Hello and welcome. I'm Dr. Rob Cotez, SMI Advisor Psychopharmacology Expert and an Associate Professor at Emory University School of Medicine. I'm so pleased that you're joining us today for the SMI Advisor webinar, A Guide to Conducting Outpatient Group Psychotherapy with Adult Patients Diagnosed with Bipolar Disorder and Depression. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers that you need to help care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Leslie Olick. Leslie received her Master's Degree in Nursing at Indiana University and has been an Advanced Practice Psychiatric Mental Health Nurse Practitioner, sorry, Nurse and Nurse Educator for over 40 years. She has taught undergraduate and graduate psychiatric mental health nursing at the University of Indianapolis and Indiana University and is currently an Adjunct Clinical Professor at Indiana University. Leslie has worked in general psychiatric practices as a psychiatric mental health nurse practitioner and therapist with individuals, couples, families, and groups. She has worked in inpatient settings doing psychiatric liaison and in the community doing corporate and legal consultation. She has a private psychotherapy practice for 20 years, during which time she conducted hundreds of groups with persons experiencing a wide variety of issues, including unipolar and bipolar depression, PTSD, trauma survivors, addictive disorders, psychotic disorders, and personality disorders. Leslie has served on boards of professional organizations at local, state, and national levels. She is currently the President-Elect of the American Psychiatric Nurses Association. Leslie, thanks so much for leading today's webinar and I'll turn it over to you. Thank you, Dr. Cortes. Welcome everybody and thank you for coming. I assume that you're here to learn about a guide to conducting outpatient group therapy with adult patients diagnosed with bipolar disorder and depression. I have no disclosures and I hope that you will have some of these objectives covered by the time you finish here. You can read these yourselves and we will move on. I want to give you some background of psychotherapy, group psychotherapy, so that you'll understand how we move forward with that. There were some early theorists and practitioners, such as Moreno, who did the psychodrama. You may have heard of that. Of course, Eric Byrne with transactional analysis, Chris Pearls and Gestalt, Kyle Rogers with his person-centered work, Aaron Beck, who is still doing CBT and at his institute, and Ellis doing RET and CBT. We need to remember that the goal of all group therapies is to make beneficial change occur. You've probably seen many group types of psychotherapy out there. Some are in-depth psychotherapy, some are support groups, some psychoeducation, and self-help groups, such as Al-Anon, NA, that you may refer to. The diagnostic groups that have been studied highly for group psychotherapy include depression, anxiety, folks with maintenance phases of bipolar disorder and schizophrenia, PTSD, substance abuse recovery, postpartum, some good studies on postpartum, perinatal women in group psychotherapy, cardiac rehab, there's tons of literature out there, and many more. How, in fact, do groups help? Why would you even choose group therapy? For years and decades, in fact, it has been an effective intervention for persons with both physical and mental health conditions. Due to the microcosm of society which groups afford, the patient can work on relationship issues in a safe environment, allowing real-time introduction and practice of new coping skills for all involved. So as a therapist and as a prescriber, you don't have to guess if what you're doing is working. You'll be able to see it in front of you in a group psychotherapy environment. Again, it allows the provider to actually see how patients interact. Is group psychotherapy effective? Indeed, it is. Empirical research for over five decades supports the continued efficacy of group psychotherapy. A recent longitudinal study found that group psychotherapy is just as effective as individual therapy for the treatment of psychological issues. Group therapy can treat more patients with great efficacy for depression, anxiety, and substance abuse while using fewer resources. Those of you who are familiar with SAMHSA have probably seen all the group documents that they've published and the tips that they have for doing group therapy for folks with substance use issues. What does this change through groups? The corrective emotional experience in group therapy requires a strong expression of emotion requiring risk-taking, a supportive group, reality testing, recognition of interpersonal and behavioral inappropriateness, typically by the patient themselves, but also by those in the group and the therapist, facilitation of each individual's ability to interact more deeply and honestly. Of course, those components require trust that each member of the group has to have a level of trust in the group, which doesn't come automatically, but comes over time. Again, all groups are about behavioral change. So as you know, in your practices, your participants bring all these things, whether it's individual, family, group, emotions, habits, sensations, beliefs, ignorant beliefs perhaps, ignorant meaning they just aren't educated about what needs to come next, instincts, observation, they've seen things, feelings, thoughts, reflexes. They bring all of that to you and they want things changed and they may not even be able to articulate what they want changed. So Irvin Yalom and his co-author, Molen Lesch, have written a most amazing book and Dr. Yalom started years ago and he identified 11 factors that have therapeutic and change effects. One, the first one is installation of hope. I'm sure you get patients coming to you that are on the border of not having any more hope, if not have crossed over the border and perhaps become suicidal. But within a group, the installation of hope is very important and it gives that person the feeling that maybe I can get better. Again, universality, I'm not alone, they will see other people. My experience has been that many patients come to me and they are sure that no one has the same experience that they do. And indeed, no one has the exact same experience as anyone else. But when they get into a group, they see that they're not alone, that there are enough similarities that perhaps they will gain some hope. Maybe they will believe that they can get