Getting The Most Out Of Group Therapy

The power of group therapy can be remarkable.  I've seen group dynamics bring out the best in people; they offer others support, guidance, compassion, and most of all, acceptance.

For some, group work provides feedback they can't get anywhere else. Often, what friends won't tell you, family won't tell you--group will, in a respectful and caring way.

Group work can help to alleviate shame around issues that you may think are only yours. Misery may love company, but a healthy group--and a good therapist--won't allow the group to become mired in misery and self-pity.  One of the greatest values of sharing difficulties with others is knowing that you're not alone. Another huge benefit is drawing on the strengths and experiences of others to find help--and hope.

Because successful group work depends on group members being vulnerable to others in the group, it's important that the room be a safe and respectful place.  Members must be able to suspend judgment in the room, and behave in a way that honors the pain and difficulty others may be going through.

This means giving others space. Knowing when to talk and when to be still.  Listening--really listening--to others talk about themselves and providing feedback to you. Done in a caring, non-blaming way, feedback from others who have been where you've been, can be powerful--and sometimes cathartic.

Of course, group work isn't for everyone.  As I mentioned previously, some clients are not in a place where they can take in others' stories and experiences. This is why most therapists require an intake interview prior to admitting you to a group.  It helps you and the therapist determine if you, the group, and group work itself will be a good fit.

For those who join my groups, I provide a tip sheet on getting the most out of the group experience. I want to acknowledge the words and wisdom of other therapists that appear mingled with mine below. I believe that these guidelines underscore some of the behaviors that make for a successful group experience; and hopefully sets expectations for participants.  I've provide these guidelines here:


Guidelines For Getting the Most Out of Group

1. Be on time. It shows respect for the group and minimizes the disruption caused by coming in late.

2. Be as honest and open as you can be with yourself and others.

3. Focus on expressing feelings as opposed to judgments.

4. Practice listening to understand, rather than to agree or disagree.

5. Try listening and reflecting when someone gives you feedback, rather than automatically jumping in to defend yourself.

6. If you feel the need to confront someone, be respectful but direct rather than commenting an aside to someone else or under your breath.

7. Use “I statements” which express and own your point of view rather than assuming everyone shares your experience or opinion.

8. Avoid generalizations and intellectualizations. These kinds of statements are usually more isolating than inviting.

9. Speak directly to, make eye contact with the person you’re addressing. This will help make connections with others in group.

10. Feel free to remain silent. Much can be learned in silence as well as through speaking.

11. Take responsibility for yourself in group. If you’re feeling uncomfortable, frustrated, bored or dissatisfied, tell us how you’re feeling and suggest a different direction.

12. Take risks. Fear is a sign that you’ve reached the limit of your self-concept. If you allow yourself to go beyond that it can be a freeing experience. Trust the group to support you in this.

13. Don’t smoke, eat or chew gum during the group. These activities tend to distract and diffuse intensity of the group experience.

14. Avoid cross-talk. It’s almost impossible to understand more than one person at a time. Please honor the person talking with your attention.

15. Power off all cell phones. The group needs your attention for only the short time we’re together each week. Phone calls/text messages are interruptive and disrespectful of the group.

In conjunction with or separately from individual therapy, group work can be transformative. Yes, it can be scary to sit in a room with strangers and talk about your innermost feelings. But, the good news is, they won't be strangers for long.  As you form bonds within the group, begin to feel comfortable, safe and emotionally held by the group, the fear can ease, then disappear altogether. Leaving you open to the strength and support of others who truly do understand. Or who at least try.

Thanks for listening.

Group Therapy: Strength In Numbers, or "I'm Not The Only One Who Feels This Way!"

Group therapy can be a powerful therapeutic modality that offers group members the benefits of  empathy, understanding and healing that comes from group feedback and support.  It it for everyone? Probably not. Some personalities and treatment of some disorders are better suited to individual therapy. For the client, it takes patience to sit and truly listen to difficulties that others are experiencing. However, when you become comfortable with listening and sharing, you may find that I'm not the only one who has experienced this! I'm not the only one who feels this way!"


