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Group Psychotherapy Column: Civilizations Die From Suicide not by Murder 

“Civilizations die from suicide, not by murder” — Arnold Toynbee, Historian

Tevya Zukor, Ph.D.
Tevya Zukor, Ph.D.

The summer has started with the tragic deaths by suicide of two prominent celebrities – fashion designer Kate Spade and Chef Anthony Bourdain.  While tragic, I didn’t have much of a personal reaction to the death of Kate Spade. As anyone who has seen me in person can attest, I don’t know much about the world of fashion; it has just never been an area of interest for me. However, having spent the last decade and a half in collegiate mental health, I am acutely aware of how prevalent thoughts of suicide are for many people; especially those who feel that their livelihood is dependent on crafting a carefully sanitized public image. While Ms. Spade’s death was sad and tragic, the personal impact on me was initially minimal.

While Ms. Spade’s death was sad and tragic, the personal impact on me was initially minimal.

The loss of Anthony Bourdain was different.  I had the chance to meet him a few years ago when he spoke on the campus where I was working at the time.  While our conversation was brief and overall insignificant, it has always been a cherished memory. For years, I have admired and respected Mr. Bourdain for who he was – a cantankerous, but insightful, man who did not apologize for the many years of self-destructive behavior in his youth and who passionately believed in equality and social justice. In many ways, Mr. Bourdain represented who I wanted to be – a person who could utilize their self-defeating and self-sabotaging behaviors of the past to advocate and shape a better existence in both the present and the future; a man who recognized his own flaws, but did not let that silence him from trying to make the world a better place.

Anthony Bourdain’s death hit me hard.  My mind flashed back to that fleeting conversation I had with him; not the content of the conversation (which has long ago been lost to memory), but rather to the vibrancy and enthusiasm of the person I admired.  I thought, with great sadness, about the people who were closest to Mr. Bourdain and the profound sense of loss they were experiencing.  I thought of the multiple times, both personally and professionally, when I have been confronted with the immediate aftermath of a completed suicide. There is a profound sense of shock and incongruence of those scenes – the dichotomy that one life has suddenly, and violently, ended while thousands of others continue uninterrupted and unaware of the tragedy that has occurred next to them.

I also thought about the work that we do as mental health professionals; where our “Prime Directive” is to keep people alive and safe. It’s a world that is actively avoided by many people.  Our jobs requires a certain type of empathy for pain and struggle that many find too overwhelming. We often work with clients who are teetering on the line between life and death. It’s a scary place for one to find themselves; both for the client and the clinician.  Yet, as mental health professionals, we have a sacred obligation to help shepherd even the most hopeless and despondent of souls towards finding their meaning and purpose once again. For many clinicians, this is both the most stressful and anxiety-inducing part of our jobs, but also the most rewarding.  There is no greater honor than being able to assist someone in finding their way out of the darkest place of their life.   There is no amount of monetary compensation or praise from others that can beat the feeling of knowing that we were in the right place, at the right time, and with the right set of skills to prevent an unneeded death.

At the risk of being biased, the work we do as mental health professionals is some of the noblest in the world. We engage in our trade to try and prevent tragedy whenever there is a risk. We are on the front lines of the fight many people have between life and death. High-profile suicides tend to remind us of the true stakes of our work. From one colleague to another, I offer my deepest and sincerest THANK YOU for all that you do to help those in despair.  What we do is meaningful and profound, even though it is rarely glorious.  Sometimes it is important to hear that sentiment out loud.

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Tom Treadwell, EdD, T.E.P. C.G.P.
Tom Treadwell, EdD, T.E.P. C.G.P.

Cognitive Experiential Group Therapy: A model for a variety of clinical and college counseling settings

Thomas Treadwell Ed.D., CGP, Deborah Dartnell, MA, MSOD, Ainsley Stenroos, MA, & Brittni Gettys, BA

Cognitive Experiential Group therapy is a powerful tool for growth and change. This model of group therapy is designed to include 10-12 individuals who meet face to face to share their struggles and concerns with 1-2 trained cognitive experiential group therapists. The power lies in the unique opportunity to experience, warming up, action, and sharing in a group environment allowing multiple perspectives, support, encouragement and feedback from other individuals in safe and confidential environment. 