better. And other group members and you, the group leader, will be imparting information to those folks. Altruism. Now, if you ask a patient, are you going to group so that you can help other people? Most people are going to say, heck no, I'm not going to a group so I can help other people, I'm the one in trouble. But what happens is, as they tell their story, they actually do help other people. And later on in the group, as the group matures and the patient matures, they realize that maybe my story can help someone else. Number five, this is a lot of words to say, basically healing wounds from childhood. So the corrective recapitulation of the primary family group basically helps people heal wounds from childhood. And that does happen in groups as well. And clearly, development of socializing techniques. Listening is one of those socializing techniques. You may have patients that you think they will never listen to anyone else if they go to a group. And indeed, the group will impress upon them that they need to. And you, the group leader, will be able to help with that. You can set up some ground rules, but we'll get into that in the nuts and bolts. Other therapeutic factors include imitative behavior. Some of your patients will say, well, if he can do it, I can do it. Or if she can do it, I can do it. Interpersonal learning, understanding and interacting with others. Group cohesiveness is what we aim for as group therapists. Members working toward the same goal, acceptance of each other and group process. And as we talk about the phases of group growth, just like persons, people have group growth. You can watch children grow and hit their milestones. Groups have the same thing. Is children's growth linear? No. Group growth is not linear either, but you still see the milestones hit and accomplished. Catharsis is the process of releasing feelings. Patients in groups can do this. They don't want to get stuck on that. And your job as a group leader is to help them not get stuck doing that. But they need to do that. That's part of moving on. And then clearly existential factors are very important for group growth and for individual growth. So therapeutic factors become mechanisms for change. And then we move into stages of group growth. So Bruce Tuchman was an early group observer and psychologist, and you still see his things. Okay, so ancient history, 1965, I can hear you all laughing. However, if you look up team, team unity, teamwork, in corporate settings, my hunch is you're going to see some of these things come forth for growing teams, uniting teams, team growth. And they happen to be quite parallel in many ways to Irving Yellum's stages of group growth. So forming, as Tuchman knows it, is very similar to orientation in Yellum's group growth. Storming is very similar to conflict, dominance, and rebellion. And these things are orientation. Obviously, as group members start to know each other, group session one, perhaps group session two, who are you? What are you here for? What are your goals? Part two, conflict. Okay, who's in charge here? And do I believe that they can handle this? So that may be aimed at you, or it may be aimed at other group members, depending on the makeup of your group. Who's in charge here? And do we really need to listen to them? And do I need to listen to these other people? You will get past this. I know a lot of group leaders aren't quite sure about that, but you will get past this. Group norms, as Tuchman says, will occur in your group. It becomes a norm to listen to other people. You have to set that boundary at first, and then it becomes a norm. Performing is when there is cohesiveness, and the group accomplishes group work. We can also talk more about that, and I have a case study, I think, that embodies that. And then there's termination and adjournment, and you're careful with that in groups, just like you are in individual therapy. I really like this picture of the baby elephant, because I believe that sometimes growing toward cohesiveness feels just like baby steps. So go ahead, laugh at this, but I think that it's pretty true sometimes of group growth, just as it is as you work with individuals. So as I said before, groups work toward cohesiveness. So why is this important? Well, most patients do come to therapists with low self-esteem. Situations they feel are impossible and or poor interpersonal skills. Groups offer the opportunity to get things off one's chest and not feel so alone and unique. Remember those therapeutic factors of universality, installation of hope. However, the major value in groups is that after doing these things, there is acceptance by the rest of these group, the group members. People can talk about what they're dealing with, and the group will accept that. Of course, I'm talking about ideal groups, but there are ways to work with that. Therapy groups generate a positive, self-reinforcing loop. Trust, self-disclosure, empathy, acceptance, and back to trust. A main focus of group therapy is here and now. The leader has to show relevance to here and now work. Your patient is there because they can't keep a job. They can't work with their family. They're about to divorce their spouse. They can't live with anybody. Everybody hates living with them. So that's important. Now, it may go back to something that happened in childhood and that therapeutic factor of healing wounds from childhood. Okay, let's go back to that. You're not going to relive the childhood. You're going to help that person work with the here and now on how to get past some of those feelings that are in their way. You can watch in front of your face, in your group, are people pushing each other away? Are they not communicating? Who's pushing their chair outside of the circle? Who's pushing their chair outside of the circle and crossing their arms over their chest and looking somewhere else in the room and not clearly not engaging in group? Who's verbally aggressive? Who's not listening to others either by withdrawing, as the previous person I described, or by interrupting? Who's doing all that? Those are here and now behaviors. Those are behaviors in front of you that you can work with. Those are behaviors that you can work with to help that person change their lifestyle and be more successful. Group leadership roles and responsibilities. So yeah, you have a lot of responsibilities, but is it any more than you have in individual therapy? Take a look. Create the group by determining each potential participant's