1. 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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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.

9. 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.

10. 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!

11. 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

12. 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?”

13. 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

14. 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

15. 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.

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

17. 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

18. 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

19. 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

20. 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

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

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

23. 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.

24. 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.