This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. So I'd like to welcome everybody to today's presentation on group therapy. This is a continuation of the series of group therapy based on treatment improvement protocol 41 from SAMHSA. If you're interested in group therapy, if you like doing group therapy, it's a great introductory tip. There's a lot of stuff they don't cover in it, but there's a lot of stuff that they do. And this is going over chapters six and seven of that treatment improvement protocol, covering leadership skills and common errors. So over the course of today's presentation, we're going to discuss the characteristics of group leaders and describe concepts and techniques for conducting substance abuse and mental health treatment group therapy. So one of the things that I kind of like about being a group leader is that you have a lot of ability, if you will, to choose how much leadership to exercise and how much not. I tend to liken it to being a parent and having eight or 10 kids. And if you're still saying after that, you want to let the kids learn to work it out at a certain point. There are going to be times where you feel you need to step in. There are going to be times when you need to set structure. So think of it as creating sort of a family. And I don't want to say a mini-family because sometimes our groups are 12, 15 people. But it's a family sort of situation or a community. So you have the ability to choose how much leadership to exercise and you don't have to maintain that same level of control, if you will, the whole time. One of the things that you'll find in, if you remember back to counseling graduate school when you took group therapy, there's the forming, storming, and norming. So in the forming phase, people are kind of trying to figure out where everything is. The storming phase, people are pushing limits. Like when you have a new teacher or a substitute teacher, you're pushing boundaries to see what you can get away with. And norming is when everything kind of levels out. And people figure out what's expected, what they can do, what they can't do. So as you go through those phases, you're going to exercise different amounts of leadership. Hopefully starting with more leadership and gradually being able to kind of turn the reins over to the group itself.  One of the things my supervisor always told me when managing people, he said, you want to start out tough. It's much easier to loosen your control than to try to take control back if you never had it in the first place. And that's really true. And in order to create a situation where people understand what the boundaries are, you're consistent in the boundaries, and you have enough structure, it's usually better to start out a little bit more controlled and structured and gradually loosen up. You can choose when to intervene. Now, I've worked as a co-facilitator with a lot of different clinicians. Some people intervene almost immediately because they don't want to see emotional upset distress. They want to keep it on a skills academic level. And if you're doing a psycho-ed group or a skills group, sure, that's totally justifiable and reasonable. On the other hand, especially if you're getting into the skills group a little bit, people are practicing, you may not intervene right away because you want to see if they can work it out and apply their skills and actually benefit from what they're learning in groups. So you have a lot of leeway in terms of when to intervene, and it's based on your clinical judgment, what is best for the group, what is best for the individual. You will know your group, so you'll be able to affect a successful intervention, whereas somebody who's coming in, who's never worked with that group before, they don't know the hot buttons and the group doesn't trust them. I remember there were a couple of times where I had to step in and facilitate a group because we had a group member leave group in crisis. The group facilitator went out with them and I would come in and take over. And we'll talk about drop back and punts later. But going into that group, they knew me as the director, but as far as my clinical style, as far as me knowing what their individual issues were, we were complete strangers. So figuring out how to approach that group at that particular point in time and de-escalate was a little bit more challenging. And obviously I went in taking over as a new facilitator, if you will, because I hadn't worked with that group before, went in with more control. And I said, all right, this is what's going to happen. You know, we're going to process what just happened, but here's how it's going to be. So they knew what to expect from me and they weren't kind of guessing. You want to be able to manage the group's collective anxiety. They're looking to you for structure. They're looking to you for leadership. And basically, if you think back to Erickson's stages, you know, think about child development, they're trying to develop these new skills, become independent with these new skills, but they want to be able to come back to a safe place, which is the group, which is the group leader. So it's up to us to be able to figure out, in order to manage the group's anxiety, how much can we let this one person escalate in order to help him or her work through this particular issue? And if the group itself has a high level of anxiety, how do we handle it? And at what point do we need to intervene versus encouraging them to figure out which skills? It's a whole lot more effective for people to learn skills and learn to apply skills when they're under a little bit of stress. Not that I'm saying we want to freak our clients out because that's not what I'm saying, but I want to know that when they're out there in the real world, not in the comfort of the therapeutic environment and they're under stress, when they're feeling distressed, they can actually access those skills and apply them effectively. So I don't want to necessarily jump in right away to intervene and diffuse the group's anxiety. I want to see how they kind of work together. And then I'll figure out based on the development of the group and the presenting issues and all that other stuff, when to intervene and how to resolve other issues that may come up, relationship issues, dynamics, transference, counter transference stuff we'll get to in a minute. So personal qualities of group leaders. If you are a clinical supervisor, you will notice, and even being a clinician, you will notice that a lot of these are reflective. I mean, we're not really presenting all that much difference in terms of what kind of qualities make us effective in these situations. Constancy, being dependable, being predictable is important for our group. It's important for an individual client if you're doing one on one. But if you're working with a whole group of people, it's even more important to be present and to be predictable in what you say, what you do, how you're going to react. Active listening, oh, that's a no-brainer. And a firm identity, knowing who you are and knowing what skills you use, what interventions you use, what you believe in. It doesn't necessarily mean that they have to believe in the same thing that you do, but being able to model your identity and how you set your boundaries and you can accept people with differing opinions and how you create, run your group and how you're willing to hear other people's, how other people run group, but this is kind of your group. So this is your identity as a group leader as well. This is something that people come to expect. When I worked at my long-time job where I was for 14 years, when I would walk in to do a group, people knew what to expect. It wasn't a surprise. I didn't vacillate. I was not very different between groups. They knew how I ran group and it gave them a sense of stability and comfort. Now, they may not have loved the way I did it, but they knew what to expect, which gave them confidence that, A, I kind of had a clue what I was doing, but it also gave them confidence that they knew how to act and react and participate in a way that was going to be productive. Now, I say all of that talking about stability and constancy and yada, yada. And then I come to spontaneity. Well, you know, every once in a while, the group or life is going to throw you a curveball. So how do you deal with it? I remember there was one group I was in and it was, it was a psycho-ed group, thankfully. I wouldn't have wanted to be in a therapy group for it, but we had a fire alarm and so everybody had to evacuate. We're like right in the middle of group and there's a fire alarm, um, which through the whole group off kilter, but being able to gather them up outside and, you know, we made the best of the situation as it was and use the skills that we were working on in group to apply to that situation and dealing with the frustration of getting interrupted and having to be out in the Florida heat in August. So being able to kind of drop back and punt sometimes if something unexpected happens, staying within the boundaries, if you will, of what's expected, which is kind of behaving with integrity, being true to yourself and your clients. It'll help them develop a sense of trust in you. So they're not always, you know, wondering if I say this, is it going to keep me from graduating on time? And when I do things, what is the repercussion going to be? If I'm honest about something, um, so they want to be able to trust that the group leader is going to be there is going to be compassionate is going to be predictable, all that stuff. Everything you would expect and want out of a friend, out of a clinician, out of a supervisor, you know, things that you want in a relationship with anyone.  Uh, and I did that frequently when I used to teach at UF, thankfully, in the, in the clinic that I worked in, we had dry erase boards, but when I taught at UF, we still had the old fashioned, um, chalkboards and my family could always tell when I would come home if I had been teaching that day, because I would have a chalk handprint on my butt every single day because I would, you know, clean the blackboard off and then I'd wipe my hands on my pants. And I never realized this. And then they finally pointed it out to me and I became much more aware of it after that. And sometimes I'd forget and I'd have a handprint and somebody pointed out and I'd be like, yep, guess I was teaching today. You know, it's all about being able to laugh at yourself, um, and laugh with the clients, being able to show some humor, sometimes starting a group, if it seems particularly tense that day, sometimes starting a group with some humor before you actually launch into your typical routine can help kind of break the ice if people seem to feel a little bit, um, agitated and empathy. You know, again, goes kind of without saying because empathy communicates that respect and acceptance. We want to be empathetic, not only to the individual, but to the group as a whole. You want to think kind of of the group as a unique entity and how they are feeling as a whole, but then you also want to look at each individual.  