readiness for group. Well, when you start working with somebody in individual therapy, you have to find out how ready they are for therapy. They may not be ready for therapy. They may need to come back. So you'll take a look at that for each potential participant. You'll know the importance of assessing which patients currently are not able to participate in the group. If you have someone who is having a new bipolar episode, they are exhibiting symptoms of bipolar disorder, they are not ready right now to enter a group. They cannot cognate for the group. They cannot follow the norms of the group at that moment. When they are more managed, when they're back on their meds, when their disorder is more managed, and they are in a maintenance phase, they will be able to come to your group perhaps. And you and their prescriber, or if you are their prescriber, will know when that's happening. The therapist must have a genuine acceptance, concern, and empathy before being able to be an effective group leader. Why is that? Because the group leader is the role model. You're role modeling these characteristics in group. A lot of your people haven't had anyone role model those things for them in the past, whether it was not in their families, whether their families were so long ago they don't remember, and since then they've had a really hard life. You're the role model, just as you are in therapy, but you will be with more than one person in a group. So the leader strives to attain this with the group. The leader hopes people will relate what they are and be very present. The patient is recalling, feeling, seeking. You, the therapist, are listening, welcoming, sensing, helping those folks, just like you do in individual therapy, but you're going to do that with your group. So the role of the leader is to create a safe place to share feelings and ensure that rules are clear. You don't want to bring people into a group and make it, you know, no rules, no boundaries. People don't feel safe that way, just as with children who push the envelope. They really do want rules. They really do want boundaries. They'll fight you on them, but they want them. The group is the same way. They may challenge you, and that's, remember, the second stage of group growth is all about conflict and rebellion. They're going to push and see, are you really going to enforce these rules? Are these really important things for group growth? You have to make it clear that they are. Again, with genuine acceptance, concern, and empathy, you need to do those things. Rather than directly interpreting, the leader bridges the members' experiences by inviting them to elaborate on emotional experiences in the room. The leader's way of relating to feelings can become transformative. Again, you're the role model. If you listen well to your group members, the other group members are going to have a role model to do that as well. They're going to learn new behaviors, so you're the one establishing boundaries for the groups. This picture has boundaries, right? There's a huge TV, and within it is the picture. Boundaries help people learn how to be respectful of themselves and others. I know in my experience as a psychotherapist, I've had patients, couples that have come in, and they don't know how to be respectful of each other, and people in groups sometimes don't know how to do that as well. Your job is to help them learn how to do that because that will help them be more successful in life outside the group. You maintain the group by being aware of issues which may interfere with cohesiveness. Even as you work toward cohesiveness, you have these boundaries for the group and that help the individuals in the group. The group won't be cohesive if nobody's listening to each other, if there's not respect for each other. The therapist must be aware of group process, individual process, interrelational process, dyads, triads. Now, even if you don't consider yourself a family therapist or a group therapist, I'm sure when you see individual people, they want to bring their families. If you're doing medication management, some days your office is more full than you ever imagined because there may be three to five more people in your office because the identified patient needs their support system around them. When that person's in there, there may be another person who's got their arms folded over their chest saying, I don't think that's the right medication for you, and the patient is looking at you for guidance and maybe the rest of the family is. So you're still doing all kinds of education, all kinds of teaching, and you're still keeping track of everybody in that room. You'd be doing that in group as well. I totally enjoy working with a co-therapist. Extra eyes and ears are invaluable. You may not have the luxury of doing that. If you do, it's wonderful. If you precept students, it may be very useful for the student to come in and they are another pair of eyes and ears. They may not be as experienced as you are in group work or in psychotherapy at all, but they are another pair of eyes and ears and they will learn a lot from you as well as a group, as a group leader and as a role model. So I would highly encourage you, if possible, use a co-therapist, have a co-therapist. Of course, make sure that it's somebody that you think you can work with, always. But this can be very useful and so beneficial to the group because the group can see you. What I have found is the group loves seeing the co-therapist disagree and it's a perfect way to role model conflict resolution. So if you have your co-therapist and you have a different way of approaching something, talk it out. They're learning from you as you do that. Group leaders must focus on transfer experiences and skills learned in group to use in their real life. The more they see you do, the more they see you and your co-therapist do, the more they learn. So is it exhausting? Sure. Is therapy exhausting? Sure. So I would encourage you to arrange for your own peer support. Have people you can talk to about your group experiences after the group. Run things by other experienced group leaders or other therapists and get some ideas. So let's get into some nuts and bolts of leading a group. So getting started. Remember I said your goals must be clear and what is your task at hand and you need to verbalize that with your group members. I find that eight participants is a sweet spot for me. Some people love six to 12. Some people like 15. I would