Voice of Experience: A Consultation Forum edited by Sarah Pollard

Dear Voice of Experience,

I am a newer therapist in the process of getting my full license. I work at an agency that provides clients partial hospitalization and intensive outpatient services. Clients attend didactic, skills-based groups that meet several times a week for several hours each day. While the groups are not specifically process groups, there is usually some foray into processing while discussing the application of skills and topics into life. The group members are at various levels of functioning. Some have outside therapists and psychiatrists they have been seeing for awhile, while others are brand new to therapy. I co-facilitate these groups and therefore spend a lot of time with group members.

By the end of the day I feel zapped, guilty, annoyed, unskilled, and hoping the group member no-shows the next day.

My question is about how to handle things both in the short-term (while the member is in my care) and long-term (throughout my career as a therapist) when there is a group member whom I struggle to tolerate or empathize with. Currently, I am having a hard time with a group member who seems to be always in crisis. When the member first admitted, they presented with a series of very real problems: the death of a pet, then a breakup, then an abrupt change in living circumstances. I was very empathetic when I met them, but as time went on I began to get a hunch that this client was enjoying the secondary gains from their victim role and was not using therapy effectively to change or improve their situation. My empathy waned. Now I find myself avoiding eye contact with them in group to discourage their input, or feeling impatient and irritated as they talk. By the end of the day I feel zapped, guilty, annoyed, unskilled, and hoping the group member no-shows the next day.

I sometimes ask what feelings or reactions others have to what the group member has said, and responses vary. Some members get riled up along with the client (“Your ex is horrible!”), some problem-solve (“What about xyz apartments?” or “You can live with me!”) and some look down and dissociate.

This predicament brings up two primary dilemmas for me:

  1. I am very aware of how I come across to the group when this client shares a new crisis. I don’t want to appear dismissive or to send the message that it’s not safe to decompensate in group. Yet, this client routinely shares in a manner that derails group and demands a great deal of attention from the therapist and other clients. How can I balance honoring their needs while staying true to the format of the group?
  2. Many of my clients are extremely sensitive to others’ needs and often use caretaking to distract from their own problems. How do I protect the group from being drawn into a caretaking role with this client?

As a seasoned therapist, how do you tolerate group members who irritate you?

I realize this group member, like many, has more work ahead of them. Yet, for now, I am with the group members for several hours each day and therefore want to maintain a good rapport with them and want them to like me. Leadership is understanding, but like in most agencies, everyone is spread thin. Some days I feel I’m “white knuckling” it through the groups.

Can I use the group to help, and if so how? How do I take care of the group member and the group and myself in times like these? As a seasoned therapist, how do you tolerate group members who irritate you?

Signed,

Reluctant Rescuer in Austin

 

Dear Reluctant:

While reading your question, I was once again reminded how stressful agency work often is. You tend to work with the least-resourced part of our society and are provided the fewest resources to serve them. I was also struck by my immediate impulse, which was to take each line and provide a “how-to” for you. Your client is bringing multiple problems they want solved, and it’s difficult to stay on topic when a “crisis” intrudes into the group. I’m wondering whether you are having a parallel experience to your clients’; perhaps I’m being induced to help you in the way you’re being induced to help your group members. Thus, I’m going to try to avoid the “crisis” approach and go a little under the surface.

Crises can be engaging, even enlivening, for group members. They are distracted from their own lives, and they can feel like they’re helping another person, which can build their sense of themselves as helpful and competent. This is a skill-building group, and it seems part of that process would be to for members to share stories about how they’ve handled similar crises in their lives. Group members are often more open to hearing from other members rather than the leader.

Crises can be engaging, even enlivening, for group members. They are distracted from their own lives, and they can feel like they’re helping another person.

The people who are quiet might be your best consultants — would you be able to ask them to be curious about their “looking down”? Your group members need help in talking to one another in ways that are helpful. You say you check in with them after a new crisis is shared. How do you do that? Is it geared to help them give a “how to” or is it designed to help them talk about their concerns and reactions?