Cognitive Behavioral Therapy (CBT) was established by Aaron T. Beck (1967, 1979), and involves several techniques to challenge negative thought patterns and increase engagement in positive and success-based experiences. Psychodrama group therapy was created based on work by Jacob. L. Moreno (1953), and involves experiential, interpersonal exercises to raise awareness and reduction of internal conflicts in order to change negative relational patterns. Although CBT is a robust, proven, and very effective treatment approach for many mental disorders, including the big ones like depression and anxiety it is sometimes criticized for being overly structured and intellectually oriented (Young & Klosko, 1994; 1996; Woolfolk, 2000).  As a result, some group therapists today use an approach based upon CBT or identify with a less structured approach called eclectic (Kellerman, 1992) that typically employs techniques that come from cognitive behavioral therapy and its related research.  Beck reports, “My employment of enactive, emotive strategies was influenced, no doubt, by psychodrama and Gestalt therapy” (A. Beck, 1991, p.196). Psychodrama is an eclectic tool to enhance the cognitive and behavioral change. Several practitioners have worked to integrate CBT into the Psychodramatic model by highlighting the ways CBT enhances psychodrama exercises (Boury, Treadwell, & Kumar, 2001, Treadwell, Kumar, & Wright 2004), adapting psychodrama to include the exploration of irrational beliefs (Kipper, 2002), and considering the way in which psychodrama could be considered a form of CBT (Baim, 2007; Fisher, 2007; Treadwell, Travaglini, Reisch, & Kumar, 2011; Wilson, 2009). The blending of the two models yields a complementary approach to multiple problem-solving strategies (Treadwell, Kumar, & Wright 2004):

  • Both the CBT and Psychodrama models stress the discovery process through Socratic questioning. The use of certain structured CBT techniques within the context of psychodrama provide ways to deepen self-reflection, problem-solving, and mood-regulation skills that can be rehearsed through psychodrama exercises.
  • Experiential role playing can provide individuals with opportunities to generate new ways of thinking and behaving. The spontaneity and creativity of individuals can be increased through the use of psychodrama techniques, thus helping to produce alternative thoughts.

Cognitive Experiential Group Therapy (CEGT) is an effective model for working with a variety of clinical and nonclinical populations. The model incorporates cognitive behavioral and psychodrama interventions, allowing group members to identify and modify negative thinking, behavior, and interpersonal patterns while increasing engagement in positive and success-based experiences (Treadwell, Dartnell, Travaglini, Staats & Devinney, 2016). The CEGT environment creates a safe and supportive climate where clients can practice new thinking and behaviors and share their concerns freely with group members (Treadwell, Kumar, & Wright, 2004).

Initially, all members are assessed using various instruments to establish the nature and severity of presenting issues and to uncover other relevant information. The first one or two sessions are devoted to establishing group norms, explaining Cognitive Behavior Therapy (CBT) and schemas, and describing the session format. The initial didactic sessions are intended to explain the group format as a problem-solving approach for working through various interpersonal, occupational, educational, psychological, and health-related conflicts. The sessions include information about the nature of the structured activities so participants have realistic expectations about how the group will run.  Each group member signs informed consent and audiovisual recording consent forms. The audiovisual recordings create an ongoing record of group activities and serve as a source for feedback when needed. The action model is introduced in session one, with the director/facilitator, introducing the Beck Depression Inventory-II (BDI), Beck Anxiety Inventory (BAI), and Beck Hopelessness Scale (BHS) (Beck, 1988; Beck& Steer, 1993; Beck, Steer, & Brown, 1996), and explains the importance of completing each scale on a weekly basis. The instruments are administered before the start of each session and are stored in personal folders to serve as an ongoing gauge of participants’ progress within the group (Treadwell, Kumar, & Wright, 2008).

In the second session, additional data on early maladaptive and dysfunctional schemas/core beliefs are obtained when group members complete Young’s (Young, Klosko, & Weishaar, 2003; Young & Klosko, 1994; Young, 1999) schema questionnaire. A list and the definitions of dysfunctional schemas and core beliefs are given to participants during the initial session (Treadwell, Kumar, & Wright, 2008).  Additionally, we administer the Therapeutic Factors Inventory (TFI) to identify four dimensions of group progress (Joyce, MacNair-Semands, Tasca, & Ogrodniczuk, (2011) during week 2, week 8, and week 16.

Each group session in CEGT is divided into three sections typically found in psychodramatic interventions: warm-up; action; and sharing (Moreno, 1934). Many CBT techniques (Beck, 2011) are utilized in the warm-up, including: identifying upsetting situations, automatic negative thoughts and triggered moods; writing balanced thoughts to counter negative automatic thoughts; and recognizing distortions in thinking and imprecise interpretations of difficult situations. The second portion, action, employs psychodramatic techniques such as role-playing, role-reversal, and mirroring, which facilitate the examination of various conflicting situations individuals experience within the group context. This enables group members to better understand the nature of negative thoughts triggered by situations and their effects on moods. The last stage, sharing, allows auxiliaries and group members to share their experiences with the protagonist. At this stage, the director may provide additional guidance to the protagonist regarding ways to begin resolving the actual situation in real life. Normally, the protagonist will be asked to complete a homework assignment that will be reviewed at the next session.

Warm-up

The Automatic Thought Record (ATR) (Greenberger& Padaskey, 1995,2015) is explained and demonstrated on a white board during warm-up.  Socratic questioning is utilized to improve their awareness of irrational thoughts, (negative automatic thinking), that allows them to consciously question their own irrational thoughts.  A group member volunteers his/her situation and facilitators walk the person through the seven columns.  This individual is referred to as the protagonist.