encourage you to experiment and see what number works the best for you. It can also have to do with the makeup of the group. If I have several depressed people that aren't engaging and I have a couple folks that have perhaps traits of personality disorders and want to monopolize, I wouldn't have more than two folks that really want to monopolize. And we can talk about that later as well. But you may, depending on the makeup of the group, you can decide the number that you feel would be effective and you may want them to introduce themselves. I would definitely verbalize ground rules. Again, you're making your goals clear. For instance, our time together will be limited to 60 minutes. Everyone in group will have five to seven minutes to share and we need to be respectful of the speaker and do not interrupt. So you, the role model, will impart to your group members to use their active listening skills and you will exemplify that. Assist the different personalities to stay on track. And one thing that I find is that folks coming to group often have trouble with priorities. So in that five to seven minutes, you need to help them practice prioritizing because five to seven minutes doesn't seem like a lot if there is a lot of rambling, they don't really know how to express what is important to them. So it's a wonderful way to practice that and help them learn how to do that. The therapist can determine the procedure of the group or it can come from the group. For instance, the group, while the group is still new, the therapist may repeat expectations, which may include reminding the group not to interrupt one another and allowing each person to complete the check-in before the person will answer questions. So in saying to Sondra, Sondra, it's your turn, would you be open to answering questions after you check in? And they have the option of doing that. Now, at times you want the person to answer questions because there may be some questions that you also have. And perhaps after trust is formed one time, you may let Sondra know that you think that it would be very important for her progress to be able to answer questions. So at the next group, perhaps she would be open to that, you're going to encourage her to do that. So you have to decide what's going to help the individuals and what will keep that individual participating in the group. The other thing is you have to consider if there's one person that's not sharing in the group, that does affect the group. The group may say, well, how come we're all working so hard and so-and-so isn't? And that's a perfectly good question. So you'll have to decide where that person is, if that person is still appropriate for group, I'm not suggesting asking that person to leave, but if the person is struggling with something and actually not capable of participating in group, that's something you'll have to assess. So you're assessing everything all the time, just like you do in your office with everybody else. But this time it's more than one person. Again, continue to address goals that were set by each individual and by the group. And talk about revisions. Now, if someone's constantly changing their goals, that's an issue for group too. So bring it up just like you would in individual therapy, but it becomes a group issue because the group is expecting that person to do one thing and the group may have questions about that. And that is another way that people learn to adhere to social expectations, which is something that many of our folks don't know how to do in group or outside of group. And always, always repeat confidentiality. What you see here, what you do here stays here, just like you do in individual therapy. So if you choose to have check-ins by your individual members, talk about what you'd like to hear in this and what can be useful to the group. What did the patient do over the past week since the last session to work on their goals? Self-care, what are they doing for self-care? Many of our folks need to improve that. You can also ask who needs time today? There may be people that periodically feel like they're progressing on their goals, they don't need a lot of time and are willing to give up their time to another person. Now, you don't wanna see that happen a lot because there may be something they need to talk about that they're kind of guarding. And again, that's up to you, you're an experienced therapist, you need to assess those issues. So they need time today, it can be a new or a continued issue. And as a tip, one therapeutic issue for the group may be how long a member's particular issue can be continued using group time. I've read several books and sometimes in ancient times and historical times, folks would meet as a group and if someone brought up the same issue three times in a row, the group decided they wouldn't listen to it anymore, that the person wasn't working hard enough on it. I'm not saying kick people out because they're bringing up the same thing, but you might reframe their issue and say, so tell me one thing you've done to work on that issue over the past week. And if they're at a loss, then obviously it's time to set a new goal with that person. Perhaps you need, maybe you would consider doing this toward that goal over the next week. So you will decide and the group can also help you decide what needs to be worked on next. Different groups will have different needs and different expectations. Group principles can be used for all kinds of diversity in groups, work situations, community groups. Once you learn how to lead a group, you will actually be more skilled in those meetings you may not like very much or that you kind of dread going to once a week or once a month, perhaps work, or you will enjoy more working with community groups, your volunteer kinds of things. You can use these skills in meetings during evaluations with peers and supervisors. Knowing these principles is really a good start to becoming a better group leader in any situation. So treating the patient with bipolar disorder. Obviously, we talked earlier about how when a person is in an acute phase of bipolar disorder, not a good choice for group psychotherapy. You wanna wait till they're more in a maintenance phase. And even well-maintained patients may decompensate. So you just need to know that. It's no different than if you're working with them individually and there are ups and downs. When a patient is well-managed and in maintenance phases of treatment, these patients can do well in group