Your own feelings may provide you with important information about the participants and need to be studied. You state that your empathy waned after having the idea that the client wasn’t using the group therapy to change or improve their life. Most of us who enter this work want to help people improve their lives, and we can feel irritated when it either doesn’t have that effect or takes longer than we think it should. And it sounds as if your feelings of guilt, annoyance, and incompetence are being induced by this client’s material. Is it possible that your group members are also having these feelings, not just about the crisis-prone member, but about their own lives? And could they be worried no one can help them? Are you worried no one can help them, including you?

I am so glad you’ve reached out for consultation regarding this group. This work is challenging, and all of us need trusted, experienced people to help us navigate it. You are at the beginning of your career, and I hope you will find people who will help you develop your clinical skills, especially when working with people you find irritating. There are a number of avenues that can provide support while you expand and solidify your personal and professional skills.  

I am a strong advocate for therapists being in their own therapy process (individual and/or group) in order to understand how their own psychology affects their work with clients. I am also a firm proponent of therapist participation in group and/or individual consultation. We all need support and help in sorting through the clinical and personal issues that are inherent in the work of psychotherapy. Receiving and giving feedback regarding clinical cases not only provides multiple perspectives, it also helps us to develop trusting, caring, supportive professional relationships. You are facilitating a group process that is designed to encourage members to help each other navigate and understand the issues in their lives. I encourage you to consider the importance of getting similar support for yourself. Consultation with my peers and mentors has been crucial in building my ability to tolerate the feelings induced by my clients.

Patricia Florence

Patricia Florence, MA, LCSW, CGP is a Clinical Social Worker in private practice, where she offers individual, relationship, and group treatment.  She has recently added a consultation & supervision group to her practice. Patricia credits her introduction to group therapy to her co-therapists and supervisors at Waterloo Counseling Center, who also introduced her to AGPS and AGPA.  She is currently in a long-term process group as well as a consultation group. Patricia participates in a training group with Ronnie Levine, Ph.D., and in January 2017 she completed the weekend training program at the Center for Group Studies in New York City.

 

Dear Reluctant:

Thank you for putting the time into such a thoughtful question! I smiled reading it because I related so much to this universal group leader experience. Feeling tied up in knots inside is usually a sign something needs to be said that isn’t. We all feel anxious or exhausted when we swallow our voice. You are very insightful, self-aware, and clear on all the dynamics at play, but it sounds like you might be holding your insights back instead of using that information to guide the group. To answer your question about how to simultaneously take care of yourself (giving yourself permission to act on what you already know), AND the annoying client (who needs to learn to relate to others and loosen the defensive victim role), AND the group (who needs to take up their fair share of the group time and do their own healing), let me run through one of the many ways you could handle the situation.

The client who annoys you (let’s call her A for annoying) probably annoys others, particularly those in the group looking down and dissociating (let’s call them HD for head down). You could interrupt A after a couple of sentences and ask A who in the group A is feeling connected to as A is talking. That redirects A to connect with others in the room and be receptive to their responses instead of caught up in the victim role. If A were able to make this shift we’d have to change his or her name to A for awesome because you probably wouldn’t be annoyed by A anymore. Perhaps I’m imagining A as a little narcissistic, because I’m really wanting A to focus more on others. A may only explore your question for a few seconds before returning to the story. You could then ask, “How do you think HD is responding to your story?”  The subject is again redirected to the interpersonal, and hopefully you have started to get HD curious and engaged as well. After a few sentences of A’s response, you could ask HD what he or she is feeling.

You are very insightful, self-aware, and clear on all the dynamics at play, but it sounds like you might be holding your insights back instead of using that information to guide the group.

Exploring HD’s reactions and the group members’ resonance with those will help draw HD out and solidify the focus on relationships in the room. If it is difficult for HD to put feelings into words, you could say: “Maybe you withdraw when you feel overwhelmed. Were you having trouble connecting with A?” Or, “It’s easy to get annoyed when you feel helpless.” Even if HD doesn’t feel that way or can’t join it, you have introduced a new possibility for how A affects the group without directly confronting A yet.