Action

The protagonist, selects a group member, to be her double.  The double communicates thoughts and feelings the protagonist is having but cannot express.  If the protagonist is agitated, she may have some difficulty getting into the psychodrama; in this case, the soliloquy technique would be helpful.  Implementing soliloquy technique, the protagonist walks around the room, thinking aloud, expressing concerns, discomfort, and hopes, allowing her to relax, focus, and prepare for the psychodrama. This is also useful in helping other group members focus on the upcoming action phase. The double walks with her, expressing thoughts he assumes she is thinking but not expressing. Doubling, modeling, and role-training are crucial in learning how to get unstuck from repeated negative behavioral patterns. Many protagonists are anxious when learning a new role; therefore, it is important to support them as they try it “on for size” in session.

Sharing

At the end of the psychodrama, group members share and discuss what occurred, commenting on their experience playing a particular role or on how the situation affected them.  Sharing is critical both for the protagonist and for each of the group members as they reflect, share, and learn from each other. Sharing is a fundamental component in enhancing group cohesion.  During the sharing stage, assigning homework to the protagonist is essential, as it encourages the continuation of work on the new role explored in the session.  Role development needs practice for habituation to take place and to move the protagonist to feel safe in her new role.

Summary

Utilizing principles of CBT and psychodrama create a powerful and effective group process, enabling participants to address problematic situations with the support of group members. Clients find CBT helpful in becoming aware of their habitual dysfunctional thought patterns and belief systems that play an important role in mood regulation; the action component allows them to actually see and feel the dysfunction.  The cognitive experiential approach enables the individual and group to explore events, concerns, or issues, both problematic and fulfilling, in the past, present, or future.

As an aside, we will be offering this as an all-day workshop at the American Group Psychotherapy Association (AGPA) Conference “Connections”, Houston Texas, March – 2018

References

Baim, C. (2007). Are you a cognitive psychodramatist? British Journal of Psychodrama and Sociodrama, 22(2), 23–31

Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Hoeber. Republished as Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Beck, A. T. (1991). Cognitive therapy as the integrative therapy. Journal of Psychotherapy 

Integration, 1 (3), 191-198.

Beck, J.S. (2011). Cognitive behavioral therapy: Basics and beyond (2nd ed.). New York, NY: The Guilford Press.

Boury, M., Treadwell, T., & Kumar, V. K. (2001). Integrating psychodrama and cognitive therapy: An exploratory study. International Journal of Action Methods: Psychodrama, Skill Training, and Role Playing. 54 (1), pp 13–25.

Fisher, J. (2007). Congenial alliance: Synergies in cognitive and psychodramatic therapies.  Psychology of Aesthetics, Creativity, and the Arts. 1 (4), 237-242.

Greenberger, D. &  Padesky, C. (2015). Mind over mood: Change how you feel by changing the way you think. (2nd ed.). New York, NY: The Guilford Press.

Joyce, A.S., MacNair-Semands, R., Tasca, G.A., & Ogrodniczuk, J.S. (2011).  Factor structure and validity of the Therapeutic Factors Inventory – Short Form.  Group Dynamics, 15(3), 201-219.

Moreno, J. L. (1934). Who shall survive? A new approach to the problem of human interrelations. Washington, DC: Nervous & Mental Disease Publishing Co.

Treadwell, T., Kumar, V.K & Wright, J. (2004). Enriching psychodrama via the use of cognitive behavioral therapy techniques. Journal of Group Psychotherapy, Psychodrama, & Sociometry, 55, 55-65.

Treadwell, T., Travaglini, L., Reisch, E., & Kumar, V.K. (2011). The effectiveness of collaborative story building and telling in facilitating group cohesion in a college classroom setting. International Journal of Group Psychotherapy, 61 (4), 502-517.

Treadwell, T., Dartnell, D., Travaglini L., Staats, M., & Devinney, K. (2016). Group therapy workbook: Integrating cognitive behavioral therapy with psychodramatic theory and practice.  Parker, Colorado: Outskirts Press Publishing.

Wilson, J. (2009). An introduction to psychodrama for CBT practitioners. Journal of the New Zealand College of Clinical Psychologists, 19, 4–7.

Young, J. E., & Klosko, J. S. (1994). Reinventing your life. New York: Plume.

Young, J.E., Klosko, J.S., & Weishaar, M. (2003).  Schema therapy: A practitioner’s guide. New York, NY: The Guilford Press.

Young, J. E. (1999) Cognitive therapy for personality disorders: A schema-focused approach.  Sarasota, FL: Professional Resources Press.

Woolfolk, R. (2000). Cognition and emotion in counseling and psychotherapy. Practical Philosophy.3(3), 19–27.

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Group Psychotherapy Column

“It’s the circle of life,
And it moves us all.
Through despair and hope,
Through faith and love,
Till we find our place,
On the path unwinding;
In the circle,
The circle of life.”

– “Circle of Life” in The Lion King

Tevya Zukor, Ph.D.

Summer – The season for lounging at the beach, enjoying a few backyard barbecues, and soaking in the sun. It’s the time of year when the trials and tribulations of the other nine months fade into nothing as we enjoy the respite that we’ve been conditioned to love ever since we first wandered into a classroom as a young child.