therapy. One author suggested that cognitive behavioral therapy, interpersonal therapy, dialectical behavior therapy, psychoeducational groups are very useful with this population. There are data out there and in some of my references at the end of this presentation. Evidence is showing that increased medication adherence, fewer relapses and mood disturbances and overall better functioning can be obtained with homogeneous groups of bipolar disoriented folks. I'm sorry, of people with bipolar disorder. However, there is also evidence that diagnostically heterogeneous groups can be effective with persons with bipolar disorder. So that doesn't say that only homogeneous, I'm sorry, diagnostically homogeneous folks will benefit from groups. Oh no, folks with any kind of diagnosis can benefit from groups. I do have an interesting case study that I'll share about a person that I had who had bipolar disorder. So useful facts, the World Health Organization found that globally more than 300 million people of all ages suffer from depression, more women than men. Among older persons, there's a higher burden of depression in women than men, which seems to be attributable to a greater susceptibility of depression and more persistent depression and a lower probability of death in women. And many older adult women become depressed even if they have no history of depression. They may have lost their spouse or partner, all their friends, family doesn't need them the same way anymore. And so they have experienced loss after loss. It's been found that CBT is an effective treatment in post-acute treatment for geriatric patients with physical illness and comorbid depression. Psychological benefit, functional and cognitive decline can be reversed by group psychotherapy. As therapists, we realize that most of our patients need to learn to trust themselves. They come to us often after trauma and usually after a series of unproductive, if not self-destructive decisions. Our job is to help that individual learn to trust themselves while also creating a trustworthy group voice. In his book, The Wisdom of Crowds, businessman James Cervicki talks about the wisdom of group. He encourages individuals to embrace a willingness to recognize that the group has diversity, that the group has done work to become cohesive and use your own personal wisdom to inform the group, not to dictate. So I may continue on and come back to the bipolar disorder case study if that's all right, because I don't want to miss sharing with you the data that I have about working with transgender folks. So I'm going to talk about the transgender and gender diverse individuals and depression because we're talking about depression and bipolar and the effectiveness of group psychotherapy. One study indicated that transgender persons experienced depression at a higher rate than the general population, and that one factor in this can be a perception of a lack of community tolerance. The measured folks were significant at 40 to 50% of study participants compared with 9.1 reported in the United States general population. As a group therapist, it was found to be helpful to be known in the transgender diverse community and as competent in transgender issues. It was also found that using extra precautions with confidentiality was important. Those participants may not be known as being transgender diverse in the larger community. There were extra controls used when folks would check into their groups. Please discuss correct pronouns with the group after learning the usual pronouns preferred. There may be some participants who do not want a pronoun used. My experience is that some of my transgender diverse patients don't want a pronoun. They only wanted their name used. These authors in the study facilitated discussion in the group about their cisgender privilege, which decreased barriers to communication with their participants. And I put in a couple I thought very useful references for you. Oops, sorry. All right. I also wanted to make it clear that Psych Mental Health RNs, if any of you are on this webinar, that you have to be careful regarding group therapy. Standard 5G in the Psych Mental Health Nursing Scope and Standards lists under competencies that absolutely you can use the therapeutic relationship and counseling techniques, both in the individual and group settings. However, it's important to check and see if your state lists counseling as part of the definition of your RN scope. And it's important to check your state practice act. As we know, counseling and therapy are often used interchangeably in the literature and in public forums. Though there may be some arguments if there's title protection for those terms. So check and make sure if there's title protection when you use terms such as therapy or psychotherapy. Obviously, if you're not a mental health therapist, you cannot allude to being a mental health therapist and that would just be for anybody. Or a mental health counselor could be a legal problem if there's title protection. So just check on that. And again, as we know, therapy is commonly used as a terminology. Now, I'm going to go back to the case study with my patient that had bipolar disorder, wonderful woman. She was in one of my mature women groups, which was for women over 50, had a high incidence of depression in the group with folks with depression, as well as I had some folks with eating disorders, maintenance phase of bipolar disorder, other kinds of losses that they may have had trauma. And this woman was in a group of eight that had many of the participants had signed up for another series, had been in a previous series, as had this woman, we will call B, who was about 58 years old, divorced female, living in an independent apartment in an active senior community. And was transferred to group each week by the one of the facility drivers and one of the community drivers. She had a long-term treatment resistant depression. And then recently in the past four to six years had been diagnosed with bipolar disorder. She was estranged from her family, had bipolar disorder that was well-managed lately, and was referred to my group by her treating psychiatrist due to depression and isolation. She knew several group members from the previous group, had been a participant, productive participant in the previous group. This group at this point was in group session number seven. So it was pretty much in the cohesiveness piece in a 10 group series. Norms had been established and