We want to be encouraging and knowledgeable and complimentary. So again, making sure, like I said last time, making sure that clients don't feel like they're just a number or a butt in a seat. Being very, um, true to, um, yourself, being very true to the group process is going to be really important and doing a lot of listening. It is possible to have structure and be constant and firm identity and all of this other stuff we've talked about without really saying a lot. Um, when I would do group, I would start out asking a question and then going around the room, letting people talk, and then I would tie it together, find common threads. So do a summary statement. Then I would give like a 10 to 15 minute psycho educational or skills kind of presentation and an activity we would do on the board. And then we would again, go around and have people apply it and talk about how it could be effective in their recovery. I wanted to hear more about how they were using it. I wanted to hear their questions. I wanted to hear them try to explain it to me more than I wanted to talk because they can only take in any of us really can only take in chunks of information at a time. Um, so it's helpful to listen and also try to elicit from them the answers that you're looking for instead of telling them. Cause if think about having kids, if your child comes up to you and says, what's 63 plus 24 and you automatically give them the answer, they're not going to learn how to add. If they say, what's 63 plus 24 and you go, well, let's figure out how to work that out. And what would you do first? You know, walk them through writing it down on paper, um, and adding it. There's no carrying any of the one of those. So it's a pretty simple addition problem. But walking them through it, instead of giving them the answer, ingrains it, it helps form those neural pathways. So they are more effective with the information that they're getting. We do want to be able to gently persuade clients to be open to the stuff we're providing. Now, some of it is not going to work for them. And I'm not saying persuade them that you are right. I'm more encouraging you in group to persuade them to be open to possibilities, figure out what works for them, keep what's useful, leave the rest. And in that, we can provide support. And that's another thing that I really like about groups, because you have the ability for people to go, that works for me and other people to go, really that I've tried that before and it didn't do diddly squat. And that's okay. And both people can be validated because they're unique individuals with their own experiences, which teaches everyone else in the room that you know, we're all unique individuals and not everything's going to work for everyone. So let me try, let me be open to new experiences.  And they may try it and they think I want them to say, yeah, it worked great. And that's not necessarily what I want to hear. And I always try to couch that when they come back in an individual with, tell me how it went, you know, again, if it didn't seem to fit, if it felt weird, let's talk about it, it may not be a good fit. But the nice thing with group is you've got everybody supporting each other, giving alternating or alternate opinions. Okay, where did my mouse go? Leaders have varying therapeutic styles to meet the needs of clients. I can be loud. There's just not a nice way to say it. I can get really excited and be very demonstrative in group and be kind of high strung, if you will. But that's not appropriate for all groups and even the same self-esteem group, I may have different clients in those groups that have differing needs, so I may need to tone it down in some groups. I may need to use altering or alternate therapeutic styles. So one may be heavy on cognitive behavioral, while another is much more focused on rogerian, client-centered, something that's, you know, less confrontational, less confrontive, if you will. With that, we want to model behavior, whatever we're doing in that group. If I'm modeling CBT or teaching CBT, then I want to model that. But I also want to model how you're supposed to interact in an ideal world, in a microcosm with other people. So I want to be accepting. I want to be validating to other people. I want to show how it's okay to have differing opinions and to agree to disagree, if you will. I avoid that phrase most of the time because it makes some people kind of get the heebie-jeebies because they've heard that before in a passive aggressive manner. So I tend to avoid that phrase myself. But, you know, it may work for you. What we want to do is show clients how do we set boundaries? How are we authentic with ourselves? How can they be authentic in group and with one another and be okay with it, even if not everybody likes their opinion? We need to be sensitive to ethical issues. So if there is an overriding a group agreement that something needs to change, let's talk about it. In what way is this beneficial to the group? In what way is making this change beneficial? In what way is not making the change potentially harmful?  What are we doing that's in the best interest of our clients? We want to make sure to inform them of options when we're in group, if they're feeling like they need to take a time out, if they're feeling like they don't want to speak, if they're, again, going back to those basic ethical principles, fidelity, non-malphysense, beneficence, well, those are the big ones for me. Being true to what we got into this profession for, making sure clients know that they have options for how to stay safe in group. If we tell them, you know, you really aren't supposed to leave group in the middle. You can't just get up and bolt. Well, what are your options? If you start to get upset, how do we handle this? We do want to prevent enmeshment. So making sure people learn how to set appropriate boundaries, encouraging them to articulate their points of view and be open, not getting their feelings completely smushed if somebody disagrees with them and not feeling controlled by one another. And we want to make sure that we are acting in each client's best interest. Remember, I said we've got the group as a whole. We want to make sure that functions well. But within that whole, there are individual parts. Just kind of think of a machine and we want to make sure every single part is functioning effectively. Because if one starts to go a little wonky, then the whole system could potentially break down. So we want to make sure if there are particular issues that are present, post-traumatic stress, something like that. And that issue comes up. How are we going to handle that? It's not uncommon to be in a group teaching something benign like self-esteem and a topic such as prior sexual assault come up because a lot of people, if they've been sexually assaulted, it takes an effect, has an effect on their self-esteem because they feel broken. They feel damaged. They feel, you know, feel in the blank. So, you know, it can come up that way. So how do we act in that client's best interest? If we have one client in there who has been a, who is a survivor of sexual assault, if that topic comes up, what do we need to do to make sure that that client feels safe and doesn't feel attacked or whatever. And we can still attend to that particular issue. Leaders improve motivation when members are engaged at the appropriate stage of change. So if clients are in pre-contemplation, for example, they are not wanting to be there. My, my first job working with involuntary clients, my clients didn't want to be there. So 80 percent of my job was to increase their motivation to be there. They didn't think they had a problem or if they did, they weren't willing to admit it. Beating them over the head with it and going, you have an addiction, you need to learn about this was going to get nowhere and they weren't going to hear me. They weren't going to be engaged, probably weren't going to show up. So some of the things that I did to help engage them was create agreements, if you will. They had to complete treatment. They had to do what they wanted to, what they needed to do to get off papers. So it's important to remember that not everybody is in the same stage of change. So things that you can do at pre-contemplation, for example, is find mutually agreeable goals. I needed them to stay clean. They needed to stay clean to get off papers because they wanted to get off papers. So ultimately, we both needed them to stay clean at least for 12 weeks. So we would start talking about that. This is one of the things. I needed them to stay clean and come to group in order to get off papers. They had to come to group. Okay. Well, you can either come to group and sit through it and hate me or we can talk about what is it since. And, you know, I was pretty frank with them. I'm like, the state is paying for you to have therapy for 12 weeks. So what is it that you want to work on to improve in your life while you're having state-funded counseling?  But that was okay. That gave me something to work with. So engage them by helping develop mutually agreeable goals. Encourage members to support each other's change efforts. So, you know, with my first groups, like I said, I don't think I ever had a single person in there who thought they had an addiction during that group period.  But I did want them to stay clean for the 12 weeks and encourage each other to figure out how to stay clean and sober and get to group for the 12 weeks. So those were the things that we focused on, not as much of self-identification with an addiction. If people are in anxiety or depression, mental health type recovery groups, they're not going to change everything overnight. So encourage each encourage each group member to listen for positive changes from other group members and provide feedback and support on that. Reinforce the positive. And as leaders, we want to model that too, not always picking up on the, well, you know, what could you have done differently? I want to be able to say, wow, that was awesome. You did look what you did two weeks ago versus what you did yesterday. What awesome progress is that and reinforce what they're doing and encourage group members to focus on positive steps forward. We can explore choices and consequences with members. I like doing this in terms of putting a whiteboard up and writing up there. What was your choice? What was the situation? What was your choice? And what were your potential consequences if you chose A versus B? You can do a decisional balance chart that gets a little bit cumbersome. Generally, if you have two or three choices and you put them all up on the board and you write down the potential consequences of each and then talk about why you chose or why the person chose one over the others. It gives people a chance to start articulating their thoughts. But when you've got 15 people suggesting consequences, it often opens up some of those blind spots that one person would have. One person may come up with five consequences for their choice. 