Topic 4: Overcoming Challenges in (CBT) Groups {by 10/1}

There are two readings due this week – Bieling et al. Chapter 6 & and Yalom Chapter 13.  Address the following two discussion points: (1) Beiling et al. and Yalom discuss some common types of “problem group members” (although they use some different terminology, there is much overlap). Identify a specific type of problem group member that you think would be a challenge for you to mange in group and discuss why. (2) Did you notice any difference between Beiling et al. and Yalom in their recommended strategies to manage these problem clients (either in general or a specific type)? Explain. Your original post should be posted by the beginning of class 10/1.  Have your two replies no later than 10/3.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

22 Comments (+add yours?)

  1. Richard Hisman
    Sep 29, 2014 @ 15:20:05

    The one that stands out first and foremost are individuals with schizophrenia and other psychotic disorders. Yalom immediately discusses how and if these individuals can come back to the group. Somehow an individual has slipped through the screening process and now it is being determined whether the group would be able to accept him/her again. With the duration of Yalom’s groups, which in his example is in session 45, reintroducing someone after an episode is at least a possibility. If this were to happen in a fifteen session therapy, I seriously doubt should an individual would be able to return. Let alone the damage on the group dynamics that would occur. Yalom and Bieling both make it clear that these individuals for most group should be feted out in the intake process.

    The advice given by Bieling was very pointed and time driven. When x happens hopefully the group has stepped forward to help redirect or the therapist may have to intervene. At one point he even asserts that if the overbearing individual type has not broken to interrupt and redirect the group. Yalom does not get so directive at most times. He tends to stress using the group members to achieve the same goals. In the end they want the same outcome but approach it from different directions. Bieling tends to use a more behavioristic approach sometimes during conflict.


    • Jessica
      Oct 01, 2014 @ 11:41:03

      I agree that it would be difficult to reintroduce a psychotic client back to the group. It can be done if the group knows the client and has formed a bond with them previously and the client comes back, apologizes for their behavior, and appears to be like their old self again. I’ve only ever seen this done in groups run at group homes in which the residents all know each other (some for a long time if they’ve been in hospitals together) and know what that resident is like when they are not psychotic and most have also seen their psychotic behavior before. I cannot imagine doing this in an outpatient setting, even in a group that runs for 40 or more sessions. It would probably damage the group dynamics too much to beneficial for the group or the previously psychotic client.


    • Sarah Gagne
      Oct 03, 2014 @ 22:59:57

      I have worked in a community outpatient setting for several years and have seen many groups run effectively with psychotic group members. I suppose it depends on the environment in which the group is held. In low-income areas, the majority of clients may be psychotic, as opposed to private practice where the “worried well” may be the majority clientele in a group setting. If psychosis at baseline is common, group members may be understanding and the behaviors or symptoms may not be as detrimental to a group. Redirection on the therapist’s part may be helpful in maintaining a manageable group.


  2. Sarah-Eve
    Sep 29, 2014 @ 17:10:32

    A type of client that might be extremely difficult to work with would be “the disbeliever” or “the help-rejecting complainer”. These two types of problem group members are similar in that they do not believe that the treatment or that suggestions mentioned by other members and the therapist would work for them. They may seek out advice, but reject any help that is offered, and seem to take pride in the fact that their problems appear insurmountable. When these types of clients are overbearing, they may challenge the therapist and outwardly undermine the therapy, creating a negative effect on other group members and the group as a whole. It’s difficult to handle clients who outwardly reject anything and everything you say as a therapist. This may model to the group that you are under qualified and that this treatment modality will simply not work for this client, and in turn this will simply not work for the rest of the group members. On the other hand, clients may become angry, irritated, and confused as their own needs may be undermined by this individual. Yalom and Bieling indicate that one way of responding to this type of a group member, as a therapist, is to acknowledge and validate the hopelessness of their situation; refusing to perpetuate the “help and reject” cycle. Giving the client the choice of continuation of therapy and expressing the implication this client is having on the group can aid in changing behavior in this type of a setting. Yalom indicates that the interpersonal and social context is extremely important in the ways in which a client’s character is presented in group. Another way of diffusing the situation, according to Bieling, is to have only group members respond to these individuals help seeking behavior.

