Positivity and Negativity in Group Dynamics

I've written in the past about how a treatment milieu can develop positive or negative group dynamics - individual clients can support each other's recovery, or fuel each other's issues. Clearly, much of this dynamic can be traced back to what clients say to one another, inside and outside of group.

After some clique formation and scapegoating with our current population, my team has been working to address counterproductive group dynamics (at least when they occur in our presence). The group's response today, when my colleague spoke with them about negativity, was that they express negativity in order to get support from the group to help them be more positive.

That raised an interesting question for me: when does expressing negativity represent a request for help changing one's perspective; when does it seek validation of one's negative perspective; and can it do both of these things at once?

Mutual aid is central to group therapy: group members are meant to support and help each other. For that to happen, they obviously have to be able to share their struggles. As group leaders, I think we hope that we have a "critical mass" of members who are more positive than negative...but even if group members are struggling, that does not necessarily mean the group develops a negative dynamic. What seems to make a difference is how open they are to alternate perspectives. A group that is feeling discouraged but still willing and engaged maintains a positive (i.e., constructive) dynamic even if what they're saying can't technically be termed "positive."

In contrast, the group develops a negative dynamic when they support each other in opposing or rejecting alternate perspectives. When this kind of dynamic develops, group members will actively talk each other out of more adaptive ways of thinking, feeling, and acting. Even when this influence is not explicitly spoken, it may be clearly implied through body language, etc. As a result, individual members each tend to become more negative than any one of them felt individually.

While the latter type of dynamic is certainly challenging for group leaders/therapists, it becomes even more challenging when both dynamics are present in the same group. A group may vacillate between constructive responses and counterproductive responses. Specific members may vacillate between accepting and rejecting feedback. They may send each other mixed messages, and otherwise express their collective ambivalence. The real art and skill of group work is to steer this process so that the group norm becomes positive rather than negative engagement.

What strategies have you found helpful in guiding an ambivalent group in a positive direction?

Repetition

Part of my job is facilitating groups in partial hospital and intensive outpatient programs. In these more acute, intensive but time-limited treatment settings, there is almost continuous client turnover, with clients admitting and discharging almost daily. The population as a whole remains at about the same point in the change process, because once people stabilize, they discharge to a lower level of care. 

As a result, group content also has to repeat quite frequently: at admission, the majority of clients are in crisis and lacking the skills, knowledge, insight and/or motivation to manage it. If we (staff) don't continue to review foundation skills, newer clients don't have that foundation. 

However, although length of stay is relatively short, there is a great deal of variability. PHP averages 2-4 weeks, but may be shorter or longer. IOP can be anywhere from 2 to 6 weeks, or longer. If someone does both programs, they might be with us anywhere from 2 to 10+ weeks. Added to that, some clients repeat the program, sometimes after a period of time in inpatient or residential treatment, sometimes after a period of time in standard outpatient (or even no) treatment. 

This poses a problem/dilemma for staff: provide foundation skills and information needed by new clients (even though people who have been with us a long time, or repeatedly, have already heard it), or try to find group material that no one present has previously encountered. I have typically taken the latter approach: feeling bad for "old-timers" who may be bored, I rack my brain and scour my files for new ideas and activities I haven't used in the last 2 months (or longer). 

However, I've come to think that repeating a topic or activity may not be such a bad thing after all. Sure, some clients take one look at a handout, and roll their eyes because they've "done it already." But this is only partially true: the constellation of the information/activity with the client's current point in treatment and recovery is new. Hearing information again after you've had a few additional weeks of intensive treatment, with all of its ups and downs, means that you're hearing it in a different way, applying it in a different way, and (hopefully) integrating in a new or more complete way. It's been a particularly powerful experience - for clients, and me - to witness new breakthroughs from this kind of repeat material. 

Maybe I can stop worrying so much about repetition, and embrace it as another part of the process!

Changes in Group Membership

Most groups will eventually face the challenge of changing membership. In open groups, people may be joining or leaving the group at any time. Closed groups may have a longer period of stable membership (though people do sometimes drop out), though these groups typically do accept new members at predetermined intervals. The only kind of group that never has to integrate newcomers is a truly time-limited group where members terminate at the end, rather than rolling over into a "new" time-limited group.

Changing group composition through the addition and subtraction of members can be disruptive and distressing. How many clients - perhaps especially those referred for group therapy - have issues with relationships, attachment, abandonment, etc.? And while group work in general is likely to bring out all of these issues, they are most strongly present during hellos and goodbyes.