15 people may come up with 15 consequences for the choice. So you've got a whole a much broader range, wider range and greater depth of answers to give the person something to think about. Throughout all this, we do want to communicate care and concern because we don't want to be calling somebody out. People won't share. They won't become vulnerable if they feel like they're attacked and called out every time. So it's important that we couch this in care and concern, again, validating the positive and pointing out each person's competencies and how much better they're doing, what steps they're making, even if they're small steps. Hey, I'm actually super thrilled with small steps because those are often some of the most constant, sustainable changes people make. People can make huge changes. Think about if you decided one day that you were going to go on a diet and you were going to start eating healthy. And I've had a lot of friends that have gone on Atkins or Paleo or one of those others or it's a huge dietary change and they maintain it for a little while. But then they quickly fall back into their old habits where if they start making small changes over time and building on those small changes, those small changes tend to last a lot longer, such as starting to drink more water and then starting to cut down on processed carbs and gradually working up to where they want to go. Maybe they do want to get to Paleo eating or Atkins or whatever it is. But if they do it gradually, it tends to stick and be more become more of a lifestyle than a change that doesn't stay and positive changes are noted in and encouraged by the group. So always reinforcing we want to work with not against resistance. So if somebody says, I can't, I won't or yes, but those are my three favorites. OK, what are you going to do instead? Or and that's obviously what I come back with.  All right.  I want to hear what why you can't help me understand because then I can help you figure out how to come work around those barriers. And we can talk about, you know, the differences in transportation issues, childcare issues versus fear issues. And all of those can potentially come out. I'm not going to argue with them. If they tell me they can't, you know, I may roll with the resistance, but I want to understand their point of view because resistance is telling me that I don't understand. If they're not willing to hear, if they're not willing to act, if they're not willing to do, then clearly I'm missing something because the current behavior is far more rewarding than whatever I'm suggesting. So I want to work with it. I want to hear it. I want to understand what are the challenges if they say I won't. That means I choose not to. OK, why not? Or, you know, sometimes it's obvious why they don't want to and you can go on to what are you going to do instead? One of my tag lines, if you will, is always OK, that's that's fine. If you won't do that, I'm not going to argue with you, but I want to know what you're going to do instead. If you're not going to go to 12 step meetings, if you're not going to take medication, if you're not going to fill in the blank, whatever it is that your clients need to do, that this issue or this intervention has been prescribed, if you will, for your current presenting issues, depression, anxiety, addiction, yada, yada. For this particular reason, how are you going to address that reason if you're not going to do this? And they may have a very well thought out alternative. Great, that's awesome. You know, let's try that if you think that's going to work for you because they're motivated to try that and let's support them in using their strengths and going with something they're motivated on. On the other hand, if they don't have a plan, they're like, I won't do that. I don't know what I'm going to do, but I won't do that. That's the beauty of groups because then we can throw it out to the group. What are some alternatives besides, you know, taking antidepressant medication? If Sally doesn't want to do that, have any of you chosen, had made a similar choice. We're not doctors. We're just presenting our experiences and hearing. The concerns that this person has about this intervention and trying to help him or her come to some sort of decision or plan about what they're going to do instead. It's our job as leaders. And I think this is one of our main jobs as group leaders to protect against boundary violations, protect against the bullies in group, protect the clients who have weak or no boundaries, which goes back to that whole investment thing, to make sure that everybody feels like their opinion and their points of view are valid and important because they are. Help people realize that it's OK to have differences of opinion. But this is goes beyond verbal boundaries. It goes beyond emotional boundaries to also physical boundaries. And I shared with you in the last presentation, I think that when I first started working in substance abuse treatment, that's a real touchy feely group. They do a lot of handholding when they say the Lord's Prayer at the end, lots of hugging, which I'm not used to. Not what I grew up with in my family, not definitely not what I was taught in graduate school. So it took me a little while to kind of understand where this was coming from. But it gave me a lot of empathy for clients who weren't comfortable with that. So it's important to be able to help clients who don't feel comfortable with other people touching them or holding hands or saying the Lord's Prayer or whatever it is. To know how they can safely confidently and respectfully assert their own boundaries. And as leaders, hopefully we get to a point in the group where we don't have to step in and stand up for that person. The group is respectful of that person's boundaries and preferences. We maintain a safe therapeutic setting, making sure to pay attention to the emotional aspects of safety. We want to make sure that people aren't using more than once. I've done a group where somebody has come in and then smelled like a brewery. I mean, there's just no other way to say it. They weren't necessarily presenting or acting drunk, but they smelled like alcohol. So creating an environment of safety where they're not triggering other people in the group. If someone is in a group for people who self-injure or who are clinically depressed, there may be other triggering cues that you need to watch out for. So being aware of those. And we already talked about physical contact. We have the ability to help clients learn how to de-escalate. We can help the group de-escalate. And a lot of our clients, if you want to go back to dialectical behavior therapy 101, a lot of our clients have emotional dysregulation issues. So we want to be able to help the group as well as each individual learn how to tolerate the distress, ride that wave and cool down. On top of that, we need to encourage people to communicate. If we're going to have an open and effective group, people need to feel free to share their opinions, their issues, their comments in a respectful sort of way. So we want to encourage open communication as much as possible. We want to help people connect with others that have similar issues and have had similar experiences, help them discover connections between their substance use or their depression or anxiety and their current thoughts and feelings. I mean, somebody who's depressed probably has thoughts that are more depressive and probably feels increasingly depressed. And what do they notice? Do they notice that it's a beautiful sunny day outside? Or do they notice that it's a sunny day and gee, I still feel like crap. There's a difference there. So we want to help them notice the difference and the interaction between their thoughts, feelings and behaviors. We want to help them learn how to regulate feelings and deal with interpersonal distress. We want to help them build coping skills in group because sometimes stuff's going to happen. Sometimes it's distress tolerance. Sometimes it's learning to be patient. There's a variety of very seemingly basic skills that we end up communicating in group. We want to help them understand the effect of their substance abuse or mental health issues on their life. You know, if you're depressed and you're having difficulty getting out of bed, what are the effects on the rest of your life?  How is it affecting your family? How is it affecting your work product? How is it affecting your health? So they start to understand which increases motivation for change. We can also point out inconsistencies among thoughts, feelings and behaviors. I prefer to try to focus on positive inconsistencies. So if they they're telling you they're still feeling awful all the time, then if I have an example of how there was an exception there, or if I don't, I'll ask for have there been any exceptions, any glimmers throughout the week to point out some of their all or nothing thinking. We do want to avoid a leader centered group. So we want to build skills and our members and avoid doing things for them that they can do for themselves. If there's a conflict, you know, initially we're probably going to intervene a lot more than later. We want to encourage them to practice those skills, just like a parent at home. I've got two teenagers and when they were younger, you know, I would intervene and, you know, help them figure out empathy. And, you know, how do you think Haley felt when you did that? And yada yada. But as you get through the group, as the group develops their coping skills and their communication skills and ability to set boundaries, hopefully it's not necessary to intervene as quickly. So we want to encourage them to try to work it out for themselves. And we may need to, you know, call a timeout and ask them to take a pause and think about what what is the next best step in this situation to get them to get out of that emotional mind and into their into their wise mind. But, you know, it's still, we're still not telling them what to do. We're asking them to take a timeout and think about what they think they should do. And we want to refrain from over-responsibility for clients. So, client's struggling. It's not up to us to fix it. Untrue in individual and group. We want to encourage them to struggle with it a little bit and figure out what they need, figure out if they need to ask for help or if they've got it on their own.  