    The “problem client” is a result of many factors: the client’s character, the group’s dynamics, the group member’s personal interactions, etc. When dealing with a difficult client, it is important to look at the various factors that may affect the group and the individual clients in order to see whether something within the group is bringing out this type of behavior. For example, Bieling indicates that group structure in CBT is extremely important. This group structure can have an effect on client characteristics though. Overly structured groups provide no opportunity for reflection and interpersonal group interaction; leaving no room to check in on clients and how they are feeling (e.g., about the group, it’s progress, their own progress). Group interaction and feedback allows for group members to understand how they are influencing each other, and openness can create the opportunity for change in the client’s character and thus the group dynamic.


    • Paige Hartmann
      Oct 01, 2014 @ 13:44:00

      As a beginning therapist, working with the “disbeliever” or “the help-rejecting complainer” may be very challenging. These types of clients seek advice but tend to reject help from group members and the therapist. These problem group members can often set a tone for the whole group that this treatment will not work for them. I would find this type of client difficult to manage, but both Yalom and Bieling offer useful strategies to appropriately handle these individuals.


    • Angela Vizzo
      Oct 04, 2014 @ 06:16:30

      Sarah, I like your discussion on difficult clients to work with in group. I, too feel that these types of group members would be particularly challenging and their rejecting behavior could very easily disrupt the group dynamics or even undermine the entire therapeutic process.


  3. Paige Hartmann
    Sep 30, 2014 @ 22:31:35

    The “monopolist” or “overbearing type” of client would be difficult to manage within a group, as this type of client would dominate the group with talking incessantly about their own experience. This type of client makes it almost impossible for other group members to participate and can also impact the agenda that the therapist has for the session. Yalom discusses how this can have a detrimental impact on the group as group members may not feel comfortable addressing the monopolist client, thus resulting in unresolved tension. Yalom suggests that the therapist handle the situation by focusing on both the monopolizing client and the group that has allowed this to persist. Bieling discusses both subtle and overt strategies for dealing with the overbearing type of client. Subtle strategies such as avoiding eye contact, nodding, or asking questions can be utilized initially to not reinforce the client to keep talking. Overt strategies can be used secondary, but should involve a balance of the needs of the client and the group.


    • Sarah-Eve
      Oct 01, 2014 @ 08:52:29

      I wonder what types of strategies would work better, overt or subtle. Perhaps depending on the person there would be differences in what they would respond to. With subtle cues, other group members would also have to catch on in order for it to work. If no other members are participating in not reinforcing this type of behavior, it’ll be futile. Addressing the issue head on in this case might be a better option.


  4. Sarah Gagne
    Sep 30, 2014 @ 23:21:13

    I would find the “helper” to be most difficult to work with in a group therapy setting. This individual may try to generalize his or her experience to the entire group. This is detrimental to the group as individuals should feel they are able to share their own, unique experiences and find commonalities, rather than one person imposing experiences that may not be reflective of everyone. Group members may feel alienated as they may not identify with the generalization. Other group members may feel uncomfortable to disclose in this situation or may not feel open to contributing to the discussion. The “helper” may also question the effectiveness of the therapist, which I think would be awkward as a beginning therapist.

    Further, the “helper” may provide “help” that may have the opposite affect than intended. For example, Bieling et al. identify an individual who suggests a person avoids anxiety provoking stimuli, which would hurt the individual as their anxiety would continue due to this behavior.

    An example of how Bieling and Yalom differ in their approaches can be seen in the description of skills to contain a shared problem client, for example, the monopolist or the overbearing type. Bieling gives an example of one client interrupting another. Bieling does not reinforce the overbearing behavior and redirects the group focus to the individual that was interrupted so that he has time to finish his comments. Yalom, in a similar situation, would bring the issue back to the group and ask the group as a whole why they have allowed the individual to monopolize the discussion. Yalom asserts that group members may come to the conclusion that they have allowed the monopolist to overtake the session so they would not have to participate as much. Realization of this issue may lead to everyone equally participating in discussion.