members were in, like I said, the cohesive phase. B came to group and could not sit still this particular time. She was muttering things kind of incoherently, didn't make sense. She was not physically loud or aggressive. She was able to follow directions. She knew where she was, she knew who she was. She knew why she was there. Well, she knew why she was there. She knew she was attending group. She was not frightened. She was not verbally loud or aggressive. And she was not, I had, I checked with her. She was not suicidal. Clearly was not quite appropriate for group that day. I asked her if the driver had left. The driver had left already. And I had our secretary call and confirm that he was not coming back for an hour. She didn't have a ride home. The physician that had referred her to our group was not available to see her at that particular moment would be closer to the end of group. So the question for the group leader is what? What I prioritized was, is she safe? She seemed safe. She felt safe with the group, but did the group feel safe with her? She was pacing, looked restless. Would it be more traumatic for the patient to call a taxi and send her home? Would it be more traumatic for the group to do this? Would the group, would the patient feel safe if a taxi were called? So I was able to discuss letting Bea stay with the group. I asked her if she would stand outside the door for a minute while I discussed it with the group. She understood that it was the group's decision and that if the group didn't feel comfortable because she was very sick today, that we would work on getting her home or to the hospital, or that we would look at some other options. So she stayed by the door. She knew it was important. All members stated they would be comfortable if she stayed and that she could sit behind the group because everybody knew she might need to pace a little bit behind the group. She was still going to be considered a member of the group and would be called upon periodically if she felt like she could say something that the group could hear, she would do it. She was invited back into the room. I asked her if she thought she could not interrupt the group as they spoke, but we would give her a chance to speak and she said she could. So she would sit at times, stand at times, pace a little bit at times. Sometimes she would start to speak and we would say, do you think you can wait a few minutes? And she would, and then we would give her the opportunity to speak. So she stayed safe. The group continued on with their work. She was able to verbalize that she was grateful for the group letting her stay. And after group, the psychiatrist was able to see her and changed her medications around. At some point, eventually she did wind up back in the hospital, but I was very impressed with the group, with the cohesiveness of the group, the group norm that day. Well, the group norm was always, let's pay attention to other people that had gotten to that point. The cohesiveness of the group was very important. This would not have worked, I don't think, with too many other groups, and certainly not with a group that wasn't in the cohesive phase of group growth. They united to make sure that she stayed safe, basically, and they continued on with their work. So I thought this was a very good example of staying in the here and now, of altruism, of universality, because many of the group members could look at her and say, there, but for the grace of God today, go I, because they too were in recovery from bipolar disorder. And it strengthened the cohesiveness of the group. So I guess I shouldn't say other groups couldn't do this. They could, and I was very impressed with this, and I feel that it showed the power of groups. Okay, so additional thoughts, and there may be some questions about that, and that would be perfectly fine. Additional thoughts for you, remember it's the group leader's job to explore each individual's uniqueness within the group setting. Even during these times of COVID-19, it's possible to reach many persons in need through group telehealth. I have a good reference at the end of my presentation that you can learn more about group telehealth. Consider more frequent use of group psychotherapy. It's a wonderful treatment modality with which you can reach lots more people than you can individually, and that if you are interested in training for group psychotherapy, the American Group Psychotherapy Association is a wonderful resource for that. Thank you all so much, and I am open to questions. Okay, terrific. Thank you so much for a wonderful presentation, Leslie. I really appreciated a lot of your remarks, and the clinical example that you gave, I thought was really helpful and really sort of put a lot of things into perspective. So before we shift into the Q&A, I wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. So you can download the app at smiadvisor.org forward slash app. All right, so now it's time for the question and answer component of this talk. So if anybody has questions, you can just put them into the chat. A couple are coming in already. So one of the first ones that comes to, that I wanted to discuss was, Leslie, if you could say a little bit more about some strategies that you have found helpful if somebody seems to be monopolizing the conversation within a group therapy meeting. Okay, thank you, Dr. Cortes. That's a very common question and a very good one because as we all know, in trying to work with more than one person in a sitting, we get that no matter how many are in a group. What I have found to be useful is considering what the challenges are of the patient that seems to be monopolizing. And typically the first session, the first orientation session, you kind of get a feel for what's going on with each of the group members, possibly by the second one. And if there's somebody who seems to be displaying that behavior, even into the second one, after reminding folks that it's important to not interrupt and important to pretty much stay to their timeframe. Sometimes you're gonna get folks that really find that hard to do. And again, I find that to be relatable to frequently those folks can't set priorities. They don't know how to express themselves and identify priorities. So what I tend to do is say this, that it sounds like there's a lot going on for you all the time and that your thoughts are kind of jumbled and it's really hard to name what's important for you. So I'd really like for you over this next