But making sure that we're not taking away their power by doing too much for them. Confrontation can have an adverse effect on the therapeutic alliance and process. So, we want to be careful about how much we call people out. Now, our clients may call us out too. So, we do want to be aware of that and how we respond to confrontation if a client calls us out on something that they don't like. Maybe they don't like the way you're running group that day or they don't like a administrative decision that you made. But confrontation can also be used to point out inconsistencies such as disconnects between behaviors and stated goals. So, if the goal for the group is to become, to deal with anxiety and develop more effective communication skills, but they're not effectively communicating, this might be a point for confrontation for the group where we can bring it up and say, you know, I notice that these are your stated goals, yet when you communicate with one another, this is what I'm seeing and this is what I'm hearing. Being objective, just like we would encourage them to be of one another. Objective about what you're seeing that is not effective at helping them achieve their goals. Confrontation in this way, when it's done gently, objectively, appropriately, can help clients see and accept reality so they can change accordingly. If they realize that, yeah, you know what, I have been harboring resentments and not stating my opinions and then getting angry at others because they don't read my mind. Well, if we kind of gently start pointing that out, then they can start seeing and making changes. Transference is when a client projects parts of important past relationships into present relationships, not just client counselor, but onto the group. So we want to be aware of transference, counter transference. The other person projects an emotional response to the group members transference. This happens a lot in groups. You've got people that remind you of family members of people from your past. If you had, for an example, a sullen, abusive, verbally abusive person in your family of origin and somebody in the group is sullen and somewhat antagonistic, maybe not verbally abusive, that might provoke a transference reaction from another client. All right. Now, so Sally starts getting anxious and nervous and somewhat defensive every time Tom talks because she's having that transference reaction on Tom, then Jane over here sees her family of origin. She sees mom and dad and she starts having a counter transference reaction to what's going on between the first two. So just being aware of is this person reacting fully reacting to what's going on in the group or is this brought on more likely from stuff in the past. And this is a repeat manifestation. So you're getting into some interpersonal process stuff, but it's important to be aware of it. Resistance arises to protect the client from the pain of change and also to identify that whatever I was doing is more effective than what you're suggesting. So as clinicians, we need to figure out how to switch the balance on that scale. So we need to understand what is rewarding about being depressed. And a lot of people scratch their heads and they're like, well, there's nothing rewarding about being depressed.  Not so much. I mean, there's a lot of it that really stinks. But change is scary as heck. And it takes a lot of energy that the person with depression may think I ain't got that kind of energy. I just can't do it. And it also sets them up for the potential of a fall. So if they start feeling better, what happens if they relapse and how horrible is that going to be? That's terrifying. So understanding the negative or the drawbacks to recovery is just as important to understanding the benefits of benefits of change. So thinking about it from their perspective and groups again can kind of start brainstorming and spit balling, if you will. Why are some what are some reasons somebody might not want to get happy, might not want to be undepressed? You know, maybe every time in their life they've started to get happy, the other shoe is dropped. So they don't want to experience that again, they prefer just to stay down here. So they're never let down. They're never disappointed. Okay, that's something we can talk about. But we need to understand why the person isn't motivated to work forward to walk forward before we can provide effective interventions. Confidentiality in groups is huge. We can't hold them to HIPAA guidelines because they're other clients. But it's important for clients to realize that if you don't maintain one another's confidentiality, then nobody's going to trust anybody and we're not going to get anything done. Trust built over time. So it's a matter of letting clients learn to develop trust in one another. And if somebody violates confidentiality, we do need to make sure to address it individually with that person, but also in group reiterate confidentiality guidelines, why it's important to maintain confidentiality and the purpose of confidentiality. Everybody on the healthcare team needs to be aware of the role of group therapy and how it in integrates in the team. What's the benefit to this? It's cost effective, but it also gives a greater breadth and depth of experience for people working on developing new skills. So we need to be cognizant and coordinate treatment plans. If you're doing group therapy and a person has a individual therapist, not unheard of, not unusual at all, but it's important to be kept in the loop. What goes on in group, we need to share with the individual therapist with respect to that person. And if somebody's going through something huge in individual therapy or is developing a new skill, the group therapist needs to know about that in order to integrate it and be sensitive to it. I've had more than one occasion where a client's been working on intense trauma issues in individual. And it was important for me to know that to understand why that person was behaving differently in group being more withdrawn, solemn, tearful, et cetera. We also need to have a medication knowledge base. So we understand the side effects what clients are on, how it might affect them. If they start taking Sarah Quill, for example, that they might be more sleepy and nonattentive in group. It's important that we know what medications our clients are on, even if they just start taking like cold medicine because they're not feeling well. Just give me a heads up. Let me know that you're on that. So if your behavior seems a little bit different, I get it. Conflict is normal, healthy and unavoidable in groups. So it's important for us as clinicians to just sit in our chair and brace for it. We know it's going to happen. We need to know ahead of time, though, how do we handle anger? How do we help clients who are angry, develop empathy, manage emotions and disagree respectfully? And, you know, obviously the first thing is to teach them how to practice the pause, take a breath, take a break, get out of their emotional mind. So then they can have a rational discussion about what's going on. But you need to know this ahead of time with my groups, especially therapy groups. This is something we start out with when we start the group, you know, session one. If you get angry, if you get upset, let's talk about what steps you need to take or what it's going to look like so you can, you know, effectively handle that. And we'll just role play a few situations. So people get kind of a preview of what they need to do when they get upset, not if because there are going to be buttons that we're going to push. We want to subtly call attention to unhelpful patterns, again, not calling people out. But maybe if we see a trend in our group that people are starting to become less attentive or talk in group or write notes or that aren't you know, taking notes, we might bring that out in group, you know, I noticed that people seem to be coming more and more disengaged. Let's talk about what's going on with that and what we need to do to get back on track. Conflicts appear to be that appear to be scapegoat, using a group member, maybe misplaced anger that the group that the group feels towards the group leader. So somebody may start calling another client, you know, teacher's pet, which indicates that they may be angry or feeling that the group leader is displaying favoritism. Sometimes if the group is acting out, you can't put it back on them. It is you. And too often we want to say, all right, you know, the people in the group are struggling. So it must be something with them. Sometimes it's you. So being willing to step back, either during group, sometimes you have to do it right then. But definitely after each group, just spend a moment to three minutes and thoughtful reflection of how the group went, making sure that you're being authentic, you're being true to the group and you're doing things that are everything's in their best interest. Because anger tends to indicate somebody feels disempowered. So, you know, I would always think to myself, was there anything that I did that might have made someone feel disempowered, anxious, self conscious, you know, I tried to avoid that at all costs.  But being aware that conflicts and disagreements that clients have with you as the group leader, the person in power, you may not be a safe target to get angry at. So they may redirect or misdirect their anger at someone who is a safer target. Subgroups are going to inevitably form. So just kind of be prepared for them. They can provoke anxiety, especially when a therapy group comprises individuals acquainted before becoming group members. This is especially true in substance abuse groups. If you've got people who knew each other from 12 step meetings, then they can kind of click together. And other people may have difficulty penetrating that click. Just because people are in sub groups isn't always negative. So you can use that and use the 12 step group to share their experiences and their points of view. And you may have this other group over here that's anti 12 step. All right. So let's have a healthy discussion and let's share and appreciate both people's points of view. If the clients are disruptive, though, one of the things that you can do if you have a client who's constantly interrupting or somebody starts talking and talking and talking, just say, okay, you know, let me stop you right there and make sure that I understand where what you're telling me. So you can stop them, paraphrase what's going on, summarize what's going on to try to, you know, wrap it up in a bow for the group. And then what I usually do is I'll paraphrase, find something to ask the group about what's going on, and then throw it back to the group or a particular other group member. And I might say, Sally, what what is your take on what you hear John saying? Have you experienced something similar? So I'm taking the floor, if you will, away from John and letting Sally have it for a minute. So John can hear and I'm balancing out that that time a little bit. If they're still being disruptive, when you have a break, sometimes you need to take a break right then, pull the client aside, discuss it outside of group and explore the motivations. Why do they feel they need to dominate in group or be disruptive in group? What's the benefit to them? And how can we help them be more comfortable and follow the rules a little bit more? If you have clients who interrupt, you can use a talking stick or whatever you want to use, whoever has the talking stick has the floor. If you've got a client that likes to go on, that doesn't always work because they're going to hold on to that. And clients who flee a session, really important to have a backup plan if somebody flees because they get upset. Does the primary therapist go after them? Who takes over the group? You can't just abandon the group because they're going to be in their own set of crisis. So make sure you have a plan. If you've got a co-facilitator, know which one of you is going to go and which one of you is going to stay. Sometimes clients are unable