    • Paige Hartmann
      Oct 01, 2014 @ 14:03:15

      I agree with you that working with the “helper” group member may be very difficult. Since the “helper” may generalize his or her experience to the group, this can cause other group members to feel uncomfortable participating. As you had mentioned, I think it would be especially difficult to handle this individual if he or she begins to question your effectiveness as a therapist.


      • Richard Hisman
        Oct 03, 2014 @ 11:04:09

        The helper and the monopolist may be difficult but certainly not impossible to work with. The biggest issue for me would be getting the group as whole to engage these individuals. That is where the dynamics of change will have to come from. Once that occurs it is more likely that the individual will see just how disruptive his/her behavior is. At that point work can be accomplished to change or modify the behavior. (All is not that simple, this is a lifetime behavioral individual aspect that will not just change over night.) It can strengthen the group and draw the individual experiences to the table. It would be interesting to see how everyone answer these questions in 10 – 15 years to see how attitudes change. One has to remember that while we help others to adapt and change, we are ourselves are changing.


  5. Michelle
    Oct 01, 2014 @ 08:12:06

    Both Bieling and Yalom, throughout their writings, continue to stress the importance of individual participation in the group. Research suggests that increased participation may lead to increased benefit, and the opposite is also asserted as true. The silent client, then, may be more problematic than he or she seems. Lack of participation may not only impede on their ability to progress, but can also impact the cohesiveness of the group, and work against the preferable group norms of sharing and openness. I might particularly have difficulty with the silent client, as I try to better understand the reasons for the silence, and help them to open up. Yalom suggests that the therapist should try to understand the reason for the silence. It’s somewhat ironic that the therapist is to work toward better understanding of a client’s position, while that client is also unable or unwilling to communicate; it seems a challenge indeed, and one that not only can affect the potential benefit of the group for the member, for the other members, as well.
    Bieling approaches problematic behaviors by offering strategies that the therapist can use in response to the particular problem. His interventions are so clear that he even offers a table that lists each potential problem, and the corresponding strategies. Therapists have an active role in dealing with the behavior, and if the group as a whole is to help rectify the problem, then it appears that Bieling admonishes the therapist to direct the group either directly or indirectly. Although Yalom does not offer a table that expressly addresses each problem, and corresponding intervention, he also delivers a directive approach. Both Bieling and Yalom share the common goal of ensuring that the individual’s problematic behavior does not interrupt his or her own growth, or the growth or norms of the group. Differences in their approaches are evident in the description of the silent client. Bieling recommends that the therapist tries to understand the reason for the silence, and then either try to get the client to open up by referencing similarities between the client and other group members, or by talking with the client about how the feel about being a part of group. Yalom discusses this problem at a deeper level, discussing the ramifications of not addressing the problem, and how other group members might respond, or feel about the member’s behavior. Yalom encourages a fuller approach to change, with the therapist continuing to encourage participation, and potentially asking the client to try to understand for him or herself the reason for the silence. His appears to be a broader approach, taking into consideration other problems that the behavior may bring up, as well as additional options for addressing them.


    • Sarah-Eve
      Oct 01, 2014 @ 08:55:14

      The silent client could definitely be tricky. Yalom explains how this type of client may not get anything from the group and be more apt to drop out, or they may apply much from the group in their daily lives and successfully benefit from this type of therapy. It would be great if all silent clients were able to successfully benefit from the group, but others in the group do not benefit from the client’s progress. As much as the client may be limited from not expressing themselves in group, the rest of the group members may also be limited.


    • Gil
      Oct 01, 2014 @ 17:27:10

      I think you have a good point about the silent client. If everyone throws their cards out on the table, then everyone feels equally invested and can feel more comfortable disclosing. The silent client however, can lead others to feel uneasy about self-disclosing. As this feeling spreads, the group dynamic takes a hit and self-disclosure and acceptance are squelched. The norms in the group might be anti-therapeutic and group cohesiveness suffers.