When people ask why I work in collegiate mental health, I often joke that I’ve been in the academic world so long, I wouldn’t know how to function in any other environment. For many of us, we’re spent the majority of our lives living on the academic schedule – Classes start around September; we get about a month off in December-January, and then we grind until May; when we finally reach those magical months of summer. It’s been that way since I was a young child and it remains true to this day. Summer is the reward we get for working so hard the rest of the year.

However, for all the hotdogs and hamburgers that one may consume during this time; for all those lazy days at the pool that seem so carefree and idyllic; the reality for those of us who identify as collegiate mental health group practitioners is somewhat more complicated. The fun and enjoyment of the season remains. Our workloads are typically reduced and those many days of vacation that we could not take during the hectic fall and spring semesters get consumed with ravenous delight.

Yet, when we put on our professional hats and think about both the semester that has ended and the new semester that approaches, we are inextricably confronted with the “circle of life” that occurs in our groups. The summer may have started, but for much of June, my mind remains with the clients and groups that I facilitated in the spring. I think about the hopes, goals, and dreams of the group members that I have gotten to know so well over the course of the academic year. Many of those members will be graduating and starting a new chapter in their lives. Did they accomplish what they needed from group? Will they flourish in their next endeavors by applying their newfound knowledge and skills? Was I able to contribute meaningfully to someone making positive change?

That first month of summer is a time of reflection and introspection. How did my groups go? What changes can I make? How can I be more effective? It is humbling to think that in just one group, we likely got to learn, live, and experience the lives of 6-8 members that we did not know when the semester started. We know how these members interact with their family and friends. We know what they say to themselves when they don’t think others are listening.  We have been privy to some of their darkest fears, but also some of their most illuminating accomplishments.  We get to know so many people, so deeply, as a result of our work…and once summer comes, our knowledge of those people ends.  We often don’t get to continue to share their journey. Group members’ graduate and transition to other phases of life.  We are hopefully left with fond memories and a sense of accomplishment in our work. However, we have also suffered a loss; a spiritual death of sorts. We know we will not see or hear from some of those members ever again. While their journey has not ended, our shared experience of it has come to a close. As we have done throughout our careers, we have to wrestle with the finality of termination and try find acceptance that the remainder of those stories will forever be unknown.

However, as is often the case in life, mourning these “deaths” soon brings about a re-birth and new life. As the summer continues and the calendar flips from June to July, our thoughts often turn to Orientation and the welcoming of new students onto campus.  With the emergence of the new incoming class, thoughts start to turn to life and creation.  Are there new groups that one might want to develop for next year? Who will be our new group members? What stories will they share and what journeys will they take us on?

It is incredible to think that as we watch these new students arrive; filled with their hopes and dreams for their new college-life; we will get to know some of these people just as intimately as we knew our previous members.  We will experience new journeys with these students, just as we did with the members that came before.  We may not know exactly what the future holds, but we know that we will soon care about these new stories and new people just as much as we did before. Our groups go forward and with each iteration, we will become a little more skilled and a little more proficient.  We will continue to refine our craft and be there for those who are struggling. We won’t forget the journeys of previous groups, but we will make room to experience new stories and new adventures.

The circle of life continues.

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Group Psychotherapy Column

Tevya Zukor, Ph.D.

A Call to Action

These are troubling, unsettling times.  The world is changing at a record pace and many of the bedrock principals that formed the United States of America seem to be more in question than ever before.  To quote the great Indiana Jones and the Last Crusade:

“It is time to ask yourself what you believe.”

Who are we as a society?  Who are we as a country?

At the most basic level, the question is always -Who are we as a Group? How do we want to define our values? How do we stand and support one another, even when we may have disparate thoughts and opinions? How do we identify as individuals who are also a member of a larger whole?

These are the questions that millions of Americans have been asking themselves in the recent days, weeks, and months. These are questions about values and identity. These are questions that shape who we truly are as people; and just as importantly, who we actually want to be.

These questions can be anxiety-provoking.  What happens when we look in the mirror and we don’t like the reflection that stares back at us? As with all potentially troubling questions; it is far scarier, and more isolating, when we try to answer them alone.

We feel better, and more secure, when we ask such questions and get feedback from others.  We benefit from perspectives that we often lose when fear takes hold. We take solace in knowing that even if the answers may sometimes be troubling or uncomfortable, we are stronger when we can lean on others and we are braver when we are part of a larger group.

As group practitioners, we know this to be true.  We have lived these experiences and we have directly beheld the power of group.  We have seen courage and witnessed bravery that would not have been possible if a person had attempted to do it alone. Our wisdom, derived from years of experience and education, allows us to understand these concepts both theoretically and practically. This is our area of expertise.

In the uncertain times that our nation now faces, we are needed more than ever.   We have experienced this journey, both personally and professionally, many times before. It is NOT new to us. It is NOT uncharted territory. Our livelihoods and passions have literally been organized around assisting people through the darkest times in their lives and allowing them to experience the immense strength they have that they never knew existed.  That is the work we do every single day. We know how to do this.  We walk this path with countless clients.

