Grab a Stopwatch: Patient Talk-Time in Group Therapy Matters

As a clinician, have you ever stopped to consider how much of your group therapy session you spend talking?

As a clinical director, have you ever inquired how much time each patient gets to talk as you observe clinicians running groups?

As an owner, advocate, payer, or patient, what are the implications talk time has on patient recovery outcomes?

While simply keeping track the next time a group therapy session is delivered will let you know for sure, it will likely surprise many to realize just how much they are talking. It is often well above half of the session. If you were to track the amount of time throughout the session that only one person was talking, whether it be the therapist or a patient dominating the group conversation, you would likely be at 90 – 100%. As we will explore, the more that patients talk, the more growth they will achieve.

People frequently underestimate the amount of time they take control of conversations; so, grab a stopwatch, and see for yourself.  If you are spending more time talking than originally thought, we have suggestions to help.  First, let’s examine the reasons why making the switch to increased patient-talk time would benefit your group and your patients.

There is evidence that increasing patient talk time will improve patient outcomes.

Educational researcher, John Hattie, concluded that, based on a synthesis of 1200 meta-analyses relating to influences on achievement, the more a facilitator speaks, the lower the engagement of the learners. Lower engagement directly correlates to comparatively inadequate knowledge and skills retention. When the facilitator talks less, it forces them to listen more, producing the indirect result of a greater understanding of learner misconceptions, achievements, progress, and current performance (understanding of knowledge and skill being assessed). Interestingly, observed tasks found to be challenging, relevant, and engaging to the learners produced a natural drop in facilitator talk time (Hattie, 2011, 2015).

The amount of time learners spend talking in an educational setting and the positive learning results it produces has reached a consensus not only in education but in sociology, philosophy, and psychology as well (Gurevitch, 2001; Kennedy, 2014; Marková, 2003). If learners, in our case, patients, are engaged in talking, then they are paying attention to the learning objective, creating or reinforcing neural links in their brains, and building on prior knowledge to create expanded understanding.

If you have ever run or observed a group where you were sure a patient was not paying attention, you are not alone. Unfortunately, you can also be reasonably sure that the patient was not learning. Conscious attention is a prerequisite for learning, and learners are at high-risk for disengagement when sitting through receptive activities such as listening to a lecture or reading a text without a specific focus task attached.

The consensus is in; the scientific community agrees; the more learners talk, the more they think, and the more they learn and retain (Resnick et al., 2017).

This obviously has implications for clinical sessions where we’re teaching important CBT or other recovery skills. The more we can engage the patients and maximize their involvement, the better.

Most clinicians are probably used to the standard model where one patient talks while all the others listen. However, according to this research on learning, that method is far less effective than pair, small group, or whole group mingle activities where patients have significant opportunities to demonstrate and practice new skills.

William Miller, Ph.D., the Emeritus Distinguished Professor of Psychology and Psychiatry and co-creator of Motivational Interviewing, found revealing and applicable information through his research. The more empathetic a clinician is, meaning they are engaged in listening and encouraging patient change talk, the fewer resistant behaviors they experience from patients. More importantly, the more change talk a patient engages in, the more likely they will follow through with positive thought patterns and behaviors outside the therapy space (Miller, 2014).

This makes sense following what we know about the science of learning. As positive behaviors are vocalized, this furthers the process of hardwiring the new neural pathways in the brain while at the same time de-emphasizing the old, maladaptive pathways. It’s the same process through which gratitude journals work (another evidence-based method for positive behavior change).

In addition to processing difficult life experiences and negative thought patterns, one of the primary goals for patients in group therapy is to learn, grow, and improve coping skills to achieve greater autonomy, self-efficacy, self-esteem, control over their thought patterns and actions, and overall success in recovery. This goal will not be met as efficiently, effectively, or consistently across a group using a purely didactic model of knowledge transfer where the therapist talk time is up and the patient talk time is down. The group's progress will slow and important opportunities to practice new skills in a safe environment with professional support will be missed.

Given the amount of information humans are exposed to daily, it should not come as a surprise that we forget far more than we remember. Neuroscientist Lisa Genova describes forgetfulness as our "default setting" (2021).