  6. Jessica
    Oct 01, 2014 @ 11:30:33

    The help-rejecting complainer and the psychotic client can be very difficult to work with depending on the severity of those problems. Someone who complains a lot but doesn’t accept advice or feedback will be a drag to the whole group. It may make the therapist question their self efficacy for running groups the other members question the effectiveness of therapy. I remember one HRC in a domestic violence support group that I grew to dislike because she would have a crisis every week, other members would rush into give her advice and she had a reason to reject everything; I could tell the other members were getting frustrated and so was I but at the time but I did not know how to address it (I wish I had this group therapy class then). I have also seen how disruptive psychotic clients can be for group, but the group is generally more shocked/scared/angry with that client than the therapist or the therapy. The group can resume after they are gone, but it is hard for that client to transition back to group. I imagine all of the others are difficult to work with as well. Many of the residents I have worked with at the Bridge have borderline personality disorder but most of them are not problematic in group. I would not consider treating someone with that diagnosis as an omen of poor prognosis that seems to be the stereotype of our field (I do however know some people who are more extreme cases of borderline personality disorder that this would be true of, but their symptoms lesson when their life/medication becomes more stable).
    Bieling et al were much more straightforward and curt in their suggestions of how to deal with problematic clients, to the point I found myself asking “is that it?”, a question I rarely find myself asking of textbooks. Of course I did not ask that reading Yalom but since he provided much more strategies of how to handle various types of problematic clients, I’d probably check there first if I find myself really struggling with a problematic client in group. I find it interesting that Bieling et al do not address characteristically problematic clients like Yalom does (Borderling, schizoid, narcissistic) and the psychotic client. These I think would all fall under “The not-appropriate-for-group-member.” Rather than discuss ways to deal with these particular clients like Yalom does, Bieling et al. suggest simply containing and managing the client’s problematic behavior, acknowledging that the group can’t meet all their needs and focusing on what the group can offer them, and terminating them from group referring to more appropriate treatment options if needed. These are great suggestions but fail to address various ways you might handle a psychotic client compared to a narcissistic client, etc.


    • Gil
      Oct 01, 2014 @ 17:38:18

      Sometimes I got the feeling from Bieling, that CBT would be less willing to work with those individual who were overly problematic. The filtering process seemed overly extensive. It is likely that the problematic behavior seen in group will also be plaguing the individual’s life outside of group. Here is where the structured aspect of CBT can prevent an individual from fully exploring his or her issues. Tangents take away from the flow of the CBT group, whereas Yalom can go with the flow to let the individual flesh out his or her needs.


      • Richard Hisman
        Oct 03, 2014 @ 10:38:01

        While that may be the outlook Bieling portrays, I do not believe it is where he intends to go. He is very pragmatic in that not all individuals are capable of maximizing there experience in group. And if one were to form a group of individuals with certain disorders, the group would be too chaotic to achieve any lasting progress. He definitely points one in the direction that some disorders are best treated in individual first, and that some may benefit from group and individual at the same time. Where as Yalom has the luxury of exploring the entire being, including anything beyond what the client intended. While this is nice, we have to agree that focusing on psychodynamic therapy has not proved to be more effective than CBT, DBT and CPT. It definitely has proved to take much longer. Yalom describes a perfect world a lot of the time, one that is probably not going to be realized.


    • Michelle
      Oct 03, 2014 @ 09:29:09

      While norms are being established early on in group, I would think that the help-rejecting member might also be especially problematic. Sometimes, an individual can set a tone that resounds through the people around them. Even in a group containing twelve members, one member who does not treat other members’ advice wtih respect, but who instead maintains a more socratic approach, could establish that as a norm, if the therapist isn’t careful to contain it. This class, Jessica, is a great place to learn. I think, too, though, that we will all have to learn by much trial and error, as you have already been doing.
      Fostering an environment where members feel safe and free to open up will be more challenging, I would think, should a member frustrate them in this way. Should this behavior first reveal itself in later sessions, members who have already established a group norm of functional helpful behaviors may become easily frustrated; not only is the group member being disrespectful, now they are also working against established norms and social expectations.