The care-taking group members (let’s call them CT for caretakers) will probably try to bring the attention back to A at some point because they don’t want A to feel dropped. At that point you can interrupt CT and make a comment: “It feels so important to you to take care of A.  Do you focus on others instead of your own feelings outside of group too?” This exploration could lead to CT’s history: “Is there someone you took care of as a child?” Hopefully the CTs can explore this dynamic and what it costs them, but if they try to quickly return to A, you can intervene again and say: “What about YOU? What are you feeling in this moment? It would be great to practice in here seeing what you need instead of playing out your pattern of focusing on others.” If you think A is having trouble handling the lack of attention, you can say something to A indirectly by telling CT: “A will actually feel more joined and less alone if you share your experience and needs rather than just responding to what A brought in. One-way relationships aren’t satisfying in the long-run.” Groups can make someone into an identified patient by choosing one person to “work on” instead of exploring what that member brings up for them and how they relate or react to these triggers. To protect the group as a whole from being drawn into a caretaking role with A, you could make a group-level interpretation: “I wonder if we want to solve our own version of the feeling A is having through her instead of owning it inside of ourselves and joining A in exploration?”

Ultimately, you may need to confront A directly: “Your pain is very important for us to feel with you so that you aren’t alone, and I worry that the length of your stories can cause some people to tune you out or feel disconnected because they don’t have a chance to respond soon enough to feel useful and included. I’m going to try to interrupt these stories early on so that others have the chance to be with you sooner and you can practice letting them in.” Hopefully this legwork will make it easier for both you and A to actively manage this dynamic in the future.  During future stories you will be able to say to A: “Let me pause you here so you can connect with others…,” and then ask anyone else what’s happening inside him or her.

You are clearly already checking in with the other group members since you know how they all respond to A. Using what they say to change the focus to them instead of A is only a small step away. To the members who express anger at A’s ex-partner, you could say: “Who in your life does his or her ex remind you of?” If they don’t go for that you could ask about who else they feel angry at and whether or not they let themselves express it, or anything else about them to get everyone exploring instead of directing communication to A. And of course you always want to encourage any opportunity for them to express anger at you if you see one.

You might ask yourself, and possibly the group, “I wonder what A is holding for the group?” In this case, for instance, maybe others don’t want to talk about their pain and so A is doing it all for them. They will have to reclaim parts of themselves to bring the group back into balance. Bringing this up with curiosity can help everyone take responsibility for the dynamic and see it as an opportunity, rather than A’s fault.

They will have to reclaim parts of themselves to bring the group back into balance. Bringing this up with curiosity can help everyone take responsibility for the dynamic and see it as an opportunity, rather than A’s fault.

 

Finally, to respond more broadly to your question about what to do when you can’t empathize with a client: when you can’t, someone else in the group will. You can easily spot this person by looking at everyone’s nonverbals and then you can ask this person who “gets it” what is coming up for him or her. In terms of how I tolerate group members who irritate me consistently, I check inside to see how much of my annoyance is about me (my countertransference). Clues on this are whether or not others in the group are responding similarly and whether or not something about this person or situation is a known hot button for me. Often it can be a combination of both my issue and the client’s (objective countertransference). Either way, I internally care for my own feelings and compassionately contain them.

I also wonder whether and how my irritation points to something useful for the client to learn. In your group, A is stuck in a victim role that makes her miserable and alienates her from others. Your feelings toward her show you how to help. If I need more compassion, I picture my clients at the age they might have developed this coping strategy, see their innocence, and try to understand what they were needing and not getting. I might see a developmental issue that was blocked and can be restarted in the group, like the development of one’s will (moving towards what you want and expressing anger). From there I feel care and also clarity about what help to deliver. Half the battle is noticing your own reaction. In your case, you are aware of your avoidance of eye contact with A and what happens inside you during and after the session, and what the trigger is. You have all the insights about the group process to make the needed interventions. Seems to me as though it’s just time to trust yourself and go for it!

Charlotte Howard

Charlotte Howard, Ph.D., CGP, is a licensed psychologist and certified group psychotherapist.  She has been practicing for 12 years at Deep Eddy Psychotherapy, specializing in group and relationships.  Her love for relationship dynamics recently began to focus on relationship with self, and she spent the past 2 years creating YourselfTruly.com, a 10-week online program to teach women to love and nurture their true authentic selves. Dr. Howard wrote Awaken to Love, a heart-centered self-help book for couples.