week to write down about five things that are really super important to you. And when you come to group next time, I want you to identify with the group the most important thing that you wanna work on here in group. Because you've told us, and most of the time your patient will, you've told us that this has been going on for a very long time and you're recognizing feelings that you haven't recognized before. So let's take it one step at a time so that we can help you accomplish what you'd like to change with that behavior. So I try to help them identify the boundary that they get their, whatever it is, five minutes, three minutes, and that their task for the next week is to have a priority that they wanna work on. And typically, again, they don't have a priority and that's what's very frustrating for them because they can never tell if things are getting better because it's all a big jumble. And we've all worked with people that, what would you like to change? Oh, I just wanna be happy. So that doesn't work, right? You've probably never seen that work with a patient when they have a global desire like that. Helping them identify something very specific gives them a chance to actually chew on it, to actually get hold of it. So hopefully that will help you with your going forward. Yes, thank you. I think that was really great. Some really wise words. You know, another question that kind of came up is, you know, especially for people who are learning to do individual therapy, sometimes the idea of doing group therapy can be a little bit anxiety provoking because people are learning kind of how to listen on a number of different levels and they're just sort of getting acquainted to doing individual therapy. What kind of advice do you have for new therapists who are doing groups? That's a wonderful question. Thank you so much, Dr. Kotez. I would encourage that new therapist to go with an experienced group therapist and be part of, you know, observe the group and just have the, I would take students with me and I would introduce the student. I would get the, I would demonstrate respectfulness and I would ask the group if they're okay with having this student be present and the student, you know, and I've done it both ways. I've either had the student be a silent observer or I've had the student be a participant in the group as far as giving their thoughts at times as well. But I think that a new therapist needs to be exposed to group work and to see, now this is my bias, the magic in group work and to get excited about that because I think one reason we don't see as many groups as we could is that individual therapists don't understand how beneficial groups can be and how much it can help them with their patients. So I would like all individual therapists to have a feel for group therapy and give accurate information about it. Does that help to answer your question, Dr. Koteas? Yeah, yeah, I think that's really great and I really agree with this idea about the having co-therapists involved when you're able to. In some of my work, I found that having a co-therapist involved and to be able to get two different perspectives in real time can be quite helpful and beneficial. And also, I think that it takes a lot of the pressure off. Like for example, like if you might be fumbling for something to say, sometimes the other therapist can kind of kick in and address the group. So I really like that idea about new therapists coming in in the group setting. You know, one thing, sorry, go ahead. No, I was just gonna say, I totally agree. I love having co-therapists and I think it's very beneficial to the patients in the group. Great, so you know, one question I had is when you're talking about some, when you're talking to a person that, you know, you're approaching the idea of group therapy with them and let's say maybe they've only done individual therapy before, how do you normally pitch this idea to them? I think that some people might be really, really interested in doing group work, but other people might be really sort of, you know, concerned about the confidentiality or just sort of concerned about being around other people and really be focused on doing individual work, which is fine. But I just, I'm curious a little bit about how do you pitch the idea of doing group therapy with people? Oh, I love this question. Because so many individuals that, so many of my patients that come for individual work are, they're kind of frightened by group therapy. They, exactly, the confidentiality, I don't wanna share all of my problems with other people and also, I don't wanna listen to other people, you know? I want this time for me. And, you know, and there are times when I'll say, well, you know, you're not ready, you're not ready for group therapy. And I make it, you know, kind of something to strive for. And I'll say, well, you know what? Let's work on this and get you ready for group therapy. Well, I'm not sure I want group therapy. I said, oh, as you improve on this situation, I bet you you're gonna love group therapy. So I'm always very positive about it, but I also tell them, you know, depending on what their issues are, you know, you can't get along with so-and-so, you've been fired three times, you and your spouse aren't getting along. What do you think's going on? I don't know, I don't know. People are just, I just, I don't understand why this is happening. And I'll say, well, you know what would be really useful would be to join a group of people that have some similar issues and kind of see what comes out for you, because there's gonna be an experienced therapist there. If some of those things start happening, they will help you identify what's going on. And I think it's gonna be a very successful situation for you. So I term it, you know, I put it in terms of, it will help you be more successful, it will help you take care of these issues, especially if they're interpersonal issues that, and most of our patients, I mean, come to us with interpersonal issues. Yes, intrapersonal as well, but it reflects as an interpersonal issue. Don't you agree? Yes, exactly. I think that's an excellent point. Yeah, that's, I think that's really helpful. And one of the things that sort of resonated with me about it is it's sometimes not exactly a one-time conversation, you know. I think that as with suggesting any kind of new treatment opportunity or intervention, sometimes it really just, it may take time, you know, and it may take a series of conversations and