Now that the very fabric of our Republic feels like it is in jeopardy; our work does NOT change – just the scope of our practice does.  This is our call to be leaders (Or, in the parlance of our profession, “facilitators” if one so prefers). Our work is no longer contained to the clients who walk through our office doors.

Our profession is about serving the needs of people and right now, the people of the country are struggling. Most of us are used to working with small groups of 6-10 members. Now it’s time to serve the large group – possibly the largest of large groups – it’s time to serve ALL members of this great country.

We, as group mental health professionals, are uniquely qualified to meet the needs of the group right now. We have the training and experience to understand the dynamics of scapegoating, oppression, and irrational fear-based behavior. Not only do we understand how these processes emerge, but we have thousands of years of combined experience helping people navigate through the worst times of their lives and being there as they to emerge from the darkness that once overwhelmed them.

We know it is possible because we have experienced it countless times before.  We have worked with the desperate, despondent client who is convinced that the world will never change.  We have challenged the hopelessness of clients when they have told us that things will never get better and their lived will never improve. We understand that their fears are often based on a lack of knowledge and perspective. We teach and encourage coping skills even to those who are unconvinced it will be successful. And most importantly, we show our groups that they are stronger and more resilient than they ever knew possible.

This time is no different; it’s just more present and the scope is a bit bigger. It’s time to do what our years of training and experience has taught us to do – It’s time to lead the group.

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Group Psychotherapy Column: Sex, Drugs, and…Politics

Tevya Zukor, Ph.D.
Tevya Zukor, Ph.D.

More than 65 years ago, Rock ‘N Roll was invented as its own musical genre.  From its inception, many people were confused by this new-fangled music and feared that simple exposure might compel one to engage in sinful thoughts, or even worse, sinful behaviors. I can only imagine that somewhere in the early-‘50s, the following group transcript may have existed:

Member 1: If Marilyn Monroe marries a guy like Joe DiMaggio, what chance do I have of ever finding happiness?

Member 2: Not that your love-life isn’t important, but has anyone heard this new song on the radio – “Rock Around the Clock” by Bill Haley and His Comets? I got to admit, it’s pretty catchy!

Member 1: That’s the DEVIL’S MUSIC!!!  How can you listen to such filth?!? First you’re swinging your hips to the son; next thing you know you’re sleeping with every suitor who comes a’ calling. Harlot!!!

As absurd as this notion may seem in the modern era, the birth of Rock was a tumultuous time for American culture.  Many people thought that the messages contained in rock songs were “Un-Godly” and contrary to traditional biblical values.  Fans of the music were just as quick to dismiss these fears and often had no problem telling detractors to shut their word holes and let them Rock Out in peace!

Cultures shift and evolve, but human behavior is much slower to change. While it is certainly rare to still find someone who adamantly believes Rock music is the primary cause of all the world’s social ills, we have simply shifted the blame from music to whatever the new fad of the moment may be. We continue to re-package and re-brand the supposed cause, while keeping the effect (ie. “The destruction of all that is Good and Holy”) the same. The human mind is conditioned this way. We understand the world works on a cause-and-effect basis.  The worse the effect, the more we fear not understanding the cause. To prevent this from happening, we are more than willing to invent any cause that can mitigate our responsibility for the effect.

“Why was that woman assaulted?”
“You saw the way she was dressed!!”

“Why was that teenager shot?”
“He shouldn’t have run. If he would have just done what the officer said, there wouldn’t have been a problem.”

Hopefully, anyone reading this column can immediately understand the logical fallacies and the immoral conclusions of the two statements above. However, we can also probably agree that we have heard other people; whether friends, family, or so-called celebrities; espouse such victim-blaming attitudes. We are quick to judge these people – we often think of them as stupid, worthless, or something worse. We question their heritage and their upbringing.  We sleep soundly in the knowledge that we are right and they are wrong. We are enlightened; they are ignorant.

The reality is that issues of equality and fairness are as old as humankind. Societies have wrestled with what it means to be just and civil since the dawn of time. Again, the exact circumstances change with the times, but the underlying questions endure. People are passionate about these discussions because it taps deeply into our beliefs about what it means to be a “good” human being.

The stakes are high, which means people are passionate.  With intense passion, we are often driven to try and convince others to our way of thinking. After all, if we are certain we are right, then why would we want our friends to be wrong about something so important?

In our pursuit to be “right,” we often forget to be civil…and that is where all of us mental health practitioners and group psychotherapy clinicians have a vital role in bettering the lives of our clients.  Somewhere in the vitriol and passion that emerges around social justice issues, people forget that their “enemy” is another human being with drives, passions, and motivations that make them more similar than different to us.  Just as we do, these people on the other side of the issue also have people who love them and care about them. They want good things for their loved ones, just as we want for ours.

