Thoughts about teaching group dynamics to residents STFM April 28, 2010 Michelle Domanchuk, APN/CPN Kay Goler Levin, PhD, LCSW West Suburban Medical Center Family Medicine Residency Program

Fears about leading groups: That no one will talk: That leader will not know what to ask of group Group members will be dependent on the group leader, won’t talk with each other That too many people will talk: Group leader won’t be able to stop them That the group leader will lose control of the group, group will disintegrate That group members will exhibit anger or hostility-and there’s more of them than me, won’t be able to resolve issues of members

Benefits about groups: Improved medical outcomes -and you still get paid, (Schirmer) Satisfaction improves Improved health behaviors Opportunities for resident education Practice based learning and improvement Improved interpersonal and communication skills Opportunities for population-based studies

Group values Sharing Identification Peer help Mutual Aid Testing Social Exchange and Acceptance Getting Things Done

Group Visit Norms: We will. . . Encourage everyone to participate State out opinions openly and honestly Ask questions if we don’t understand Treat one another with respect and kindness Listen carefully to others Respect information shared in confidence Try to attend every meeting Be prompt so meetings start and end on time

Roles are different in group visits and individual visits Unique skills residents can acquire through group visits (Rosenberg & Gawinski, ) Skills needed to: Decentralize physician’s role: Talking with and not talking to Eliciting information instead of offering it Listening to, adopting their language Manage “being outnumbered” by our patients Teach fundamentals in collaborative group process

Group Dynamics Group Stages/Phases Group Purpose and Content Planning Beginning Middle Ending Evaluating Group Purpose and Content Group Leadership Different role at each stage Power and control issues Constructive Ways to Deal With Conflict

Group leader roles at different stages of the group‘s development: Beginnings: Leader sets the stage for open non-judgmental communication. May point out commonalities as group members introduce selves. May ask for clarification further information, refer to purpose Begins to verbalize norms, expectations, builds on strengths, invites participation.

Group leader roles in the middle stage of the group: Reach for consensus, check to see if most members agree on how things are going. Reach for difference, to help group members see a range of possibilities and to include different viewpoints. Confront situations as they arise. Reach for feelings to invite members to amplify what is said.

Group leader role in the middle stage of the group (con’t): Reach for information to clarify from members what was said. Give feedback. Check out inferences, make sure what is said is understood -The message sent is not necessarily the message received. (from communications theory). Give information. Support group member interaction, which often means talking less than you did previously!

Group leader roles at the ending stage of the group: Summarizing, communicating that the group member’s experience has been communicated and understood. Voicing group achievements, verbally summarizing with appreciation indications of progress, growth. Helping individual members to appreciate their own contributions and growth

Topic Discussion “Has anyone else ever had this problem before?” “How has anyone dealt with this situation before?” “What have you heard about _____?” “What do you wish that someone would have told you?” “That’s an interesting question, who would like to respond to that?” “A lot of people say or think that, but the newer thinking is that__” If it’s alright with you we can try to talk about that later or at the next meeting, but let’s try to get through this topic first.” “You bring up some really good points for discussion, but for now, we need to move on in order to give everyone a chance to talk” “You have lots of good questions that we don’t have time to address right now. Can you research and report back to us on that?”

Group leader tasks at each stage of the change process: Precontemplation: Raise doubt, increase group members’ perception of risks with current behavior Contemplation: Tip the balance, evoke reasons to change, risk of not changing, strengthen the group members’ self-efficacy for change of current behavior

Group leader tasks at each stage of change process (con’t) Determination: Help patient determine best course of action to take in seeking change Action: Help patient take steps toward change Maintenance: Help patient to identify and use strategies to prevent relapse

Group leader tasks at each stage of change process (con’t) Relapse: Help patient review the process of contemplation, determination and action without becoming stuck or demoralized because of relapse.

Summary of motivational strategies (A-H) Giving Advice Removing Barriers Providing Choice Decreasing Desirability Practicing Empathy Providing Feedback Clarifying Goals Active Helping (Shulman)

Problems members can bring: Overaggressive member Shy member When disagreements occur How to handle divergent opinions How to handle “the expert” How to deal with a group member, when you may dislike that member. How to limit, or support a member

Challenges in teaching group medical visits: Traditional Collaborative Passive Expert Bio-medical treatment approaches Advice giving Interactive Shared collective experiences Promote psychosocial health behaviors Self-efficacy and empowerment

Resident Skills: Content Process Promoting health behavior change Motivational interviewing Goal setting Group facilitation skills Stages of Change model Experiential learning Planning group activities and group content Teamwork and negotiation skills

Patient Attitudes: Content Process Self efficacy Peer support Build confidence and competency Identify areas of progress (with check ins and behavioral Rx) Reinforce progress Sharing expectations

Discussion: What did we learn What worked What didn’t work What to do differently

References Berman-Rossi, T. (1993). The tasks and skills of the social worker across stages of group development. In Social Work with Groups 16 69-82. Gallagher, R. (1994). Stages of psychotherapy supervision: A model for supervising trainees of dynamic group therapy. International Journal of Group Psychotherapy 44. (2)169-183.

References Goldberg, A., Rickler, K., McMurray, J., Sullivan, G., & Nothnagle, M. (2009). Teaching Residents to Lead Mini-Group Medical Visits. Shulman, L.(2010). Dynamics and Skills of Group Counseling, Brooks Talen, M.R, Shah,A. (2009). Teaching Residents the Knowledge, Skills and Attitudes to Lead Group Medical Visits.

References (con’t) Levin, K. (2006). “Some thoughts about leading groups”, presentation to adjunct faculty, Stritch School of Medicine. Miller & Rollnick, (1991). Motivational Interviewing Prochaska & DiClemente (1982). Stages of Change. Schirmer, J., Shahady,E., Stello, B., Candib,L. (2008). “The finer points of group medical visits,” presentation to Society of Teachers of Family Medicine. 4-28-10