it may depend on kind of where people are in their treatment. I agree, and I think a lot of times, if a patient hasn't experienced group therapy before, it's all about how much trust that patient has with you. And if you think that this is the best treatment for them, they may give it a go. But if they don't trust you yet, if they're still kind of working that out, I have experienced that it may take, as you said, more than one conversation. Yeah, you know, one thing I wanted to circle back to was this concept of the installation of hope. Because I think that, you know, for people with severe mental illness, and you know, really for anybody, this whole concept of providing hope is so important. Can you talk a little bit more about how you're intentional about the installation of hope? Gosh, I, so when new folks come into group, or when a group is forming, or when I'm referring people to group, I tell them, this may be more helpful, I tell them there is, there are three people that will be in group with you that have experienced such similar situations. I would like for you to meet them because they're dealing with it. And there are two folks that have done really well with that and have moved on to another issue. And I'd really like for you to hear how they've worked with that issue. So, and the other thing I tell people is, and I'm sure in your experience, you've done this as well, Dr. Kotez, is, you know, I've seen people with similar situations to you, and I've seen people get well. And, you know, none of us can say, everybody I've ever worked with with this has gotten well, because it's not true. But I have seen people manage their issues and be successful in their lives. And I want you to know that. So I often will have a hard conversation with them about instilling hope even before they go to the group, and then talk to them about the group. And there are other people that have experienced similar things who are doing better that you will meet in group. Does that help? Yeah, that's really helpful. You know, I think that this sort of personal conviction and experience of seeing people do well can really be very, very powerful. You know, and sometimes that's much more powerful than saying, you know, this is the efficacy and these are the percentage, and this is the data and the research. Like that, I think, in my experience, has often gone a lot further in, you know, communicating help is this idea of seeing other people get better. I agree. They need that hope. Absolutely. Everybody does. Another question I had for you is, you know, at the end of the talk, you talked, you mentioned a little bit about how COVID-19 has changed things and sort of the move to virtual groups rather than in-person groups for most people, you know. And I'm just sort of wondering a bit about how that transition has been for groups. And, you know, has there been any unique considerations that you've had to make as a therapist in groups doing virtual groups? Or is there any sort of thing that, any maybe tips for working with groups in a digital kind of space? Unfortunately, I don't have any. I'm learning about it as well and would love to do some. So I am trying to do some research on how to get that going as well. But I know, I mean, I've got some references and I know that there have been organizations to do that. And I think it's wonderful because as we know, teletherapy, we can reach people in rural areas. We can meet people all over. And I think that if there are seniors in the population that are isolated, that I think it would be so useful to help them figure out how to use the computer if they haven't figured that out already and go to a meeting on Zoom or on another platform on a regular basis to decrease the isolation and depression that may happen. But no, thank you. That's a great question. And I am learning more about that as well. Mm-hmm. Okay, sounds good. You know, you had spoke to the, sometimes this magic that can occur within a group and that kind of really resonated to me because it's something that I've certainly seen in my experiences doing group therapy. And it can sometimes be hard to put a finger on it. But I guess what I'm wondering is, from kind of what, can you say a little bit more about what led to your interest in doing more group therapy? When I obtained my initial graduate degree, I was educated by several people who were quite skilled in group. I was educated by a protege of Moreno's in psychodrama. And several of my other professors were very, as I said, very skilled in group, were AGPA members. And they wanted to make sure that we knew how to do group. And ever since then, I have just, I loved it then, and I have totally enjoyed doing it since then. I've tried to keep up with the latest literature. And I just find that there is a magic in groups that, and people do change. And people, you know, I love how the isolation changes and how the group frequently will, after the group is over, become friends and know that they have a common bond. And I don't know if you have found that in your groups as well, but I've done a lot of groups with older women. And there is, as I told you in the statistics, there's a lot of depression in older women. And in fact, that's why they were referred to the groups. And it was very useful. They learned how to set goals for themselves, but also they learned how to not be isolated. So I've done young, I've done groups, I've been honored to do men's groups. It's just decreases that isolation and increases that universality. And I just think that's magic. I think, you know, people don't understand that until they get into a group where they see people getting better. Well, thank you so much, Leslie. I think that was just a really wonderful presentation. And we really can't thank you enough from SMI Advisor about, you know, for giving this talk to us today. So now to kind of wrap things up, if anyone has any follow-up questions about this topic or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. And the consultations are free and confidential. So SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the mental health, addiction and prevention PTCs as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. And with that, thank you so much for joining us. Until next time and take care.

Dr. Rob Cotez

SMI Advisor webinar

outpatient group psychotherapy

adult patients

bipolar disorder

depression

Leslie Olick

group therapy benefits

trust and confidentiality

managing monopolizing behavior