to participate in ways that are consistent with the group agreement. If you have to remove someone or if they discharge AMA, it's important to process that with the group because it's going to be a group loss. It's going to affect the group dynamics. So we want to let people work through, say what they've got to say about their experiences with that client or with that client's behavior. If people are coming late or missing sessions, it's important to address that because that's disruptive and disrespectful, not only to the group, but also to themselves. They're not talking at all. It could be a social anxiety issue. We can talk about that. If they're just being passive or passive aggressive, we want to deal with that. If they participate only around the issues of others, they never share anything of their own. Other people may start to feel uncomfortable or feel like that person is trying to be better than them. So it's important to encourage mutual sharing, equal amounts of sharing. If they're always sharing about somebody else or providing experiences, you might occasionally call on that person and ask them what their experience is or what's one challenge you faced this week. So it doesn't seem like they are always the know it all. Some clients fear losing control. So we want to be able to make sure that they feel like they're safe. And they have a backup plan if they start to get upset. So they know when group starts that, okay, it could get intense. But if that happens, I know what to do. And the same thing is true if clients have anxiety and resistance after self disclosure, they kind of regret putting it out there. Normalizing that, being compassionate, being empathetic to the client and encouraging the group to be supportive of, you know, Jane, that took a whole lot of courage to share with us. So the person doesn't feel like they just exposed themselves and people are staring at them. We don't want to be impatient with clients if they're slow in dealing with changes, everybody has their own pace. So let clients move at their own pace. If they seem to stall out, then you might want to talk with them before or after group or work with their individual therapist. Be sure to recognize counter transference issues and make sure group rules are clear. It's important, especially in therapy groups, I've seen too often where therapists will conduct individual therapy in a group setting. So it's just the therapist and John talking for 80% of the group. That's not group counseling. That's individual counseling in a group setting. So make sure to involve the group. Make sure that they have input, they have say, they have equal time, and it doesn't revolve just around one particular person. If that person brings an issue that they are distraught about, it's possible to ask other people if they've experienced similar things so they can share support and provide empathy for that client. It's important for us as staff members to know where we're coming from, but be familiar with different techniques that we can use in group. And that's great for continuing ed. It's awesome if you can sit in on groups, study tapes of other people's groups or your own tapes, and watch groups. Again, if you can watch somebody else's tapes in addition to your own, to see dynamics, to pick up on things, to hone in your skills, to learn different techniques. You can participate in a training group or be a member of a personal therapy group to get an experience from kind of the other side of the chair. And it's important not only for individual counseling, but for group therapy or group therapists to get ongoing training and supervision on group therapy, not just how to handle John Smith's problem. In supervision, it's essential that we make sure that our group leaders have training in group counseling, understand the stages. They're culturally competent. They're aware of co-occurring disorders, mental health, substance abuse, and their knowledge of signs of intoxication and withdrawal. Even if you're not doing a substance abuse group, you need to be aware of those signs so you can address any issues as they might arise. A supervisory alliance is required to teach skills needed to lead groups and ensure that the group accomplishes its purposes. So in order to assess leader skills, we want to make sure that the clinician knows how to select prospective group members, design treatment strategies, and plan and manage termination of the individual client as well as the group. Because sometimes individuals will terminate sooner than the entire group ends. They need knowledge of co-occurring disorders, knowledge of their preferred theoretical approach, and the institutions prefer theoretical approach. Diagnostic skills for determining co-occurring disorders are important because if one starts to develop while the client's in-group, you need to be able to refer out or handle appropriately. Leaders need the capacity for self-reflection to be aware of your own vulnerabilities to things that are going on, any trigger points you have, and monitor your own reactions to things. Leaders also need consultation skills so they can consult with the referring therapist, provide the feedback, coordinate with other members of the multidisciplinary team, and we need the ability to be supervised, including openness to corrective feedback and to supervision. Ultimately, in group, we want to make sure that clients feel safe, and we are doing our best to enhance their ability to effectively communicate, set boundaries, and get their needs met. Are there any questions? If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com, providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists, and nurses since 2006.


Hi. Uh, I'm not trying to brag, but I recently went to Australia for a couple of weeks. How you doing? Got a couple of new friends. While I was in my hometown of Adelaide, I ventured into the city to a little store called Shintokyo. This store used to be, and still is, probably my favorite store in Adelaide. It was like our little slice of Japanese culture where you could buy imported figures and video games, but not just from Japan. Shintokyo also imports a lot of European games, which means between Australian exclusives and other European exclusives, there are a lot of Nintendo Switch games in this store that I had never seen before, games that just don't release here in the US. So I bought a lot of them, a lot of games. Ew. It was very expensive. Australia is not cheap, I forgot, and very quickly remembered. Turns out that most of these were co-op games, and also they were all very weird. Anyway, here they are. I also filmed some video of me talking at Shintokyo, but it sounded like this. I don't know. It's fun to actually buy games in another country, so we're not going to be using that footage. And then I also tried to shoot some footage of me outside the Airbnb we were staying in, and that sounded perfectly fine, but I was very tired and that looked like this. I got Devil's Third. I'm not going to be using that footage either. But here's what we are going to do. Kim and I are going to play all three of these games in co-op mode, and then I'm going to let you know if they were any good or not, and it could really go either way with all three of them, although I will say that all three look very bright, bubbly, and fun. I got no idea what kind of game any of these are. I'm not going to lie. I immediately raced pun intended to throw this one in my switch as soon as I got home, because Nippon Marathon by far looked the most interesting to me.  Didn't expect there to be a story mode, so I went ahead and started that. Oh no, I saw the character models and the animations, and immediately I thought I had discovered the worst Switch game. Maybe even one of the worst games of all time. Oh my. Like, she's not even holding the microphone, it's just kind of resting between two fingers. And then look at this crowd, the character models are so bad. Like, I wonder what these people are actually supposed to look like. Oh, that's actually pretty accurate. It was about at this point that I started to clue in that maybe this game wasn't taking itself too seriously.  And then I started reading dialogue like this chick telling me that her jet pack is 100% gluten-free. And the fact that in between scenes in this story, it doesn't just fade to black and then move on to the next scene. No, the character models realizing they're no longer needed in this scene decide to just up and sprint out of the screen. Everything here is very intentionally bad and it's hilarious. So while racing, you can jump over obstacles or duck underneath them. There's item blocks, Mario Kart style you can pick up and then you'll either hold them in your left hand or right hand. If you use the left or right trigger, you can throw that item, the left or right bumper, you can eat that item. The aim of the game here is to avoid, leap over or duck under every single weird and wacky obstacle in your way and leave everyone else in your dust. If you can make the screen follow you far enough ahead and everyone else falls behind, they pause the race, give you a point, reset everyone and you do it again until you all hit the finish line. So you can get multiple points during a race or stars as they call them if you just keep getting ahead of everyone else and that's how you really dominate. But it's not as easy as it sounds because all it takes is one little thing to glitch or trip you up and suddenly you're flying face first into a wall or into the sea and it's just hilarious chaos. And as soon as I raced my first race, I stopped everything and I went and got Kim to play because I just needed somebody else to experience this game with me. What kind of game do you think this is just by everything that you've seen so far? I imagine it's just a racing game? Okay. Yeah, on foot. Okay. Got something, how do I throw it? So press the left bumper? Oh, that's how you throw it. Yeah, and that'll hit me and I'll fall. Oh no! Oh no! Is that guy dead? That's me and yeah, I think I passed out. Oh, what are the dogs doing? The dogs are.  Oh, that's fantastic. Yeah. No, I'm going to get left over again. Simon is being very distracting. These dogs won't leave me alone. Here we go. Rocky steps. I think this is it. Yeah. What did you think? I think it's very interesting. Is it? I think if you play it enough, it'll make sense. I imagine playing with four people would be really fun. Oh, yeah. Yeah. So if we go to party games and go-go trolley. So it's bowling. Okay. With the shopping cart? Yeah. So you line up where you want the cart. Okay. Then you pick your direction and then you just kind of run into it and hope for the best. Okay. Oh, a strike, huh? Oh no! They came back up. Oh, see, if I had got down there quicker, you could have pushed it. I could have pushed it. Oh, wait, no. It still counts. Okay. All right, you try. Oh, God. Boom. I don't know if it counts because you're right out of time. Probably not. But, okay, you get another one. Oh, I do. Oh, right. To pick up the spare. Yeah. Here's my recommendation. Jump into the cart. Okay. But you got the, you cleaned up the spare. Okay. Here we go. Now. Okay. Okay. You know, I feel like it works better when you weren't in the cart. But if I just don't, there we go. Oh. And then I, oh, see, you know, if I had to do it on the left, I could have cleaned up the right side at the same time. It's okay. Now, you can kind of control yourself. So it's going to the right. So you go to the left. Yeah. You go to the left. I am. Okay. Okay. I think, all right. No, I didn't count it. You got that one left standing. Oh, you're going to jump in it. Okay. That's cool. I think you got it.  