Group therapy has often been described as a microcosm for the larger society.  The skills that group members learn translate into the real world because group is a reflection of that real world, but on a smaller scale. The benefit of group is that it can also be a social laboratory – a place to explore new and different ways of being with other people. However, as is true in the larger world, group is also a place that when core beliefs of members clash, conflict often emerges. Conflict can be destructive, but it doesn’t have to be. Fortunately, unlike the larger world, there are facilitators in the group and our role is to assist members in navigating challenges that might otherwise be overwhelming.

I work at a university; which means all of the members of my groups are college students – the “best and the brightest” who are motivated to learn and grow and share that knowledge with the world.  However, in recent years, I have noticed an alarming trend. Specifically, there seems to a disturbing lack of civility when disagreement is involved. The old expression, “Reasonable people can disagree reasonably,” seems to have been replaced with, “I’m right and you’re wrong. Either change your position or accept that you’re terrible human.”

I have seen conflicts emerge in group that have become personal very quickly.  I think back to a few years ago when I was running a process group at a fairly conservative university.  One of the group members was facing a personal crisis in their life.  She had recently learned that she had unexpectantly, and unwantedly, become pregnant. She was torn about what to do. She knew that one day she wanted to be a parent and that having children was important to her identity, but she was also concerned that having a child at that point in time could not only derail her ability to graduate college, but might also lead to a poor quality of life for her child; as she did not have the means to support a family.

The woman truly did not know what to do.  She considered having an abortion, but also contemplated adoption or keeping the child and raising it on her own. She recognized that each option presented the possibility of some wonderful positives, but also some terrifying negatives.  Finally, when faced with such a significant, life-altering decision; she did what we would want almost anyone to do in that situation – she brought this dilemma to the group; not because she wanted the other group members to make the decision for her, but because she knew that she would need support and compassion from people she had learned to value – no matter the decision she ultimately made.

Unfortunately, this story does not have a happy ending…and I honestly have no idea what choice she ultimately made regarding her pregnancy.  The reason for this is that the young woman; who was seeking support, empathy, and kindness from her cohort; instead was greeted with divineness and judgement.  Within minutes of her sharing her situation with the group, one member told her, “You’re not a murderer, so I know you won’t get an abortion.” Another member asked her how she got pregnant if she wasn’t planning on having a baby. A third decided to shift the focus of the group away from the woman’s particular situation and instead to the larger issue of a woman’s right to choose what happens to her body.

While each of these three group members were passionate about their perspectives and points of view, none were able to adequately attune to the woman’s primary purpose for disclosing to the group; which was her need for support and empathy while navigating the most challenging situation she had ever experienced. Within minutes, the woman was in tears. She had been seeking support, but instead found hostility and judgement from people she valued.  Shortly after her disclosure, she ran out of the room in a panic.  Before any of the facilitators could intervene, she had left the counseling center and would not return e-mails or phone calls. She would not respond to repeated requests to meet and process what has happened.

It is one of the saddest moments I have ever witnessed in group.  For weeks, I could not stop thinking about this young woman who was trying to make the best decision she could in a brutally tough situation. Instead of finding solace and support, she was driven out of the group and further isolated at the very time she needed connections and empathy.

In the aftermath, I wondered what I and the other co-facilitator could have done to assist this young woman. Was there some intervention that we missed? Was there an opportunity to refocus the group to the emotional needs of the woman rather than the alternate agendas of the three other group members? Like most moral conundrums that emerge in group, there are no easy answers or ideal solutions to such complicated issues.  Ultimately, my co-facilitator and I had to accept that while we may have acted differently with the benefit of hindsight, there are no guarantees that this situation would have ended any better (or worse).

As often happens, I hadn’t thought about this situation in years…until a colleague shared a story about something that occurred in their group last week. A young man on the Autism Spectrum arrived for their first group of the semester.  He was wearing a “Make America Great Again” hat, in support of Presidential candidate Donald Trump. Another group member, upon seeing the hat, immediately stated that she would not participate in a group with a bigot. She explained that her parents immigrated to the United States from the Middle East and that her entire family was proud to be American. She deeply believed that if Donald Trump were to become President, her family would risk deportation. She was scared; afraid of this possibility for her and her family. Instead of remaining in the group, and possibly talking with the new group member about his reasons for supporting Mr. Trump and using it as an opportunity to learn and educate, she walked out of the group when the facilitators refused to ban the newest member, or at least insist that he remove his hat.

These two situations have one thing in common: People who most needed the opportunity to process their intense feelings of sadness, rage, and potential loss never got the opportunity. The attitude of “My beliefs are right, so I will not tolerate those that are different” ended up winning the day at great cost to the members who may have simply needed some support and understanding.  While it may be easy to blame people for their close-minded attitudes, the truth is that we are products of our environment. We grow up and develop in the context of a larger society.  When our current political system reinforces divides and differences; when society tacitly accepts that it is okay to demonize and shun those who disagree with us; it is hard to blame the group member for being a product of that environment. After all, they are simply behaving in a manner consistent with their years of upbringing.