There is power in being supported by others who genuinely understand your distress.  Is group work for you? Read on.

A few ways group and individual therapy differ.
1. Obviously, in group therapy, you share the floor with others.  In groups that I lead, I structure them to provide each participant with time to "check in," that is, to share recent developments, challenges and accomplishments related to their therapeutic goals.  Then, typically, we open the floor to individual members who have issues or challenges (preferably related to the group's work together)  they wish to share and gain feedback on.

2. In many groups, there can also be an educational component provided by the therapist.  For example, in groups on drug and alcohol addiction, I often provide the group with information on how people change,  how various drugs affect the body, as well as group exercises to help participants understand the effects of addiction on their own emotions, values and relationships.

3. Sometimes there is homework where, individually, you are invited to examine some of your personal beliefs, behaviors and values; then, back in group, you're invited to share what you're comfortable sharing with the group. In my groups, and in most groups I know of, no one is forced to share anything. Keep in mind, sharing is an invitation, not a command.

4. Group therapy sessions usually cost less than individual sessions. This can be a consideration when deciding on the treatment that you want.  Typically, group session charges can be half of the cost of individual work or more.  Your therapist will discuss cost with you prior to your enrollment in group.

5. Group therapy sessions are typically longer than individual sessions. While my individual sessions are 50 minutes, my group sessions usually last between 90 minutes and two hours, depending on the group.

Making a commitment to your group experience.
In groups that I hold, in order to ensure that the group setting is a safe and comfortable place for group members and, to ensure group continuity, all members are asked to make these commitments to the group:

1. Commitment.  All group members are asked to agree to attend for a minimum time period ranging from several weeks to several months. Because the group benefits from each other’s input and support, you agree to make this commitment a high priority. You agree to arrive on time for each group, as latecomers can be interruptive to a group in progress.

2. Confidentiality.  You agree to keep confidential the identities of other members in the group. I also ask you to agree NOT to have discussions about group content with other members of the group or anyone else outside of the group setting.

3. Dual relationships. Because dual relationships can create experiences outside of the group that can be problematic for the rest of the group, I ask that you agree not to socialize with, date, or have sexual relations with any other group member while active in the group.

4. Payment. I ask members of every group honor the payment schedule that we agree on in advance. Because your commitment to the group ensures you a seat each week that cannot be given to someone else,  I ask that you agree there will be no refunds for missed groups.

5. Goals.  Because it is important to know what you want from your group experience, I ask that you agree to establish some goals, giving some thought to what you want from the group and how you would like things to be different for you when group therapy ends. 

How is group therapy sounding so far? For many, it can be a life-changing experience or, at least, one which helps your clarify your own thoughts, values and goals by entertaining differing perspectives.

Next time: Guidelines for getting the most out of your group experience.

Until then, thanks for listening.

It's Your Time, Your Money, Your Life--Your Therapy. Who Do You Choose?

So, you've come to an important decision: you'd like some help with the distress in your life, and you want to choose the right person to help you.  You've heard of counselors, therapists, psychologists and psychiatrists? Who's right for you?

Only you can answer that question.  It can be a complicated decision, based on many factors. But, depending on your difficulty and the help you're looking for, you may find it helpful to consider the following.

One place to start: What are the symptoms of your distress?

Are you having intrusive thoughts that won't go away? Feeling depressed and can't shake hopeless feelings?  Wondering if you have Attention Deficit Disorder?  Frustrated with your life choices? Feeling angry with a loved one? Struggling with an alcohol addiction?

So you'll want to determine Is this person qualified to help me with my particular difficulty?

There are many ways to choose a person to help, but one way is to consider the scope of practice of the person you're considering.  Scope of practice refers to what this person is trained to do and services he or she is deemed capable of providing safely, by either a state licensing board or other certifying body.