Goodbyes are hard because they obviously signify a loss. People who are staying in the group may feel abandoned by those leaving (especially if they have abandonment issues). If someone is leaving because they no longer need the group, remaining members may compare and feel bad about their own level of functioning, feel jealous, etc. If someone has had to leave the group because they were not a good fit or unable to participate appropriately, or needed a different level of care, people may worry that they may somehow "mess up" and get "kicked out." Whatever the reason someone leaves, everyone is likely to think about the nature of the connection between them, and what happens to that bond if they are no longer together. Some may wonder whether the ending of the relationship negates its value from the beginning. Then, the remaining members may worry about how the loss will affect group dynamics. Who will take on the roles played by the person who left? Will the group function as effectively? And so on.

Hellos are hard because they can trigger fears of the unknown, as well as personal insecurities (which may, again, be particularly present in those referred for group therapy). People may wonder whether the new person will like them, and whether other group members may like the new person better. They worry how their role in the group will change, and how the overall group dynamic will change. Often, people assume the worst, and may even act as if it were true, disrupting the whole group dynamic. Some people may make assumptions about, or even judge the new person as well. And, of course, the new person is coming in with their own fears about what type of people will be in the group, whether they will fit in, be liked, etc. The group may revert to an earlier stage of group development as it tries to find a new equilibrium with this change in membership.

While both hellos and goodbyes are hard, potentially emotional transitions, they are also incredibly rich opportunities for therapeutic growth, if the group can tolerate them enough to continue doing the work at hand. Sometimes simply naming the fact that it is hard and emotional can allow the work to proceed. Other times, hello and goodbye rituals may facilitate the process (and processing).

Also bear in mind that these issue come up not only for therapy groups, but for all kinds of groups - classes, clubs, teams...even treatment teams. While the challenges may not become a manifest topic addressed by these groups, it helps to consider what members may be experiencing when membership changes. Expect some bumps in the road, and perhaps a period reduced cohesion and productivity as the group tries to sort out everything going on under the surface. However, just as the original group established itself as a unit, we trust that the same thing will happen again.

Do you have any hello or goodbye rituals that you use to ease the way during membership transitions, in any kind of group?

The Role of Group Dynamics in Bullying

There has been a lot of news coverage this week about a viral video of a group of middle school boys verbally harassing their bus monitor, including cruel comments about her weight, age, and the fact she shed tears in reaction to their comments.

Reactions from the public have been split between vilifying the boys, and collecting donations for the bus monitor. In fact, the boys have reportedly received their share of cruel comments in return, including death threats. One of their fathers appeared on the news, stating that he had not raised his son that way, and planned to take the child to therapy to figure out whether there was something more serious going on with him. A clinician who had not met the boys also got on the news talking about sociopathy.

However, before we pathologize these boys (and possibly create a self-fulfilling prophecy), I'd like to encourage everyone to slow down a bit, and not rush to judgment. Yes, the boys certainly did something wrong, and certainly should have known better. However, their behavior needn't be attributed to sociopathy. In fact, it seems much more likely that the boys were demonstrating a perfectly normal, albeit negative in this case, function of a social group.

Please don't mistake this for condoning their behavior, but let's use it as a learning opportunity for all of us - after all, the public exhibited a similar group dynamic against the boys in retaliation! Here is how I understand it:

In social groups, people are motivated to conform to the group's behavior - in other words, each individual adapts his or her behavior to more closely match that of other group members. We all do this, for a variety of reasons: we want to fit in, be liked, or at least not actively disliked; we want to be right (and assume the rest of the group is right); we want to belong - experience ourselves and be experienced by others as part of the group. The pressure to conform is quite powerful. For example, in one research study, Dr. Asch put one participant into a group of confederates (i.e., people helping the researcher, but unidentified to participants as such). Then he showed the group a line, and asked which of three other lines was the same length. It wasn't one of those optical illusions - it was supposed to be obvious which answer was correct, but the confederates intentionally gave an incorrect answer. 76% of participants agreed with the wrong answer at least once, and on average participants conformed with the group about a third of the time. And this was with adults - the pressure to conform, as we know, is much greater for young adolescents!

Sometimes this (natural) conformity leads us in positive directions, and sometimes it leads us in negative directions. What would cause it to be negative (such as group bullying)? There are various theories on what may contribute. In an earlier post on hazing, I described some possible influences, such as groupthink, and social roles. Other factors include group contagion (one person has a negative idea/impulse, which s/he may or may not consider acceptable individually, and others in the group go along with it, which validates it as acceptable to everyone), and deindividuation (people lose their sense of separate from the group, and therefore their independent evaluation of group behavior).

