Bored patients, disengaged patients, patients re-entering treatment so many times they can repeat curriculum topics back verbatim: these are some of the problems providers today struggle with when it comes patient experience in group therapy.
In the recent past, there was such high demand for services that finding an underserved area and opening up a shop was enough to maintain both census and profitability. However, nowadays, many, particularly metropolitan, areas of the country are “overbedded.” With private equity investing tens of billions into behavioral health, there has been an explosion of addiction treatment programs, acute care psych hospitals, outpatient programs, MAT clinics, and, now, even telehealth.
While up to 25% of Americans will struggle with a mental health or substance use disorder at some point in their lives, the reality is that the majority of those with a diagnosis do not seek formal treatment, not because they can’t access treatment, but because they don’t want to (SAMHSA 2020). There is not as much demand as it was originally thought. This mismatch in the investment has and continues to saturate the market for behavioral health.
Now, as in any maturing market, to effectively compete, providers have to differentiate, not only to stand out from the competition, but to be better. If I’m a patient or a community referral partner and I’m looking at four different facilities in my community, which one am I going to choose?
The problem is that most patients and community referral partners couldn’t give you a strong reason to choose one over the other. Think about it yourself. If a community referral partner asked you why they should refer to you versus a competitor, could you give an answer that isn’t a mirror image of the answer your competitor would give to the same question?
And therein lies the opportunity for providers to stand out.
As the owner of Circle Social Inc., a strategic marketing and consulting firm for behavioral health providers, and the owner of The Institute for the Advancement of Group Therapy, a training institute for therapists, I’ve personally sat in over 100 group sessions. I’ve been in luxury programs, Medicaid programs, residential, intensive outpatient, telehealth sessions, programs with Master’s level licensed clinicians, programs with counselors with a LADAC, you name it, I’ve seen it.
Of all the different programs at all the various facilities I’ve observed, what was the biggest difference? The answer is nothing. All therapeutic interventions in the group setting look the same everywhere I go. This doesn’t mean that the care being provided is good or bad. It simply means that it looks the same everywhere.
It also means that providers who deliver something different have a tremendous opportunity to stand out and differentiate themselves.
Standard delivery in the group therapy session generally consists of all the patients sitting around the room with a therapist directing turn-taking. Sometimes the therapist will simply go around the room in a circle, other times they may ask a question to the entire group to see who answers. In both cases, only one person is speaking at a time.
In a 60-minute session with 12 group members, that means that each person gets less than 5 minutes of potential talk time. The other 55 minutes, patients are, theoretically, supposed to be listening to the other group members during their turns, but we all know this is rarely the case.
This is bad for engagement, but it’s also bad for outcomes. Disengaged patients do not achieve good outcomes. Disengaged patients also don’t refer, don’t leave positive online reviews, and don’t give positive feedback to any individual that may have referred them into the program. In short, disengagement contributes to a lower census by reducing goodwill in the community as well as reducing actual positive clinical outcomes, which further affects a provider’s ability to build a reputation for excellence in care.
The challenge for providers is that most therapists have not had formal training in pedagogical techniques to maximize patient engagement and skill set building in the group therapy setting. Instead, training has centered more around processing memories, emotions, experiences, and behaviors, all of which are of critical importance as well, but which work better in one-on-one versus group settings.
In this sense, therapists can learn a lot from the world of education, particularly evidence-based practices found in adult learning theory. Therapists already have expertise as subject matter experts in the areas of behavioral health and addiction. Now they need to be provided the techniques and resources to effectively deliver those therapeutic interventions in a way that maximizes patient engagement and skill building for everyone.
Through the Institute’s training programs, we teach therapists how to engage every patient, all the time. As an example, instead of handing out an article to every patient and having them read out loud one by one in a circle, we have them provide a single copy of the article with instructions for everyone not reading to formulate 2-3 follow-up questions based on the text. Notice how this very simple technique went from everyone staring at their own papers, reading at their own pace, then disengaging until it was their turn to read to everyone paying attention and focused on the subject at hand the entire time.
At the Institute, we also teach therapists how to use pair, small group, and full group mingle techniques. Rather than listening to their therapist describe constructing “I” statements, they create their own list of blaming and shaming statements that they then share with a partner and work together to convert to a more positive “I” statement. By maximizing repetition, we help patients go beyond memorizing factoids to actually building procedural pathways in the brain that automatize the process and make it the default behavior outside the walls of the therapy setting.
Just like jumping on a bike and pedaling away without a thought to balance, physics, or muscle movement, we want patients to automatically use skills taught in the program when encountering triggering situations or difficult memories and emotions. Simply knowing what to do isn’t enough. It has to be as automatic as riding a bike, which requires extensive practice.
These are just two examples of dozens of techniques, strategies, and activities we teach therapists that go beyond the traditional talking circle format.
Think about this like learning to swim or learning to ride a bike. These skills can’t be learned from books or teachers talking at the front of the classroom. Instead, they have to be practiced to the point that you no longer have to think about how to do them; they become automatic. That’s exactly what we want to do for patients when it comes to recovery skills such as restructuring negative thoughts, using “I” statements, setting incremental goals, self-calming techniques, relapse prevention strategies, etc.
The result of incorporating pedagogical techniques as part of delivery is a group of highly engaged patients that have moved from largely passive reception of information to active users of new skills, new skills that then become their default behaviors by the time they discharge from the program.
By maximizing engagement and skill building, therapists will also see improved patient outcomes. As Dean Spitzer, a leading researcher on motivation in learning states:
“The truth is that no matter how excellent any instructional program is, learning will be no greater than the level of student’s motivation. When motivation is low, learning will be low.” (Spitzer, 1996)
Patient engagement is a prerequisite to enable both receptive acceptance of new information, concepts, and frameworks as well as to prime the brain for the learning of new skills (Hattie, 2012). Once engagement is achieved, a key goal in therapy is to provide patients with the skills to succeed in continuing their recovery journey outside of the therapeutic setting. This is often attempted through purely didactic instruction, transferring knowledge and information from the therapist to the patient. Most therapists do not move past this declarative learning stage, as it’s called in the pedagogical literature. Didactic instruction should be no more than 1/5th of total session time. The other 4/5ths of the time should be spent maximizing opportunities to practice and refine new skills in increasingly challenging and variable settings to the point that they’ve become as close to second nature as possible given their time in treatment.
Providers who really dig into their clinical delivery processes and provide ongoing training that helps their therapists go beyond the standard treatment delivery found in the majority of programs will be the ones most likely to succeed in today’s increasingly competitive behavioral health space.
Nick Jaworski is the CEO of Circle Social, Inc., a behavioral health marketing company. He has helped build startups across the globe, from Turkey to China to the United States. A passionate recovery advocate, Jaworski sits on the board of Above and Beyond Family Recovery Center and also advises the Behavioral Health Association of Providers. He has helped numerous companies start from humble beginnings and grow to multi-million-dollar a year organizations through strategic marketing and operations, driving results for many behavioral health clients.