If you seek a counselor, be aware there are many types of counselors with varying degrees of training.  For example, a peer counselor may be trained to listen and provide practical life advice, but is not trained to assess or provide treatment of mental illness.  Career and rehab counselors usually have master's degrees in their  specialty. Other counselors such as "life coaches" may have varying degrees of training (from several weeks to several years).  Pastoral counselors may offer counseling tempered with a particular religious view. When you interview your counselor, ask: What training have you had? Do you have a specialty? How long have you been practicing? Do you have a license or a certification?


A licensed therapist has received the training and the approval of a state licensing board to treat a variety of mental disorders that can cause moderate to severe distress such as depression, anxiety, chemical dependence, anorexia, bulimia, stress, personality disorders and marital and relationship problems, among many others.  A licensed therapist has studied human psychology, lifespan development, individual as well as couple/family counseling techniques, drug addiction and treatment, psychopharmacology, multicultural implications for counseling, theories of psychotherapy--among other studies--over the course of several years. When you interview your therapist, ask: Are you licensed? Do you have a specialty? How do you like to work with your clients? Where did you go to school? 


You may choose to see a clinical psychologist. In addition to the talk therapy work that therapists do, clinical psychologists are trained to administer and interpret a variety of diagnostic tests which can clarity diagnoses of mental disorders or addictions.  They have extensive training and are licensed.

Finally, you may choose to see a psychiatrist. A licensed medical doctor, a psychiatrist cannot only assess and diagnose your difficulty, she or he can also prescribe medications to help combat the symptoms of depression, anxiety, Attention Deficit Disorder, and a host of other disorders which have been shown to respond to medical treatment.  Psychiatrists can provide short- or long-term talk therapy as well, or  provide medication management while working in conjunction with your therapist or psychologist to coordinate your care.

What about insurance? Most insurance companies invite licensed therapists (MFTs), psychologists and physicians to serve on their panel of providers, subject to the approval of the insurance company.  Some providers of mental health care choose not ally with insurance companies and therefore require you to reimburse them directly.  When you contact any mental health care provider, be sure to ask: Do you accept reimbursement from medical insurance plans? If so, which ones? How can I find out if you are on my insurance panel of providers? What are your fees? How are insurance claims submitted?


You can see that you have many choices when it comes to mental health care, and this discussion just scratches the surface.  When it comes to sorting out who to choose, ask questions. Decide if you want to utilize your insurance coverage. Consider the scope of practice, experience and training of the person you're considering. Ask friends for recommendations.

And finally, try him or her on for size.  If it's not a good fit, you have the right to say goodbye and try someone else.  After all, its your time, your money, your therapy--and your life.

Thanks for listening.

Counselor, Therapist, Psychologist, Psychiatrist? How many does it take to...?

Therapy. The word conjures up a variety of images from Freud to voodoo dolls. But when the laughter dies down and you find yourself in need of help the question becomes Just exactly which professional do I turn to?


For the purposes of this discussion, I'd like to look at four options (of many) which are available for mental health consultation and therapy.

 Counselors. The term "counselor" can refer to anyone who offers another help. There are lay counselors, peer counselors, pastoral counselors, career counselors, rehabilitation counselors--and the list goes on.  The thing most counselors have in common is specialized training. Lay and peer counselors usually do not require a degree program, but often involve a variety of training, usually specific to the type of of counseling being offered.

Pastoral counseling may be a part of a cleric's training, but usually does not involve diagnosis of mental illness. Often, pastoral counseling is rooted in the fundamentals of the religious denomination of the practicing pastor or priest. They are not usually required to be licensed by the state.

Some  career counselors have completed master's degree programs which are devoted to this specialty.  They are usually extensively trained in basic counseling skills and theory, with a concentration in their specialty.  Some who provide career counseling can do so without a degree program; sometimes this is referred to as "life coaching" or "career development."