Add to this the boys' developmental stage, which often includes challenging the authority of adults, and I imagine the scenario thus: Somebody says something disrespectful, but not all-out mean. The bus monitor does not respond (perhaps trying to avoid reinforcing the behavior through a response). When the first boy "gets away with " being disrespectful, some other boy wants to look cool/conform, and says something a little more disrespectful. Peers reinforce the behavior by laughing, gasping, whatever - and so it continues to escalate. Each of them probably had at least one moment of thinking "this is wrong," but it was likely followed by thinking "everyone else is doing it, so maybe it's not wrong," or "if I don't at least laugh along, they're going to think I'm a loser; maybe they'll even do the same thing to me!"
I bet most of us have been in situations that felt like this - gone along with something we suspected was a bad idea. So, let's have a little compassion. Let's not use groupthink and anonymity to lash out against these children. Let's teach them, and others, that you don't always have to "go along to get along."That you can't check your moral compass at the door when you enter a group. And that we (as a group) should respect courage rather than conformity...but sometimes we don't.

Stages of Group Development

Groups are fascinating - truly "more than a sum of their parts." It's almost like the group itself becomes a living, breathing organism. And, like any organism, groups also have a life cycle, and go through predictable stages of development. 

There are various descriptions out there for these stages of development. Perhaps the most famous is the so-called Boston model, and while this is also the version I like the most, it's not the one that I use the most. Instead, perhaps because I learned it first, but more likely because it is...catchy, for lack of a better word, I frequently refer back to Bruce Tuckman's stages. 

Like the Boston model, Tuckman identifies five stages, which he calls: Forming, Storming, Norming, Performing, and Adjourning (see? catchy!). 

Forming refers not only to the physical act of initially getting the group together and arranging logistics, but also to all the inter- and intra-personal dynamics that go along with it. People come to groups with a lot of baggage, including goals, expectations, past experiences, and related anxieties. Everyone wonders whether they will fit in, whether people will like them. They wonder if their needs will be met. They wonder who these strangers are. Therefore, forming involves a mutual process of feeling each other out, and trying to present oneself in the best possible light. People tend to be polite, but independent; the group has not yet become more than a sum of its parts.

Of course, as imperfect humans, we can only be polite and present our best sides for so long. It is inevitable that competing expectations, goals, and differences of opinion will come to light. Enter the Storming stage. In the Boston model, this stage is referred to as "Power and Control" because it often involves some degree of jockeying for position, including status and roles within the group, along with testing or challenging behavior. The group leader is frequently the target of such challenges as members test the leader's authority; one or more group members may even take over authority in the group. The group environment can feel charged, like a storm. But, while this stage is uncomfortable, it's inevitable and necessary to turn the group's parts into a cohesive whole.

Once issues of power and controol (i.e., Storming) have been resolved, the group can finally proceed to the purpose for which it was organized. However, before real progress can be made in working on that purpose, the group has to determine how it will go about its work. The group establishes a group identity and group narrative, rituals, and social norms (hence, Norming). Members are assigned or take on roles, and fall into a comfortable groove, more secure in how the group sees them, and trusting of the group dynamic as a whole. The result is a sense of cohesion.

With this foundation, the group addresses its purpose in the Performing stage. Real, tangible progress is made, and members typically feel like the group has finally begun to meet their needs or be productive. The cohesion that has developed continues, but slowly, members begin to also differentiate from the group, which makes room for the individuality of its members, including diversity of needs and interests.

Both doing the work of the group, and differentiating of individual members set the stage for the ultimate move into the group's final stage: Adjourning, also known as termination. This is a time for naming and consolidating gains, affirming the value of the group experience, and each member taking what they can from the experience for their everyday lives. The group changes back into parts as people say goodbye, but each part is still more than it was before the experience.

So, what do you think about this model? Do you see this process at work in groups you're involved with? How else do you understand the evolution of a group?

The Milieu

Merriam-Webster defines milieu as "the physical or social setting in which something occurs." Milieu therapy is treatment that intentionally utilizes physical and social context to intervene with multiple clients, typically as part of inpatient, residential, or day treatment. Specifically, it involves proximity within a safe physical space, and group therapy that builds on a sense of community that forms among clients. While a protective physical environment is obviously a primary purpose of inpatient treatment, I think the social environment has greater overall significance for treatment across levels of care.