Simple Strategies to Increase Patient Talking Time

1. Stick to open-ended questions - Open-ended questions allow patients to answer with as much detail as they like, often offering more profound insights and opportunities for discovery; patients are more likely to share unanticipated behaviors, concerns, emotions, and motivations.
2. Ask all patients to write down their responses first - To keep the pacing of the session, there may be times when everyone in the room might not have a chance to respond. Additionally, a patient may be at a stage where they may not feel comfortable verbalizing detailed responses with the group. In this case, having every group member write their reply ensures they consider and work through the prompt. It will also help patients explain their position more clearly, as they will have a chance to consider it first.
3. Promote reflection and analysis following activities and breakthroughs - Metacognition, or thinking about thinking, improves neural links that promote memory retention and enhance the application of knowledge or skill beyond the context from which it was delivered (Chick, 2013). Following a role-play or collaborative exchange with questions like, "What was challenging?" "Is there anything we missed?" or "How can we organize these responses in a way better conducive to recovery?" can push patients into deeper thinking and develop a more advanced level of awareness.
4. Practice elicitation - As uncomfortable as silence can be, especially in a group setting, it is important to remember that individuals have different processing speeds for their working memory. If a clinician is running a group discussion, it is better to wait for a patient to respond than to provide the answer following a brief moment of silence; this will help patients connect the new information to existing conceptual frameworks.
5. Encourage building upon ideas - Rather than repeating or rephrasing patient responses, invite the patient, or other group members, to expand upon the answer. "Do we agree?" "Are there any avenues that we have not considered?" "Does anyone have advice?"

It is important to note that there will be times in a session where it may be appropriate to disregard these strategies. As always clinicians must skillfully balance their objective to help impart useful recovery skills with the human need for moments of compassion and process affordances. Patients are struggling with a lot of strong emotions and negative life experiences. Helping patients work through these as well as building a supportive milieu among group members is just as important as imparting new skills.

Suppose the therapist recognizes a time when a patient needs to stop and have their feelings affirmed or where having other group members offer advice may be counterintuitive to the session objective or patient growth. In that case, they should absolutely follow their instincts and clinical training to address the situation accordingly. A prepared small group exercise for other group members to engage in so the clinician may offer individual support will allow for appropriate, continued group progress in these situations.

To conclude, the next time you run or observe a group therapy session, remember to bring your stopwatch. Every patient benefits from increased positive change talk and learning engagement.. The clinician benefits from increased patient talk time by gaining a deeper understanding of each patient and through the increased delivery of corrective feedback through more frequent interactions. While complicated at first, do not give up on maximizing patient talk time; your whole group will benefit.

References:

Chick, N. (2013). Metacognition. Vanderbilt University Center for Teaching. Retrieved [todaysdate] from https://cft.vanderbilt.edu/guides-sub-pages/metacognition/.

Genova, L. (2021). Remember: The Science of Memory and the Art of Forgetting. Harmony Publishing. Mar 23, 2021 | 272 Pages | 5-1/2 x 8-1/4 | ISBN 9780593137956

Gurevitch, (2001). Dialectical Dialogue: The Struggle for Speech, Repressive Silence, and the Shift to Multiplicity. British Journal of Sociology, 52, (2001), pp. 87-104.

Hattie, J (2011). Visible Learning for Teachers: Maximizing Impact on Learning. Routledge. ISBN 9780415690157

Hattie, J. (2015). The applicability of Visible Learning to higher education. Scholarship of Teaching and Learning in Psychology, 1(1), 79–91. https://doi.org/10.1037/stl0000021

Kennedy, D. (2014) Neoteny, Dialogic Education, and an Emergent Psychoculture: Notes on Theory and Practice. Journal of Philosophy of Education, 48 (2014), pp. 100-117

Millar, W. (2014) Motivational Interviewing and Quantum Change. The University of Chicago. https://www.youtube.com/watch?v=2yvuem-QYCo&t=1896s

Resnick, L. B., Asterhan, C. S. C., & Clarke, S. with Schantz, F. (2017). Student Discourse for Learning. In: G. E. Hall, D. M. Gollnick, & L. F. Quinn (Eds), Handbook of Teaching and Learning. Wiley.