Rehabilitation counselors have master's degrees in their specialties, usually followed by a rigorous certification examination.  Rehabilitation counselors can work with those with illness, injury, mobility challenges, deafness and other disabilities.  Rehab counselors work to empower people with disabilities to make informed choices, build careers and live independently.



Therapists. In the mental health field, therapists are master's degree graduates who have (in most states) completed up to 3,000+ hours of clinical practicum work and passed a rigorous licensing exam administered by the state. In the past, in the state of California, these therapists were designated Marriage Family and Child Counselors.  Today, these same professionals are called Marriage and Family Therapists. They work with couples and families dealing with relationship issues; they also work with as individuals struggling with a variety of disorders that are causing difficulty in personal and professional relationships such as anxiety, depression, eating disorders, stress, phobias, personality disorders and more.

Traditionally, therapists practice talk therapy, which is precisely as it sounds.

Psychologists. Clinical Psychologists have usually have doctorates in psychology or philosophy. While they hold doctorate degrees and are addressed as "Doctor," they are not physicians, and cannot dispense medication. 


In order to be called a "psychologist" you must be licensed. Clinical psychologists work with those who have life adjustment problems, emotional disorders or mental illness. They also provide diagnostic assessment or "testing services" which can be essential for clarifying diagnoses of a mental disorder or addiction. 


Psychologists must complete a specific number of hours of supervised training, usually two to three years, prior to finishing their Ph.D.  They must pass licensing examinations; most have produced a doctoral dissertation on original research.  In addition to Clinical Psychologists, there are also Educational Psychologists, Neuropsychologists,  Forensic Psychologists, Organizational Psychologists as well as other specialities.


Psychiatrists.  These individuals are medical school graduates with years of advanced training in their specialty, Psychiatry. They are physicians, licensed to treat patients and prescribe medications.  In the past, many psychiatrists had full-time talk-therapy practices and functioned as the prescribing physician as well as admitting physician should a patient need inpatient psychiatric care.

In more recent years, some psychiatrists have shifted their focus to evaluation and medical management of mental illness, providing an extensive psychiatric evaluation at intake, prescription of psychotropic medication as needed, and followup visits on a regular basis.

So, now you know. Who's the best fit for you? Only you can decide what you need and who the best provider will be.  The answer will depend on a variety of factors, which we'll take a look at in the next posting.

I hope to shed more light on the subject then.

Thanks for listening.




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From The Therapist's Deck Chair, or The Mental Health Benefits of Watermelon.

I'm sitting on a deck overlooking lush vineyards. A gentle morning breeze is washing over me. In the distance I hear a dog barking and sheep bleating.  A cranky rooster is making himself known.  It's just after 9 in the morning.

Clearly I'm not in my office. It's a holiday. A day off. One of life's stress-reducers.

I'm a big fan of time away from work. Studies show that absence of work stress--even for a day--can lower blood pressure, heart rate, and even improve our odds against cardiovascular disease. When we slow down, our bodies slow down.

For "type A" personalities, slowing down can be a challenge, but one that can change lives.

I have a theory about holidays like the Fourth of July. We march in parades. Some people paint their faces red, white and blue.  We wave the flag, beat drums, and set off explosions of multicolored grandeur in the air.  Tonight, all across America tonight, millions of children (and, ok this adult) will coo in unison: ooooh, ahhhhh! as pyrotechnics light up the sky.

And, for most of us, it's a day away from our normal work. I count this as one of life's blessings, and hold in high regard those who work holidays so the rest of us can run out for that extra head of garlic, have a meal out, grab a box of Band Aids or the can of cat food we forgot the day before.

Oh, yeah, my theory. I'm getting to it. I'm distracted by hawks who are riding the air currents in the valley below. My theory is this: holidays are permission-giving occasions. On holidays, we get permission not only to skip work, but to be a bit childish again. Just observe anyone, of any age, at any picnic eating a juicy slice of watermelon. I rest my case.