If we, as group facilitators, want these scenarios to have a different ending, then we need to model the change that we believe to be important.  We all have an obligation to teach and encourage discussion. Conflicts do not have to be dogmatically reinforced and highlighted, but instead can be explored and gently challenged. We need to set a clear message for our groups: Disagreements are not automatically personal. People can still like and care for one another; even when we do not share every value or belief.  We know that our similarities are far more important than our differences, but we must forgive some of our clients who have never received this message…and we must teach them a better way.

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Group Psychotherapy Column

Tevya Zukor, Ph.D.
Tevya Zukor, Ph.D.

Welcome to the Jungle

Academia has often been referred to as the “Ivory Tower.” I’ve never found it to be quite so idealized. I’ve spent the vast majority of my career working in University Counseling Centers. As a result, I’m often exposed to the soft underbelly of Higher Education. No student ever comes in to say, “Life is great and I had to tell someone about it.” Instead, my clients talk frequently about their experiences with institutionalized racism, sexism, and inequality. They often struggle with understanding and navigating unequal power dynamics that are inherent in the educational environment. Many of these students believe that the Academy is oppressive and that without such tyrannical rules – such as, you must be 21 to drink alcohol and don’t smoke pot – they would be thriving and able to live their most self-actualized life.

As Mark Twain famously said, “Never let the truth get in the way of a good story.” While I may differ with these students regarding the externalization of their difficulties, it does not change that many of these students, by the very nature of their beliefs, are ripe to benefit from the power of group. As senior group clinicians have witnessed countless times over the years, group therapy has the incredible power to affect change; even in those who may be resistant or initially unwilling to acknowledge their own contribution to their problems. When you get enough college students in a room – who by their nature are intelligent and determined problem-solvers – it is only a matter of time before the group members feel empowered enough to offer feedback and perspective on the problems that the other members are experiencing. And more often than not, either through a quick intervention by the leader or an astute observation by another member, clients are able to recognize that the feedback they so generously and freely gave to others is just as applicable to their own dilemmas. It is amazing how powerful it can be to simply note, “How has that feedback worked for you?”

I love working in a college setting. The students, almost by definition, are high-functioning and socially engaged. They are truly the future generation and helping them to understand their problems and solve their interpersonal issues pays immense dividends down the road on both the micro- and macro-levels of society. By fostering engagement and resiliency at such a developmentally important time, college counseling center group practitioners play an important part in not only making the world a better place, but also ensuring that such a pro-social legacy continues to the next generation of college students.

However, life as a group clinician at a college counseling center is not without its share of challenges – some of which I have only come to recognize through the painful process of age and maturity. For starters, the pay is rarely what one can make in private practice. When I first started my career and had finished internship, I was ecstatic to earn more than double my previous salary by going from a trainee to a full-time staff member. Having previously made roughly $20,000 as an intern, this new salary looked amazing. Now, more than a decade later, I am no longer an early-career psychologist and while my salary has certainly improved, it is still not close to what my friends make in private practice. While there is more to life than money, it sure does help when paying bills. One can certainly make a fine, decent living working in collegiate mental health; but if you’re in it for the money, you will never be satisfied.

More so than salary, one of the challenges of working in a university setting is there is always another boss. First, you report to your Director. But your Director reports to a Vice President, who themselves answers to a President. And the President? Even he or she usually has to answer to a Board of Trustees. While having such a “Chain of Command” does not necessarily equate to problems, it is almost guaranteed that these administrators will have different priorities and motivations than that of the college counseling center group clinician. One of the challenges of being a group clinician in the college environment is that your specialty is sometimes unknown; and if known, at least under-valued. It is rare that Upper Administration is populated with people who have experience in mental health. Even many Directors, by their experience and training, were never taught the direct benefits and clinical utility of group psychotherapy. To this day, I know of too many Counseling Centers where the Director is a good manager and excellent clinician, but still struggles to view group therapy as anything more than a niche or sub-specialty. At some centers, staff are tracked and evaluated on the number of individual client hours they see per week, but they get no credit for running a group as group therapy does not count as direct service. It can be hard to feel appreciated in an environment where you literally don’t get credit for what you do.

The academic calendar also adds to the challenge of collegiate mental health. There are always artificial deadlines around every corner. No matter how much progress a student has made (or not made) in a semester, it is overwhelmingly likely that services will be terminated in either December or May. Do college students magically get better and resolve their most pressing life issues right as the Fall and Spring semesters are ending? Of course not. Instead, it is the time when most of these students will be leaving the university and returning home, either for winter and summer break. Some of these clients will continue with treatment with a new provider, while the majority will choose to either resume treatment when they return to school or will discontinue therapy altogether. This means that the work of college counseling center professionals is veritably brief and time-limited by nature. Almost as soon as therapy gets started, the client and clinician need to begin thinking about issues of termination. These challenges are only magnified in a group setting. It takes time to get enough members to form the group. Then there has to be sufficient time for cohesion amongst members to develop before therapeutic progress can be accelerated. Finally, due of the number of group members and the depth of sharing that tends to occur, termination is always a multi-week process. All of which must fit within these hard and fast deadlines – the semester starts on a specific day and it ends on a specific day – whether the clients and group are ready or not.

