can talk forever about groups. Okay, let me move us along. Obviously, I'm not going to read everything on this slide. It's for you to reference later. But when we think about group management skills, I think it's easiest to break this down into kind of four main areas of what are we actually doing. And it can look different depending on the group. But the question, Carla, that you actually brought up is, is that first skill? It's orienting. It's helping people understand why are we here? What are we doing? What is the goal? What's expected of me? And it's not something that you do once. It's something that you're doing frequently and often. So if somebody's coming into a group and they're using it, the group that Dr. Blazes and I did, the amount of times I had to remind them that we're not here to debate politics. Oh my gosh, I would be a billionaire if I could get paid for every time I had to intervene in that regard. But that's what they did when they were avoided. That's what they did. They'd go into and they enjoyed it. They enjoyed the kind of like fighting, kind of snapping at each other thing. That required a lot of orienting, orienting them to why are we here? What are our goals for here? Without trying to make them feel like what they were saying was completely irrelevant. But it sometimes was. Another really important skill set is the transitioning. And that that can be really tricky when you have, you know, I'm going to talk more like if it's more of a process oriented group. And you have a couple members talking about losing a friend to suicide or overdose or something. And then somebody comes in kind of jarringly because maybe it was too heavy. Maybe just they were getting too activated. It was too heavy of a session to talk about. And they bring in something really, you know, they tell a funny story about, you know, somebody that pissed them off in a grocery store. And it can make the people who just were really vulnerable and sharing something really heavy feel invalidated. But you're trying to figure out, like, how do you incorporate this? How do you make sense of this kind of sideways comment? And that's where you're transitioning the what the topic was grief. Right. And you're noticing that there may be something somewhat avoidant by what the member brought in. So you can just pose it as a question like, I wonder if it feels easier to talk about this frustrating thing that happened in the grocery store because it's so hard to sit with grief. And then the conversation becomes about maybe avoidance about sitting with grief. So it's connected to where you started, but you're trying to kind of bring it back and make space for the people in the room who wanted to kind of get out of there and run because there's going to be other members who don't want to sit with grief that these two members brought in. Does that make sense? Hopefully. Okay. And then there's shaping. Right. So there's what do you want to follow up on? What do you want to what do you want to kind of encourage continued exploration for? And in an early group with people who are relatively new to group, a lot of responsibility of that is on the facilitator. So getting quiet people to talk, getting really verbose people to kind of try to be more concise, but you're also trying to listen for and track themes. So if people are talking about kind of day to day life experiences, you're trying to hear for what, what, if anything, is connecting these things. Maybe their themes of feeling helpless or feeling not competent in some way because there's kind of different interaction stories that they've talked about. And so you're really trying to get out of the kind of facts of the day to day and into a more group oriented discussion where everybody can contribute but you as the facilitator saying I'm hearing a lot of invalidation or I'm hearing a lot of avoidance today. I'm wondering how people are kind of holding that or thinking about that. So you're really actively trying to kind of figure out what you're going to talk about as a group. And then the last one I think is the hardest in some ways, depending on your personality or style or your past experiences. But at least in my experience, a lot of a lot of providers, especially those that go into trauma. And addiction like you really want to validate you want to decrease shame you want somebody to feel really comfortable with you and be able to talk to you. And what can be really hard is when what they're sharing or how they're sharing is totally detracting from the group and you have to step in for the sake of the other members, and you know you're going to have that person have a negative reaction you know they're going to feel shut down or insulted in some way. And yet, if you don't, your lead like the group safety goes down because other members are like this guy's been talking for 45 minutes about fishing and like that's not what I came here for. And you will lose trust and safety in the group if that happens. So I find protecting skills, some of the hardest to do some of them, depending on your experience don't feel as hard like if somebody is intoxicated. This is also a co facilitation is really helpful somebody comes in and they're not able to be kind of in the group and I'm using addiction a lot because of, you know, what we all do. But that could be somebody who's manic or somebody who's like really in so much grief or so severely depressed like you're making a judgment call depending on the group depending on how much the group can tolerate when you have a co facilitator if somebody is really not in the space to make use of the group being able to take that person out and meet with the co facilitator where the other one continues to facilitate the group and process what it's like to see somebody in so much distress, or to see somebody who's intoxicated is invaluable, much much harder to do when you're running solo. And de escalating anger, I think is big so when people describe an event especially with PTSD. You can watch them physically get so activated and what they're saying is relevant but they're saying is is pertinent to the group. But as you notice them getting more and more tense their breathing is getting more shallow, you can feel the tension in the room rise and so as a facilitator again to bring safety back into the room you want to name it, and you want to point it out to that person take a breath and get curious about like what are you feeling in your body. How was that. I know I just asked you to kind of take a breath but what do you notice, and then you're trying to engage the other members and understanding, and they're witnessing like when you get activated, your body kind of takes off. So it's this kind of experiential group experience of trying to help regulate at least one member even though you know several other members are probably getting triggered and activated by a lot of expression of anger. So, different different ways of interacting with that. Any questions about that anybody struggled with that in groups that they've done. Are you like this is easy peasy no problem. Oh, 15 minutes. Oh, great, great. Let's let's skip forward. I'm just gonna assume everybody's got this down pat so life, lifelong skills. We've already covered a lot of this. So I think this is a good place for us to maybe kind of end and open it up for questions. But having done, you know, groups with different populations I think with with PTSD, the four things I'd really pay attention to would be engagement, number one, just because we know how prominent avoidance is and there's one thing to get somebody out the door, get them in the room. There's another thing to fully get them to be present. So just having attendance isn't necessarily engaged. Are they willing to share, are they willing to feel, are they willing to interact, engage with anybody in the room. That is, that is huge. And there are a lot of things