We also get permission, on these "special" occasions, to do "special" things: we might spring for a steak instead of hamburger, pull out that "good" bottle of pinot we've been "saving," whip up our special salad, invite over special friends, indulge a little in that dessert we only have on special occasions.  You get the point.  It's a delicious bit of indulgence that, in moderation, lets us not only enjoy a few of life's treats, but also, in my mind, give us permission to treat ourselves well.

Two quail have just crossed the garden path, looking for worms?  Their treats, perhaps? They walk slowly, oblivious to us humans, seemingly content with their leisurely stroll in the morning sun.

We could learn something from the quail.  But wait, we're on holiday, so I'll suspend the learning, the "shoulds," the must-dos and the agendas, just for the day.

Enjoy your holiday. Spend time with friends.  Ooo and ahhhh at tonight's fireworks.  And have an ice-cold slice of watermelon, and let the juices run down your chin. I can almost guarantee the sight will provide you--or at least those around you--with a genuine, child-like grin.

I can almost hear the blood-pressure dropping.

Thanks for listening. Happy Fourth.

The Depression Quiz, or Is It All In Your Head?

What do Buzz Aldrin, Winston Churchill, Agatha Christie, Rodney Dangerfield, Charles Dickens, Eminem, Terry Bradshaw, Dick Cavett, Courtney Cox, Nelly Furtado, Janet Jackson, Beyonce, John Lennon, Abraham Lincoln, Isaac Newton, Marie Osmond, Edgar Allan Poe, Sergei Rachmaninoff, Anne Rice, John D. Rockefeller, Brook Shields, Mark Twain, Kurt Vonnegut, Mike Wallace and Walt Whitman have in common?

Sorry for the long list, but the famous people listed above are only a few of a long, long list of notables who have suffered from depression.

Yes, a man who walked on the moon, legendary recording artists, sports greats, noted authors, gifted composers, presidents, moguls, celebrated actors--all have experienced bouts of serious depression.

And yet, despite revelations from public figures, the stigma and misunderstanding about depression persists. Just how informed are you about depression? Can you separate fact from fiction? Try your hand at the quiz below.

TRUE OR FALSE:

1. Depression only happens to people who are weak emotionally disturbed. 

2. Depression isn't really a medical condition at all--it's all in your head.

3. Depression is like getting the blues--a normal part of life. Stuff happens.

4. Teens don't suffer from real depression--they're just naturally moody.

5. Symptoms of depression can last for months, even years.

6.  Thinking positively will make your depression go away.

7. You're not certain to "inherit" depression even if it runs in your family.

8. Depression can cause emotional and physical pain.

9. Developing depression requires a specific negative event.

10. Taking anti-depressants will change your personality.

The answers are below:

1. False. Depression is an equal-opportunity disorder that affect millions of strong, decisive, functioning and otherwise healthy individuals every year.

2. False. Depression is a medical condition that affects not only mood and thoughts but also your body.  Those suffering from depression have been found to have higher levels of stress hormones as well as decreased levels of activity in some areas of the brain.

3. False. Depression is to "the blues" as pneumonia is to a cold. Unlike feeling blue, depression is pervasive, deep, long-lasting and can lead to far greater and more damaging outcomes including suicide.

4. False.  Depression can affect people of any age, socioeconomic group or ethnicity. And depression isn't the same as "moodiness."

5. True.  This is one of the characteristics that separates true depression from the occasional few days of feeling sad or down.

6. False. You cannot "think" your way out of depression any more than you can any other illness. Depression is a condition caused by a variety of factors which are thought to include changes in brain chemistry and structure due to environmental and even biological influences.

7. True. Just because family members have suffered from depression, it's not a given that you will. While you may inherit a tendency toward depression, and genetics can play a factor,  it takes a combination of factors to develop depression.

8. True.  Depression can be accompanied by changes in body chemistry which not only affect mood but also how you feel physically.

9. False. While there are precipitating events that can trigger a depressive episode, depressive symptoms can arise suddenly, even when your life seems to be going well.