I didn't touch anything. It just happened. I don't know. I don't know. I feel like you touched it. Oh, yeah, you can turn it. Okay. I'm kind of turning it. Not really, though. All right. Well, that's that. That's that. That's interesting. Oh, no. Oh, no. Oh, I got to write up the ramp. No. Oh, you slide under the bus. It's okay. I'm still in the game. Oh, come on. Oh, it's just you and me. What are we doing? Running through here? Oh, no. Oh, this way. Oh, I thought I was supposed to run into that. Oh, God. No. Oh, no. Oh, I technically won. No. Oh, this happens sometimes. I don't know. It's always different. Okay. So we all get an item from now. That's pretty close. Okay. Can I move? I can't. I didn't even get to go. No, I didn't either. Oh, no. Oh, yeah. Yes. Yes. Oh, come on. I was so excited to write the trolley down. Oh, boy, not for you. Take this. Oh, come on. So it turns out this game was indeed made as a parody of itself. Actually, it's made as a parody of what outsiders think of Japan looking in. For example, if the developers of this game wouldn't make one based in Australia, we'd probably all be riding kangaroos and dodging giant spiders and snakes. Oh, and playing the game upside down, of course. It's everything stereotypical people think and say about Japan.  It's like $15 on the eShop. And I really think that it's a party game must have for the Switch. I'm not even kidding. I really can't wait to bust this out at the next party game night I have. Sadly, last fight doesn't quite live up to the same hype that Nippon Marathon managed to create for me. It's very okay. There's a lot that I do love about it. The art style for one, the character design, the game design in general. Everything visually and even musically is really good. But for a game that is based solely around fighting, the fighting's not very good. I mean, Kim really liked it. I just think it's a little too basic. Oh, there's a hawk guy. I like this fish guy. Yeah? I'll take him. Yeah. Oh, you got to presay a lot apparently. I don't know why. I know. I won. Oh, to decide who gets to play. Oh, that's kind of a cool mechanic. Okay. Oh, we'll do the lost, your favorite TV show, Lost Plane Crash. Oh boy. Or also the most upsetting episode of Grey's Anatomy. Was it the most? Yes, it was. Oh, that's, that kind of looks really cool actually. I like this character. She kind of looks like the green giant, but not. Oh, that's a really tiny. Oh, interesting. I don't know. Oh, oh, it's kind of a 3D Roma. Oh, what is happening? Oh, it's blue smoke in your face. Take a missile. Oh, I dropped the missile. Oh, I can go up here. Oh, you can take stuff off the plane. Look at me go. What is this? No. What is happening? Now you're max apparently. What does that mean? I'm assuming you can do some kind of special What is the special? I don't know, but I want my max. Oh, was that it?   I can't get away from them. How'd you get max again? I don't know. I don't know how to do it either. Can I be honest? It's not great. I really like the design of the characters. Oh, I threw the missile. There it goes. I'm gonna beat you. Look, I do like a, well, if I get a second free, I do a football charge. You see that? You don't care.  You already almost have a special. Probably could you're kicking my butt? I am kicking your way. Oh, no. Oh, that was cool. So was that though? All right. Now my special player is completely gone and I haven't touched x once. Oh, really? So I don't, I don't, I don't, so you just, oh, okay. Oh, so you don't need to build up any kind of special. So how did you build up a special then? By hitting you?  Yeah, she's not great against me. I can't even figure out, she's got grabs. She can jump. She can throw. She can do that. And she can, she can do this. Yeah, but I feel like this character is awful. You have all these like different attacks and ranged attacks. It's really not. I'm just pushing the same button. Whoa. I know. And you've got all these attacks out of it. All I can do is the splits. This character is the worst. Well, if there was a gymnastics round, you'd be all set. Yeah, well, it's in a gymnastics. All right. I said gymnastics. Gymnastics, gymnastics. I mean, for example, there's not really that many moves or attacks you can do. Every character has only a few moves and then one big special move. So immediately fights become pretty repetitive in that sense and characters that have a better default move set to other characters are going to win every time. Like this crack jack guy that Kim used, his basic attack was this big sweeping arm move that when you just spam it, there was nothing I could do against it with my character who her equivalent attack was dropping down and doing the splits. What am I supposed to do with that? Also playing against the CPU is frustrating because the maps are filled with objects and items that you can pick up and throw or use against your enemies to bash their head in with. And the CPU seemed to love these objects very much so. Their main goal seems to be to just target these objects. And in fact, most of the CPU fights I had was just me chasing after the computer while they were hunting down objects to pick up and throw at me. And what's even more frustrating is that the CPU seemed to know exactly when these objects were going to appear on the screen. And they just waited there for the moment the frame that those objects clipped into play and then they were just already holding them and then throwing them at me felt very unfair. It can be fun just having throwing things around fights, especially when you have objects like picking up a phone. And if you hold on to it long enough, you call in a massive missile strike on your opponent, which did lead to some really intense moments right at the end of rounds. So needless to say, I wasn't totally impressed by this game. And I did play through some of the story mode, but it was really just a few lines of text and pictures and then a basic one on one fight and then rinse and repeat until you complete the story mode. I don't feel like I got the $50 I paid out of the game, but that is Australian prices. I'm sure the digital version is much cheaper. I haven't looked at it, but I still wouldn't be rushing to get this one. I would definitely get nip on marathon first. Then we have super cane magic zero, which quickly became Kim's favorite of the bunch and surprised me a lot. There is no way I'm not playing Dudwood. That is 100% a character I would pick in a game like this. A lot of ways to. Because it's an eye. That is also a mouth and is very creepy. Where? Right there. Do you only eat pepperonis? Oh, what did you do? Oh, I did it too. Oh, that's, I guess that's a spell of some kind. Is that a Nokia phone? Yes. Am I supposed to break it? You can't. Oh, I found pepper. Maybe. Maybe I found pepperoni. What is that? I don't know if I ate it. Oh, okay. I don't know if I'm supposed to eat it. You just ate a skull. I ate a skull. They didn't say I ate it. So I did. So it turns out this game is a procedurally generated dungeon and local PVP arena style game, which allows you to fight solo or play in local co-op.  It has a very charming art style and we really like it and can't wait to actually sit down when we're not recording and trying to be entertaining and actually play through it together and have a lot of fun. It just feels really fleshed out and polished as an RPG. I mean, they call it a comedy adventure RPG and they could have just heavily leaned into the comedy side of it and trusted that it would be enough to keep players invested because really fantastic writing and great humor, which this game has, can be enough to make a game fun enough to play through despite however the gameplay turns out. But as it turns out, the gameplay and the core mechanics of the RPG side of it is equally as good as the writing and the humor and everything else. It's kind of a perfect little adorable package. I really hate that I had never heard of this before because I wish I could have jumped on this one sooner. There are so many different items and objects that you can smash around or pick up or eat or equip onto your character. I feel like maybe I've played games like this before and ones that definitely aren't as funny or as fun, but they're usually single player games. It's really cool to see this not only being a co-op game but a four player co-op game. I imagine this would be a really chaotic and fun game to play through the story mode with four people. Kim and I are more the content to play through just the two of us and we're really excited to do it. Oh, okay. Oh, we both get one. We get one each. Okay. Oh, that's cool. Fair. All right. Now what? I like how happy your guy looks when he attacks. He loves it. Oh, we've got to fight this guy. Take this. Beat him up. Be smush. Ah, we beat our first enemy. Yeah, I think we still have to beat these guys up. Oh, can we throw these? Give me like two little high fives. I just ate glue and got really strong. Oh, what's this? I don't know. Some sort of orb.  It makes, okay. I don't know. Oh, now this, I don't know what that did. Wait, where if I throw it? Oh, oh. Thanks so much for that. It's okay. Come back to life. I'm doing resuscitations on myself. No, I was doing. How about you no more grab things? Okay. Well, don't throw it at me. I'm not going out there.  All right. They're feet monsters. Feet monsters. They're feet.  Oh, fuel. I'm going to eat it. Oh, I don't eat the fuel. Why would you do that? I really like this game. It reminds me like of the Adventure Time games kind of like with Undertale humor and really great like 8-bit music. There's a lot to like here and I really hope the game stays consistently fun like this. I got to be honest, when I bought these three games, I didn't really have high expectations. I was kind of hoping they would at least be funny or humorous or I could make fun of them in some way when I bought them, but I was mostly just buying some exclusive games I couldn't pick up here. Not even sure if I could make a video about it, but then all three of the games ended up being really great or two of them ended up being really great and then one was pretty fun to look at. There, I'm really happy with how these turned out. I don't feel like I wasted my money and I feel like maybe hopefully they made for an interesting and fun video and maybe you found a couple games you might go out and buy now. Maybe not. I don't know. I really don't care what I could do. What I do care about is you liking the video here all over the subscribe button. We are all, we are all so close to a million. Just make it happen guys. Then I'll stop talking about it.