 

Dear Reluctant Rescuer in Austin:

You are not alone in what you’re feeling about your work and about your clients! Your reaction to your group says a lot of positive things about your emotional receptivity and self-awareness. Your curiosity about what might be going on inter- and intra-psychically should be a source of hope for you as you explore this topic.

I have the idea that the “irritating” group member is re-enacting something from their past, and is also serving an important function for the group as a focal point of a group resistance. The re-enactment likely has to do with how the group member learned to make themselves a target of contempt in their family, and they probably felt helpless and controlled by others. They are talking about their troubles in group (which is their job), but they are also denying the group an opportunity to feel powerful and effective by not taking any of their advice or ideas to heart or making any changes. The “irritating” member is defeating the group, thereby engendering a sense of power and control.

The “irritating” group member is re-enacting something from their past, and is also serving an important function for the group as a focal point of a group resistance.

Earlier I commented on your emotional receptivity, and I want to encourage you to consider the possibility that the feelings you are having about the group and about that particular member are actually not your feelings at all, but rather feelings that are being induced in you. The irritation, frustration, despair, and contempt you described are probably also felt by group members, and I also suspect they are feelings the that person’s parents or caregivers felt toward them when they were growing up. These feelings can be referred to as objective countertransference. Most people would have similar feelings toward this client.

As to how you can help this member and help the group, I think it’s important to remind yourself that there’s no one way to do this work (thankfully). You have to be willing to take risks and make mistakes with your group in order to help them grow. I find truth in the adage that if a leader isn’t making at least three mistakes during every group session they lead, they’re not taking enough risks with the group. Your group is using the “irritating” member’s problems to avoid talking about their own problems. Your job as one of the co-facilitators is to protect that member from being scapegoated, and you can do that by drawing the group’s anger and irritation toward yourself. Over time, as the group resistance resolves, you will be able to focus on the individual members’ resistances.

You ask another important question, how you can make sure to  take care of yourself so that you can continue to make a living helping other people. Working in an agency doing clinical work can be incredibly rewarding, but also demanding. Clinicians working in agencies are often not adequately protected from institutional stresses. It’s very important to your longevity in this work to be taking the best care of yourself that you can. Being in your own therapy is the best way that I know of for clinicians to take care of themselves. Having a trusted therapy relationship in which you can talk about everything will, over time, have a significant positive impact on your ability to continue this work.

If a leader isn’t making at least three mistakes during every group session they lead, they’re not taking enough risks with the group.

Your last question is a great one: “How do I as a seasoned therapist tolerate group members who irritate me?” I was in an Institute group at AGPA led by a well-known group leader who has a reputation for being very skilled and also somewhat narcissistic. As the group had just wrapped up, many of us were talking to the famous group leader about their style and how it has evolved over time. One group member commented on how the leader’s style had changed and “softened” so that the leader didn’t seem as demanding and confrontational as they had in previous groups. The leader smiled and said almost as a matter-of-fact, “Well, as I’ve learned to love myself more, I’ve learned how to be more compassionate with myself and with other people.” It took me some time to fully appreciate what the leader said, but it has helped me at a very deep level. When I’m feeling irritated with a group member, or with a group as a whole, I’ve often observed that what’s actually happening inside me is that I’m frustrated with myself and with my own inadequacies and limitations. I’m not loving myself enough. If I’m able to notice what’s happening with me, I can be more forgiving of my faults and shortcomings as a leader or as a person, and I soften and become more friendly toward myself. When that happens, I seem to automatically soften and feel friendlier toward whomever or whatever is irritating me and I can understand their situation much better. I’ve noticed again and again that my own growth seems to help my groups go to a deeper place.“Reluctant Rescuer in Austin,” I hope that as you continue to grow as a group leader and clinician, you can learn to love yourself more. The situation you’ve described is a very common one in this profession!

Allen Lambert

Allen Lambert, LCSW, CGP, is a psychotherapist who has been in private practice for 11 years. He’s led groups for 15 years, and co-leads two mixed gender Modern Analytic process groups, as well as a Modern Analytic Gay Men’s process group. He’s worked in federal, county, and university mental health settings as well as in non-profit counseling centers.

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