Of course, while the physical environment is largely under staff control, the social environment is...not. Sure, we influence it - we establish group guidelines, reinforce adaptive/positive/recovery-oriented behavior, and redirect maladaptive/negative/non-recovery-oriented behavior. However, the specific makeup of individuals in the milieu always influences its atmosphere. Anyone who has worked on a milieu knows what I mean. It may be sunny weather...or the atmosphere may be charged with tension, cloudy with depression, slowed like it's under water, or chaotic with manic or anxious energy. Like mood, attitudes also spread easily from person to person so that a stance taken by a subset of the population can spread to the rest of the clients in the milieu. I'm not sure the exact mechanism by which this happens, but I suspect it is some combination of subtle norming, peer pressure and feedback, and modeling.

Since opening at the beginning of February, we have been lucky to have enough positive and motivated clients coming to our partial and IOP programs to bring the whole milieu up to their level. However, as the more motivated and positive people have discharged, the milieu has recently shifted into a more ambivalent or even negative space. I find it more draining to facilitate groups when the milieu takes on this attitude - it takes more out of me to be advocating for change against the current of the population. There is more undertow. And there can also be more momentum in counterproductive directions. As a colleague said yesterday, the group can "get away from you."

However, even - and perhaps especially - with that kind of group, effective redirection can create a course-change that spreads among the population, and ultimately becomes momentum toward change. It's often the case that people become more positive and motivated as they progress in treatment. When they discharge, there can be a less-positive period (like we're having now), but that is (usually, hopefully) just growing pains in the milieu's development, which ultimately lead the group to a higher level of recovery.

Group Composition

I am part of a team opening our agency's newest satellite clinic. It includes a partial hospital program and intensive outpatient program for adults with eating disorders, and will eventually include some adolescent programs, with a separate staff. Tomorrow is the first day the adult programs are open to clients.

It's an exciting development, and has been months in the making. The biggest challenge left for us to tackle will be actually running a program in this opening period when our census is really low. Referrals are hard to predict no matter what, and even more so with a totally new program in a new location. It's great that we have as many as we have (3 in PHP, and 2 in IOP, with a few more slated for later in the week). However, when group therapy is the primary treatment modality, that kind of census is definitely challenging.

The program will definitely look a bit different this week than it will look later on. We may not be able to follow our group schedule exactly, especially since clinicians, dietitians, and psychopharmacologists have to take clients out of groups for individual meetings. A group of two, with one person pulled out, is no longer a group! We don't want people to get used to whatever adjustments we have to make for the low census, but it does offer an opportunity to think about what makes (or breaks) a group.

At these levels of care, groups look a little different than they do in standard outpatient care, where there is usually stable membership - a set number of people who attend a predetermined number of session, the same people each time. Even in long-term groups with rolling membership, there is a core of members who attend over time. As a result, we see groups develop their own character as a group, and move from disconnected people to a unified cohort.

Other levels of care, such as PHP and IOP, have a more fluid population, so group membership is constantly changing. Clients attend multiple groups with the same people each day, but various clients may be pulled out of various groups without warning. It's a constantly changing picture, and interpersonal connections that form tend to be to the program rather than to the group per se.

Nevertheless, group composition can drastically change the tone of the group, and therefore, of the treatment clients receive. In my ideal world, I like groups to have between 6-10 members, who have enough in common that they can relate to one another, and enough NOT in common to offer each other new perspectives. Our clients already have something in common by virtue of having an eating disorder, but when it's a mix of anorexia, bulimia, and binge eating disorder, that similarity may not go very far. We typically have all adults, and they tend to be similar functional levels, which helps...but in this beginning period, we've had to accept a few adolescents mixed in with the adults, which could make it harder for group members to relate to each other.

At these levels of care, people tend to be at varying stages of recovery, with varying degrees of motivation for change; I think that's an asset to groups, as people further along in recovery can serve as role models and exert some healthy peer pressure. Of course, the opposite process is also possible: when a majority of the group is early in recovery and/or unmotivated for change, they can bring the group as a whole down to their level. Part of the facilitator's job is to keep that from happening. Another challenge is when most group members are reluctant to speak; it can be pretty painful to get through an hour with a bunch of people who just stare at you, their feet, or the clock! I really hope that, with such a small group this week, they will at least be willing to talk.

What factors do you think make for a productive, or detrimental, group dynamic? How would you navigate this awkward period of low census, and the shifting census that will always be part of the equation at this level of care?

Sometimes the Bear Gets You (and What to Do Next)

A thoughtful supervisor once sagely shared with me a piece of practice wisdom: "Sometimes you get the bear. Sometimes the bear gets you."