Doggies, the rotator cuff muscles, there's four of them. We've already looked at them when we looked at the shoulder joint. But now we're just going to take it a little bit further and look at their attachments so that we can be sure that we're like, oh, we know how the rotator cuff muscles are carrying out their function now. They all have major actions. And you, more power to you if you would like to memorize all of those or learn all of those different actions that they have. And the actions are very similar. You could sort them into piles. It isn't crazy to know their actions. But what I want you to know is that they stabilize the shoulder joint. And that's the piece that I want you to know. So they are literally holding onto the humerus, the head of the humerus, and holding it into the glenoid fossa. And those muscles surround the head of the humerus and attach to various places on the humerus and attach to various places on the scapula and keep those two together. I mean, the shoulder joint is pretty mobile. It's the most mobile joint in your body. And because it's so mobile, it's also the least stable joint. So thank you, rotator cuff muscles, which often take a beating because of the incredible mobility of the shoulder joint. Everybody, hug your shoulders right now. Thank you very much. Okay, so our action for these guys is just going to be speak to stabilize the shoulder joint. That's what we're going to do. Now, before we even go look at these guys, this sorting process is easy. There is one muscle that attaches to the lesser tubercle of the humerus. One. All the rest of them attach to greater tubercle. All of them. So subscapularis attaches to the lesser tubercle. Now, think about that for a second. That totally works for me. Subscapularis, where is the other attachment going to be? This subscapular fossa? Subscapular, the infraspinous fossa. It's a fossa. I hope that it's the subscapular fossa because I won't tell you how late it is right now, but that is my excuse that it's really late right now. Subscapular fossa. Since you already know the scapula and all the parts of the scapula, knowing the rotator cuff muscles and their attachments is easy, easy peasy. Supraspinatus attaches to the supraspinus. Fossa. Infraspinatus, infra, oh geez, spinous fossa. And teres minor. Remember teres minor? We were looking at, we saw that trapezius, okay, I think I just have to go show you teres minor so that we can see where it actually is. Remember, teres major was inferior, teres minor was superior. They both attach to the medial border of the scapula. Teres minor attaches superior to teres major. And then the long head of triceps slips between them. So what, medial edge, medial border of the scapula? Wow, I can totally do this, I really can't, I promise. Medial border of the scapula. And just for perspective, superior to teres major. Okay, let's go look at them all. This is teres minor. Dude, we don't even have to shift gears. We've got, who's this? Below the spine, spine, I said spine. Infraspinus, I mean infraspinatus attached to the infraspinus fossa. And then who's this? Supraspinatus. These are actually nice and easy. And then you tell me, think, where are we going to look? Where do you see subscapularis from here? What are you going to expect to have happen? You've got to look from the anterior surface in order to see the subscapularis, which is this thing right here. And does it make sense when you think of subscapularis being on the anterior surface of the scapula, right? So when you're looking at the anterior aspect of a human, you can see their subscapularis through their ribs. You can see how their guts and stuff, that's cool. Makes sense to me that it's going to attach to the more medial bump. It's going to attach to the, what? The lesser tubercle. I knew it would come out of there eventually. It attaches to the lesser tubercle and it's the only one that does that because it's the only one that we need to see from the anterior surface. There's all sorts of ways that you can remember this. Now our shoulder joint is nice and stable. If you rotate or cuff, let's talk about the muscles that are going to move the forearm. I'll be right back.