    • Sarah Gagne
      Oct 03, 2014 @ 22:55:13

      I also think the self-rejecting complainer may be difficult to work with. If group cohesion is high and members feel comfortable helping each other and providing advice, I can’t imagine how disruptive it must be for an individual to not only reject suggestion from the facilitator but from peers within the group who are genuinely trying to help. Negativity is contagious, and one group member rejecting all suggestion can bring everyone down.


  7. Angela Vizzo
    Oct 01, 2014 @ 15:40:41

    Both Yalom and Beiling identify numerous types of problem group members; the clients who may be considered challenging in individual therapy are not necessarily the same clients who may be considered challenging in group therapy. In individual therapy, the client I would have the hardest time with is the silent, quiet type, as I think many beginning therapists would. However, in group this is the opposite as the group can rectify this behavior with minimal prompting from the group leader. In contrast, the monopolist or overbearing client, who may be easier to deal with in individual therapy, seems particularly challenging in group. I think I would have a hard time with this client because I would have trouble knowing when to stop them from speaking and how to do so. I would also be afraid to alienate this client and make them not want to share at all, or even to send the wrong message to the group as a whole, therefore making other members less willing to share. On the same lines, the helper would be hard to deal with as well for the same reasons.

    Yalom and Beiling both offered strategies to control problem group members. One major difference that I noticed between their suggestions is that, in general, Yalom preferred strategies where the group as a whole manages the problem member, while Beiling preferred strategies where the leader manages the problem member. For example, Yalom suggests asking the group why they allow one member to monopolize the conversation, in doing so he puts the problem on the group. In contrast, Beiling suggests containment strategies utilized by the leader to deal with the overbearing member.


    • Michelle
      Oct 03, 2014 @ 09:37:17

      Throughout our readings, one thing that is clear is that it is best for members, both for themselves, and for the sake of the group, to open up. I would think that a more mature group, or one that has an environment of safety and open communication, might be more likely to intervene when members act in problematic ways. The more directive CBT might suggest that the therapist is responsible for the direction of the group, and in ensuring that session goals are moved toward, and the agenda followed. I would think though that even with this perspective, a therapist could motivate the group to work through the issues, with participation, but not necessarily direct leadership of the therapist. To me, it might benefit the group even more to have the autonomy of working through issues. While doing so, not only is the group helped, but the members themselves are opening up, and may be even increasing in efficacy. The therapist, then, should be ready to mediate and redirect, in an effort to keep things productive, and going in a functional direction.


  8. Gil
    Oct 01, 2014 @ 17:07:25

    The helper seems like an individual who would give me trouble. Many of the behaviors exhibited by the “problematic members” can be discouraged or redirected with the other group members learning to not do the same behavior. One who goes overboard and gives advice while failing to look at his or her own problems will not benefit from group. However, one member giving help to another can be very helpful. The situation is tricky because you would not want the other members to learn that it is bad to give advice or to be discouraged by the correction of the other person’s advice. Ideally, the therapist can be supportive of the comments made in order to reinforce feedback and self-disclosure. So correcting a member’s advice or curtailing their advice must be done, but not in a way to scare off the other members from venturing their own support to others. Finally, correcting or redirecting a member’s advice may start a power struggle if not handled properly.

    Yalom seems to focus on the problematic behavior as a large reason that the person is currently in the group, whereas Bieling et al. focuses on the behavior as an impediment to therapy and not the goal of treatment. Therefore, Bieling has specific strategies to try with each client so that the lines of communication can be opened again. Yalom, on the other hand, usually will incorporate the behavior as a treatment goal and will use the group forces to explore the behavior so that the member can gain insight to the underlying function of the behavior or the significance of the behavior in the problematic member’s life.


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Adam M. Volungis, PhD, LMHC

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