that can prevent somebody from doing that but that is usually like at the forefront of my mind when I've got new group members or I'm starting a group is, how are you going to make this a safe enough place for people to fully show up. And when they're not fully showing up when they're having a really bad day validate the fact that they got their feet in the door, and that they may just not be able to be as present with us as they normally are but name it, help them understand that that's okay, but that you recognize a difference because when when somebody is really shut down one day versus another day when they're active and you don't see anything. It's like, you're not noticing that they're in distress, or that they're in pain so I think sometimes we err on the side of like not wanting to draw attention. All of these things matter when you're trying to develop safety you wanting to communicate I see you, and however you show up today is okay, but we're going to continue to encourage you as much as you can to fully be with us. Okay. Conflict. If you're doing, if you're doing your job, there should be plenty of it. Because you want people to be real you want people to show up now there are times that the fight flight or the getting into something like there's meaningful differences that get played out and then there's also kind of avoidant and posturing and habit, and kind of how people communicate. So wanting to get clear about, is this a conflict of true differences, is this an avoidance strategy, and being really firm and clear with expectations, especially around violence or around language of just what isn't isn't accepted and I would say one of the most important things with handling conflict is you do not waver on your rules. Somebody breaks the rules, you reinforce you reinforce the boundary. Do not waver, you will not regain the trust of the group. Full stop. And what can be really interesting is even when you enforce the rules, just be prepared. Like, you know, we said that if you threaten to hit somebody you have to leave the room, you enforce it they leave the room, other members may be angry that you asked them to like oh people say that people you know he was just blowing off steam like you can process their anger at you, you can encourage them to talk to you about why you're upset that you held that boundary. But you have to hold the boundary for them to understand that no one, it's not okay for anyone to be threatened. So just know that even when we all agree to a rule, you're still going to get pushback when you hold it but it's, it's so valuable and it's so important. Relationships outside the group. This always happens like this, you know, you can try to avoid it but it's not going to be avoided there's always the group after the group. There's the group and then there's the group that happens in the smoking shack there's a group that happens on the sidewalk. There's additional kind of like, you know, ideally you're helping them avoid less and interact in the world where they're going to interact in the world, and they're going to start to develop relationships and so you can start to realize that some guys might go hiking together I'm giving good examples this time, some guys might go hiking together. You know, they might go to meetings together, there's other things they might do together but when that happens, like what you really want to stress is whatever happens outside of the group, be willing to bring into the group. Because if you start holding secrets and you find out somebody relapse and the group doesn't know but you know you're no longer freed up to be a full group member because you're holding someone secret. And that completely changes the dynamic of the group so you can't catch it all but you can really reinforce the importance of go ahead and have connection with each other outside of the group just be willing to say whatever's happening out there in here and I was really proud is a really tough session but I was really proud of a couple of guys who brought up when one guy got really drunk he called him left horrible voicemails for them. And they actually brought it up in group and we had to negotiate that with the guy called barely remembered but called and kind of did that and it was really uncomfortable. But you saw a total shift in the group afterwards, there was a deepened sense of safety in the group afterwards. And that was all on the members, that means so many members wouldn't have done that, and they did, which was amazing. And then the other thing, worsening of symptoms. So, especially with trauma, especially if you're reducing substances, when they stop avoiding when they approach something it's going to feel worse so sometimes people will join a group and be like oh it's just making me worse or, and you don't want people to like share a bunch of trauma details that's almost always a rule that you don't go into details you talk about the impact of symptoms but not the details of your specific trauma, but even when people interact. Like we said groups are powerful so they're very empathic and they can like feel a lot. And so there's this, this idea of you need to be ready to explain to them like it's going to feel more intense because you're not avoiding, but that doesn't mean you're getting worse. Usually, there are some examples where it might just be a poor fit so you want to be really careful about somebody who might get scapegoated, where you start to see this enactment of everybody's kind of making that person the identified patient or that person can fight against it and we don't have time today but there's strategies to like, not let them do that. But if you can't get them to stop. It's not benefiting the scapegoat and it's definitely not benefiting the members who are doing it because it's it's like you're stuck, you're blocked and so then you might want to think about, like shaping up the group membership and the scapegoat might need to be in a different group. And the thing about enactments. They may happen you usually catch them after the fact. But with trauma in particular, you're going to look for language of internalization of the aggressor if anybody's ever heard that you're going to start to see that or hear that so there's some harsh feedback that people may give that you want to catch and if you know their history you know them as a patient, like with enough background information that can be really healing, because you can talk about like oh whose voice was that or where did that come from you seem really upset with so and so about something that on the surface doesn't seem that big of a deal. And that's that's just something you have to catch because when the person who's been traumatized is receiving that enactment it's very, it can be very triggering. And that's why having two people in the room is very helpful. But if not, these are just things that you kind of want to catch if you're working with trauma survivors, especially in a less structured group. Okay. I did not leave a lot of time I'm sorry I left two minutes. Well, I think that we're all I think wishing for a part three, we're grateful that you have time to do this with us. And maybe we'll have you come back to talk about some more of the details but thank you again Dr Berkman for teaching us about this and I feel smarter for having attended expected places. Oh, David, who's up next I forgot. Yes, let me just refresh my memory here it's on mindfulness for addiction and chronic pain. Well, we'll send out the links. It is Dr. Eric Garland, Dr. Eric Garland next month so again thank you everybody for attending and thank you Dr Berkman. Thanks for having me. Bye everyone. Bye.

Addiction Psychiatry

Advanced Psychotherapy

Group Therapy

Trauma Survivors

Substance Use Disorders

Developmental Trauma

Moral Injury

Cognitive Behavioral Therapy

Psychodynamic Theories

Veterans

Psychological Safety

Co-facilitation