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?

Making Haste Slowly (Or, 8 Reasons Change is Hard)

Change is hard! I know it's cliché, but it's also such an important thing to remember when you're in the business of helping people change. 

Lately, I've found myself becoming forgetful about how hard change really is. Sometimes I feel frustrated sitting with a client, who is saying the same things they said the last time, and the time before that - complaining about a situation that is within their control, but about which they have done nothing. (Don't worry, I don't express the frustration outside of supervision. Instead I remind myself of what I'm writing about here!)

There are all kinds of reasons why a client may not be working to change a problematic situation.

1) They may not see the problem. I know that sounds crazy, but as they say, denial is more than a river in Egypt! People may not acknowledge the presence of a problem at all, or may think the problem is something totally different from what other people see.


2) They may not be sure they want to change. Many people come to therapy very ambivalent about change - they feel pulled just as strongly away from change as they are toward it (and vice versa)

3) They may want somebody else to change - a very common phenomenon, particularly in family therapy, but also in individual therapy. I saw someone today for the second time, and his ideal "treatment goal" is to get me to tell his girlfriend that she's wrong and should do what he says.

4) Staying the same is familiar and comfortable, even when it sucks; change is scary, even when it's good.

5) They may not know that change is possible. If things have been this way for a long time, they may not have really imagined any alternative.

6) They may not believe change is possible for them. Even if they know that it's theoretically possible (or at least that their naive, delusionally optimistic therapist believes it to be possible!), they may have developed learned helplessness - the expectation that their efforts to change the status quo will fail.

7) They may not know where to start. If this is the dilemma, that's good news, since hopefully the therapist has some sense of how change happens! However, if they have had some false starts due to strategic errors, it can erode morale when it's most needed.

8) They may get frustrated with how slow the change process is (much like me at the beginning of this post!) When that happens, it can help (clients and therapists alike!) to review and highlight the little changes that have already taken place, instead of continuing to focus on how far away the goal may be.

I'm sure there are other reasons (feel free to add them as comments!), but these are the ones I encounter most often. Remembering these potential barriers to change helps me stay patient and empathic when I'm tempted to become frustrated. I also remember that my discomfort with my client's "stuckness" is nothing compared to the client's discomfort - they have to live in it, while I just visit.

How do you understand stuckness, and the change process? How do you help clients stuck at various points along the way?

Resistance is Relational

"Resistance" is a common issue in psychotherapy - that moment when a client metaphorically digs in his or her heels, refusing either the direction of treatment, or change more generally. It can be confusing and exasperating for therapists. Haven't we all said at one point or another: "Why is this client even coming to therapy if s/he's not going to do anything?"

In the past, resistance was understood to be a problem with the client - a function of the client's unconscious defenses, and/or "secondary gains." More recently, however, the field has started to understand resistance a bit differently. Motivational Interviewing is an approach largely based on such a reinterpretation of resistance. Its creators, Miller and Rollnick (2002) define resistance as something that occurs in the relationship between therapist and client when there is a mismatch between the therapist's approach and the client's readiness for change.

Motivational Interviewing assumes that change is difficult, and that ambivalence (feeling torn) is a normal part of the process. Resistance becomes an issue when the therapist doesn't adequately address this ambivalence, and instead jumps ahead to change. It often looks something like this:

• Client: "I'm not going to the party - I just feel like staying home." (expressing intention not to change)
• Therapist: "That's the depression talking. You'll start feeling better if you get out and socialize more." (assuming the expert role)
• Client: "I don't feel better when I'm trying to be social - I feel worse because it's more obvious what a loser I am!" (arguing the disadvantages of change)
• Therapist: "Maybe you'll find out that other people have similar worries - that you're not the only one" (arguing advantages of change)
• Client: "Whatever." (shutting down)

As this dialogue shows, therapists often respond to client statements against change by arguing more strongly in favor of change. Consequently, the client then feels compelled to argue the anti-change side of the ambivalence just as strongly - in the process, convincing him/herself not to change.

We can conclude from this phenomenon that directly confronting resistance only serves to strengthen the resistance. Instead, Motivational Interviewing suggests "rolling with resistance" - reframing or shifting it to create momentum toward change (think judo). In rolling with resistance, the therapist avoids arguing in favor of change or trying to impose new ideas on the client. Instead, the client is invited to consider new perspectives, but is given responsibility for generating answers or solutions to their problems (based on the assumption that he or she is knowledgeable about the problem and what may help).

Resistance, when it occurs, is a signal to the therapist that he or she needs to change tack and respond differently. It may be that the therapist's response doesn't match the client's stage of change (the right intervention at the wrong time), or that the therapist is responding in ways that tend to trigger resistance (the wrong intervention). Responses that invite resistance include: directly arguing in favor of change, taking on an "expert" or paternalistic role, acting rushed, and criticizing, shaming, blaming, or labeling the client.

So if those are the responses to avoid, what are effective responses to resistance? The general principle is to respond to resistance with nonresistance. Below are examples of responses to the client statement about ("I'm not going to the party - I just feel like staying home"):

• Direct reflection of the client's statement   "You feel more comfortable staying home"
• Amplified reflection of the client's statement (slightly exaggerate the client's stated thought/feeling, which can cause them to back off a bit, perhaps expressing the other side of the ambivalence - i.e., the pro-change side)     "You just feel like staying home. In fact, why leave the house at all?"
• Double-sided reflection (acknowledging the anti-change side of ambivalence the client has just expressed, and adding to it the pro-change side of ambivalence based on things the client has said at other times - i.e., not just your own opinion or agenda)    "You'd prefer to just stay home, but you also feel lonely at home sometimes, and have wanted to make friends."
• Shifting focus away from whatever seems to be the barrier    "You don't have to go to the party; maybe you'd rather just hang out with one or two people."
• Reframing (acknowledging the validity of the facts behind the client's statement, but offering an alternate interpretation)   "Depression makes the idea of going to a party feel daunting, but once you're there you know you'll feel better."
• Agreeing...with a twist (reflection, followed by reframing)   "You really feel like staying home - but sometimes you can push through that feeling."
• Emphasizing personal choice and control     "It's up to you whether to go to the party."
• Coming alongside (the therapist makes an anti-change statement, which may cause the client to argue the alternate - pro-change - side of the ambivalence)    "You're right. If you feel like staying home, you shouldn't go."

How do you "roll with resistance?" When do you find it hardest to do so?

For a fuller discussion, see Miller and Rollnick (2002) Motivational Interviewing, Second Edition: Preparing People for Change