Now, I don't know the source for this quotation, or to what it originally referred. It was first told to me in the context of work with preschoolers. However, I have found it most relevant to the practice of group work - no matter the population.

If you've led groups, you've most likely had the experience of things...not going as planned. After all, there are many variables in group leadership that are out of the leader's control - for example, who attends on any given day, what mood they're in and what else is going on in their lives when they get to group, and how they will interact with each other. Because group composition and dynamics change over time, it's very likely that you will walk into a group that's changed in subtle ways since the last time it met - whether that's the next week, the next day, or the next hour!

I've spent a lot of time working in partial hospitalization programs - day programs that offer short-term treatment for acute psychiatric conditions, as a way to reduce or avoid hospitalization. Treatment happens primarily in groups, and the population changes on a daily basis as people are admitted and discharged. Combining acute psychiatric symptoms with constantly-changing group composition, and people at various stages of treatment, makes it hard to plan a group that's appropriate for everyone. It can feel risky to challenge the group too much, or to introduce a new intervention when you can never be sure how it will go over.

Sometime things go pretty much as expected - with various group members behaving predictably (in both helpful and unhelpful ways), and grasping the material to whatever extend their symptoms and abilities allow. These are the days  when no (metaphorical) bear puts in an appearance.

Occasionally, things go better than you could ever have anticipated. The group has a breakthrough, connecting to each other and/or the material in new, deeper, more authentic ways. Their passion, compassion, and creativity outstrip yours and take whatever you've planned to levels you couldn't have come up with (after all, we all know that a group is, in many ways, more creative than an individual). On these rare but precious occasions, you get the bear.

However, things don't always go as well as you hope, or expect (even when your expectations are low). Sometimes a group will go to pieces (metaphorically and literally). Members squabble, form cliques, and are unkind to each other. They become oppositional, clown around, make a scene, or otherwise interrupt the group process. Perhaps members who were previously divided suddenly find common ground, uniting against you (as happened to an unfortunate colleague today). At best, you spend the time putting out fires and responding to inappropriate behavior, and don't get to convey whatever material you had planned (in other words, the behavior is effective in its goal of disrupting/derailing the group for the day). At worst, you have to invite (*insist*) one or more members leave, or even just end the session. These (you guessed it!) are the occasions when the bear gets you.

It doesn't matter how brilliant you are as a therapist, or how motivated and cooperative your clients usually are - sooner or later this bearish group dynamic will take over, and get the best of you. It's normal, and sometimes a necessary stage in the group's development. The trick is to respond in a way that moves the group dynamic toward a more productive resting point. Perhaps, to continue with my metaphor, the way to prevent that bear from getting you again is to tame the bear as a circus performer instead of locking it up in a zoo. (Of course, remember that other bears will inevitably come along eventually!)

Easier said than done, but here are my suggestions:

1) Interrupt the disruptive behavior as soon as possible, to keep a counterproductive dynamic from becoming a new norm. Redirect, or when necessary remove instigators or stop the group.
2) If there are a small number of instigators, address their behavior 1:1 to figure out what happened to trigger it, and discuss how they can be more productive when the group resumes.
3) When the group resumes, reiterate the group guidelines, however they have previously been decided/conveyed. Invite the group to discuss the last meeting in the context of these guidelines. Hopefully, more positive group members will confront the disruptive behavior, thereby reestablishing pro-social and productive group norms. (It's more powerful when the message comes from peers rather than the facilitator).
4) When appropriate, invite further processing of the underlying issues that contributed to the group dynamics that occurred at the last meeting.
5) Move on to the real "work" the group has gathered to do, and whatever material you have prepared.

When the bear gets you, it's also incredibly helpful to process it with colleagues and/or in supervision. Process your own reactions and frustrations, try to figure out what (if anything!) you might have done differently, and discuss a plan for the group's next meeting. This step is absolutely crucial when the group is meeting as part of a milieu (e.g., the partial program), where other staff are running groups with the same participants, and working with various clients individually. Without good communication and mutual trust, negative group dynamics can infect the treatment team and become "staff splitting" - which has negative results for clients' treatment, and staff morale.

So, in summary: Bears will come and go. Sometimes you will get the bear, but other times the bear will get you. It's inevitable...but not always negative in the long run, because it offers an opportunity for groups to address specific issues that might not otherwise come to light, and it offers you an opportunity to hone your skill at leadership, and conflict resolution.

What suggestions do you have for when the bear gets you?