All of these challenges are very real for the college counseling center group clinician. They are the obstacles that have to be navigated not just for our own personal sense of accomplishment and fulfillment, but also so that we can assist in bettering the lives of our clients. It is both fun and rewarding to work every day with such high-functioning and motivated students. It is gratifying to know that the work we do with our clients will benefit them for the rest of their lives. It is an honor and a privilege; one that is certainly somewhat unique – but does it feel like being in a cloistered, Ivory Tower; separated from the realities of the rest of the world? No…it’s a Jungle out there!

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Group Psychotherapy Column

John Breeskin, PhD
John Breeskin, Ph.D.

The Co-Therapist Model in Groups

It is an unfortunate reality that many group therapists run a group therapy session by themselves and while this may appear to be an obvious income generator by the organization, I consider such a practice to be a significant professional error and I will list my reasons for this statement.

  • A single group therapist, no matter how skilled, cannot conceivably keep up with the richness of group experience. Important cues, particularly nonverbal ones, are in danger of being missed.
  • Running a group by yourself significantly increases the possibility of therapist burn out since there is no way that you can pace yourself.
  • Running a group by yourself falls below the minimum benchmark of approved professional practice and can damage you, your clients, and the agency for which you work.
  • Last, but not least, running a group by yourself is dumb; spelled D.U.M.B.

I feel so strongly on this subject that when young professionals ask me for my support, I am only too willing to supply them with ”the letter,” which comes in three flavors: Mild, spicy, and hot. An example of a mild letter follows:

Director of Training

Mercy Day Hospital

Anywhere, New Jersey

Dear Mrs. Campania,

         A young professional in your organization, Thomas D. has asked for my opinion as to the practice of having a single mental health worker running a group by himself. I don’t think that this is a wise idea, and I’m willing to share my thoughts on the subject, as I am national and international specialist in the area of group therapy under discussion.

           No therapist, no matter how experienced or skilled, can possibly follow the complexity of group process without running the risk of significantly missing important cues.

       In addition, because of the stress involved, it is all too possible for beginning therapists to become quickly burned-out.

     From a professional point of view, running a group with one therapist falls below the minimum professional requirements in the mental health field, and I’m sure your organization would not want to be in a position of giving that impression to mental health regulatory agencies.

         The sad fact is that the young man under discussion has many demonstrable potential skills to become a fine therapist. It is my concern that unless he works within a supportive professional environment, he will become discouraged and seek another professional career.

           With respect to finding an appropriate co –therapist, nothing could be easier. Asking for a volunteer and qualifying that person through a volunteer training program will cost the organization nothing. There are many fine group therapists, whom, it is embarrassing to say, have never set foot day one in any graduate school program: they are naturals and relate to people in a very positive and empathic manner.

         I hope these comments have been helpful. It if you have any questions, please do not hesitate to contact me.

Respectfully,

John Breeskin, Ph.D., A.B.P.P.

Many times, in my career, I have been asked to consult to co- therapy pairs. I have not all been surprised to find it that this compares very closely with couple’s therapy. The problems, although they come wrapped in different packages, are quite similar. The pair involved has not been able to acknowledge, let alone resolve, the power differential that exists between them. To say that”we are both the same,” is a copout. This can never be true. One person in the pair may have higher academic degrees, may have more initials after his or her name, may be more charismatic or may have more time in the organization. The nature of the power differential imbalance is immaterial, but it must be acknowledged by the two people involved in order for them to work smoothly together.

The pair has the opportunity to model collegial support and respect by their interaction for the group participants. It is not too strong a statement to say that their interaction must be seamless. They must practice picking up on each other’s comments in a non-competitive manner.

If Bob and Alice are running the group together, Alice says,” picking up on a comment of Bob’s. I would like to add…………. Bob says” that comment of Alice’s helped me understand what just happened……….” this kind of collegial support and respect will provide a powerful interpersonal model for the group participants and will significantly diminish the amount of anxious gossip that the group members exchange with one another in the parking lot just after the group meeting.

I always choose a woman to be my co- therapist in a group. This creates issues that must be addressed. In terms of dysfunctional dynamics, it is all too easy to consider my co- therapist and me to be parental figures and the clients themselves the children. If not carefully anticipated, this dynamic can turn into potentially disruptive sibling rivalry based upon the scarcity model. My second wife was a psychologist herself and we did groups as a co-therapy pair for 10 years. This could have provided a rich screen of fantasy and projection on the part of the clients since my wife and I were not only working together but we were sleeping together as well. This is still another reason why a co- therapy pair must model healthy relationship behavior in front of the group participants.

Additionally, according to my group developmental model, the person who is taking the lead for the first third of the group history, steps down, and the indigenous leaders, with the active support of the co-therapist, takes over the leadership of the group in stages two and three.

I am a superb bus driver; the passengers will get to their destination safely, and they will hear an interesting rap about the journey itself. I am also a loyal and helpful bus passenger provided, of course, that I trust the bus driver. This is still another positive role model that co-therapists can offer to their groups.