10. False. Anti-depressants are designed to work with the body chemistry related to the symptoms of your depression, not the neurochemistry related to personality.  Many people who take anti-depressants report feeling more like themselves, with relief from depressive symptoms.

So, how did you do?  More and more, people are demystifying mental illness by shedding light on the facts, and talking about their own experiences of depression, anxiety, phobias and more.

And the prevailing views on depression are becoming less shame-based, and more tempered by understanding and compassion.

All in your head?  Hardly. If you've been feeling deeply sad and hopeless for more than two weeks, with little hope in sight, and have difficutly just getting through everyday activities, you may benefit from time with your physician, therapist, lay counselor, even your minister or rabbi.  There is help for how you feel.

And the good news is, feeling hopeless doesn't have to last forever. Just ask Buzz Aldrin, Janet Jackson, Eminem, Beyonce, Mike Wallace, Marie Osmond, Anne Rice...well, you get the picture.

Thanks for listening.

No Quick Fix or, Therapy: It's Not For Sissies.

I have a confession: I love to look at other therapist's websites.  Not only does it help me understand how other therapists view our profession, it gives me a clue as to how others approach the therapeutic process.

In my site-surfing,  I often notice words like "journey," "discovery," "insight," and "collaboration." When I took a look at my own site (www.therapistsf.com) one word keeps jumping out at me: work.


I fully believe that, of all the things therapy is, it's primarily a commitment to do work. Yes, it can provide insight, self-revelation, healing, change, coping skills, hope, direction and repair.  But not unless you're willing to do the...wait for it...work.

I had a client several years ago who came to me in true despair.  In our first session, she flooded--spoke rapidly and non-stop--about her history, her deep hurt and her need to be understood. We were off to the races. It seemed to be a good start, with a clear direction for the work. She seemed as though she would be a good candidate for therapy.  However, I should have seen the warning signs when, in our second session, she strode into my office, kicked off her shoes, plopped down on the couch, propped up her feet, put her hands behind her head and said, not-half jokingly: Ok. I've told you everything. Fix me. How do I get better?

There is a place for reclining in therapy but  I'm not a Freudian or even a neo-Freudian, so the work done in my office is done sitting up, facing one another.  After inviting my client to sit up, I also invited her into the therapeutic conversation. Her refrain, for this session and most of the remainder of our work together was, in essence, "I feel so bad.  Fix me. Make it better. That's your job."

After assuring her that I am not in the business of "fixing" my clients, and inviting her time and again to participate in her own therapy, I eventually terminated our work together, referring her to a colleague who I thought might be a good fit. Postlogue: my client never went to see my colleague.  I can only guess that she just didn't want to do the work--or wasn't ready to do it at that time.

Therapy is not like a spa-treatment.  It isn't done to you. Therapy, at its most effective, is more like a collaborative safari.  You and I work to set goals, coming to an understanding (over time) of where you'd like to arrive at the end of our work together.  My role, if I'm doing my work well, is to provide not only guidance in the process, but also safety.  If I do my job as I'm supposed to, I can help to make the therapeutic conversation a safe one.

Not only do I not judge you, I'll try help you be less judgmental, less critical, less hard on yourself. When the room is safe,  when the internal focus shifts from finding blame to finding understanding, it's more likely that clients can actually look at issues that, while painful, can be examined with an eye toward change.

Easy? Not all the time.  Again, it's my role (among others) to monitor the room, to watch the intensity of the work, and to make sure you have time to "decompress" from the deep work, so you can feel composed and safe to go back out into the world when your clinical hour is up.

So, does therapy have to be chore? I hope not.  Challenging? Certainly. Difficult and emotional at times? Yes, often.  But the very word--work--suggests accomplishment.  And that can make the challenge, the difficulty and the time spent not only worthwhile, but life-changing.

And when's the last time you got that from a mudpack and loofah scrub?

Thanks for listening.