Fiery horse with a speed of light, the cloud of dust and a hearty high old silver, the Lone Ranger. With his faithful Indian companion, Tonto, the daring and resourceful masked rider of the plains led the fight for law and order in the early western United States. Nowhere in the pages of history can one find a greater champion of justice. Return with us now to those thrilling days of yesteryear. From out of the past come the thundering hoof beats of the great horse, Silver. The Lone Ranger rides again. Mrs. Molly Carson, busy in the kitchen of her small house on the edge of town, looked up expectantly as she heard the front door open and closed. I'm out here, Bob. What brings you home from the banks so early, son? I wasn't expecting you to plain sakes bring in Mary Blake right into my messy kitchen. Oh, don't mind me, Mrs. Carson. Mom, Mary and I weren't... we're going to get married. Oh, Mary, I don't know what to say. I have to sit down. Oh, gee, Mom, I know you and Mary will get along and everything will be fine. Of course, son. It was a shock to me to think my boy was grown up all of a sudden. Mary, I know Bob and you will be very happy. I'm sure of it, Mrs. Carson. Mr. Blake is offered to take me to the bank as a junior partner, Mom. He insists on it. Lame sakes? I can't believe it. Oh, just when are you planning on having the wedding? In about a month. Your father would have been very proud, son. Bob has told me how wonderful his father was. Yes, of course. Bob was too young to remember, but I've told him all I could about his father. He must have been very brave. Bob told me his father was killed while helping to capture some outlaws. That was over in Pecos County, wasn't it? Yes. Later I brought Bob here to Clarkville with Bob's Uncle Tom, my brother. Oh, yes. I've met Tom, Jensen. Tom lives here with us, you know. He was my only brother and much younger than I. I've always looked after him, sort of. I... I guess Uncle Tom means well, Mom. But, well, I wish he'd stay away from the café.  So let's not worry about him. Come along, darling. I have to get home. And I promised Dad I'd see you back at the bank within an hour. All right, let's go then. Goodbye, Mary dear. Run in any time. I will. Bye. See you at supper time, Mom. Goodbye. Goodbye. It's all so sudden. Isn't that Bob who was just in here, Molly? Yes, Tom. Bob and Mary Blake. They're going to be married. What? You mean Bob's going to marry Banker Blake's daughter? That's right. Oh, I think it's wonderful. I'm so proud of Bob. Yeah, you have the kid thinking as old man was some kind of a hero. Why haven't you told him the truth? That his father killed a man and lit out for Arizona 17 years ago. Please, Tom, forget it. You promised. For Bob's sake. Heaven, forgive me for telling him what I did. But all I could give him was a good memory of his father. And if he ever runs under the truth, he won't thank you for telling him what you did. Bob's 20 years old now. It's not time you quit traveling. It was about two weeks later. The Lone Ranger and Taunta were riding from Clarkville toward their camp in the hills with supplies. As they rounded a curve in the trail, they saw a rider coming toward them, a large man with a heavily bearded face. Seeing the masked man in Indian, he stopped and drew a gun. Watch out, Kimus, hubby. Oh, my, easy, Silver. Come on, Silver.  You drew on us without warning. I was your mistake. We're not outlaws. Sorry to hurt you, but you were too careless with that gun. It'd be funny, easy. I'll get your gun and I'll look at your arm. I'll just keep this gun for the time being.  No, this bed is a third. Just a scratch. Bad enough to be painful. You wish you were quick on the draw, stranger. Comes in handy at times. It sure does. That was flu shooting, too. I'm sorry I lost my head, but seeing that mass... Yes, I know. Are you from around here? Not exactly. Rued down from Arizona. You used to be over in Pickles County. Well, if you come with us to our camp nearby, we'll attend to your wound. Easy, Silver. See, Che, have my gun. I guess he ain't much here.  Very well. Come along with us. Come on, Silver.  A short time later in the Lone Ranger's camp. Aftix, I'm good. Thanks, indeed. Going far? Well, right now I was seeming to go to Clarkville. Know someone there? Well, eh, I'm hoping to find someone there, no. The fact is, I'm not the information about a woman named Molly Carson. She has a boy named Bob. Wow. Me here talking about a fella named Bob Carson. Clarkville. He did? What kind of talk? Well, me hear him say, him get married soon. That's the talk I heard, too. An outbreak came through from Clarkville a week ago. I met him in the town some distance wester here. He learned my name and asked me if I knew the kid that was marrying a banker's daughter in Clarkville. Is that what brought you out this way? Yeah, yes it is, mister. Your name is Carson, too? That's right. Jim Carson. What's the connection? Well, it's a long story. If you'd like to listen, I'll tell you. I'm very much interested. Go ahead. If you do believe my story, then I'm taking the chance. But I gotta tell somebody. There's no reason yet why I shouldn't believe what you tell us. Well, about 17 years ago, I was a happy married man, living with my wife, my baby son, and my wife's young brother on a little farm back in Pigos County. I see. Living in the cabin near the edge of town was an old miner called Old Pete. The town knew he owned a lot of gold, that he didn't trust banks and that he buried that gold somewhere, keeping just enough to live on. Mm-hmm. They said he carried a map of where he hid the gold. Well, one night I was right now to my place and was approaching Old Pete's cabin. I guess Molly'd be waiting supper for us, fella. We're a little late tonight. That's shot. Give him Old Pete's place. Come on, boy, get up there. Oh, oh, boy, hold it. Somebody shot Pete. Run out the back way. No use. He got away. It's the Montbray way in the mask. You better look at Old Pete. He wanted a map. I made map in two parts. He got only one part. Other parts under mattress. You take it maybe someday. Maybe there's something I can do. Too late. Get other part of map now. All right, Pete. Look here under where my head is. Sure. They don't seem to be any... Oh, here it is, Pete. What do you want me to do with it? Put this part of the map in my pocket. I guess I better go get the shift. I heard shooting over this way. Jim, what are you doing here? What's happened to Old Pete? Well, howdy, Tom. I'm glad you come along. Pete's been killed. We shot him, Jim. How do you know? Some Montbray went out the back doors. The front after I heard the shot. That's funny, Jim. I came up the back way. I didn't see anybody leaving. Well, somebody did leave. Just seemed, Tom. It's too bad you didn't come along sooner. Maybe then you might... What are you staring at, Tom? Is your gun here on the table, Jim? Looks like it. Well, sure, that's my gun. I said it there after... After? Your shot, Old Pete, maybe? What? Say, I told you that... Your gun's just been shot, Jim. Only one bullet used, too. Sure. I shot after the Umbray. You must have heard two shots, Tom. Here's a handmine. I heard only one, Jim. You see here, even if you are Molly's brother... Jim, I got you covered. Hell, look here, Tom. Just what are you aiming to do? I ought to turn you in for murder. You being my brother-in-law, I'm giving you a chance for the others to get here. Get on your horse and ride. Don't stop even at home. Set out for Arizona territory, and don't come back, Jim. Now, get going. But I didn't do it, Tom. If I run away, there's just... They'll hang if you don't. Now, don't tempt me, Jim. Get going right now, or I'll have to take you in. Now, get riding. Pronto. There was nothing there for me to do. I left without even seeing Molly and the baby again. And made no way into Arizona territory. You've been there all this time? No. I grew this beard and sideburns, and then after a few years, I rode back to Pegas County. I hunted for a mass man that might look like the hombre to kill Pete. That's why I took a shot at you. It was that mass that got me excited. I see. I learned that Molly had moved and was living in Clarkville. I didn't dare try to see her or the kid knowing that Tom was still living with him. Then I heard the boy was going to get married. Oh? I decided I'd get a look at the wedding and see what kind of a man he turned out to be. Someday, I hope to find Pete's killer. But it seems hopeless after all this time. Whatever happened to the part of Pete's map he gave to you? I still got it. It's no good without the other part. Yes, I know. The man who has the other part is the killer. Then you believe my story? You don't think I kill him? I believe you, Jim. And if the killer is still in this section of the country, perhaps I can help you find him and clear your name. Stranger, if you could do that, will that do anything you ever asked me to do? My reward would be in seeing a wrong writer, Jim. Now, I have a plan that will bring the killer to light. He is still around. Tomorrow, we'll start to put that plan into effect. The curtain falls on the first act of our Lone Ranger story. Before the next exciting scenes, please permit us to pause for just a few moments to our story. It was dusk of the same day on which the Lone Ranger had met and talked to Jim Carson. In town, Jim's son Bob stepped in the door of the bank and started toward his home. Oh, it's you, Uncle Tom. Now, you'd better come along home to supper. Oh, I got to see a couple of hombres over in the cafe. I've been waiting to talk to you. Talk to me? What about? Look, I've come to the point that I need a bit of money. Now, look, Uncle Tom, I gave you $10 yesterday. I haven't any more to give you. Oh, you're working a bank, don't you? What difference does that make? That money's not mine. Oh, well, aren't you going to marry the banker's daughter? Yes, I am. But I... I can't give you any more money. Oh, I wonder what that girl and her old man had say if they learned the truth about your father. What do you mean by that?  Skimped and saved, educated.  Now, look, there's something you want me to know, tell me. Then go on back to your cronies at the cafe. Getting high and mighty since you took up with those swells, aren't you? Molly married a no-good hombre who lived out after killing a poor old coot leaving her with you to raise. Your pie's never been heard of since. You lie. A strong talk coming from you. Maybe Banker Blake won't think it's a lie when I tell him. You don't want him to know you better get me some money?  Our next time, you'll get worse. So keep out of my way. Child. Hit me, Willie. His own uncle. I'll get even with him for that. It was the following night when Tonto rode into the Lone Ranger's camp where Lone Ranger and Jim Carson were waiting. He told him that Bob had broken his engagement with the banker's daughter. The next day, Bob was at one of the teller's windows when one of his fellow workers came to him. Bob, Mr. Blake wants to see you in his office. All right. Thanks. He said, come in right away. I'll take over here for you. All right. Yes, sir? I'm right in, Carson. Yes, sir. Oh, I didn't know Mary was in here. I had no idea. Dad's idea, Bob. Not mine. Sit down, Carson. Thanks. Mary has told me about your sudden decision. Tell me, don't you love my daughter, Bob? Dad. Please. I just can't go through with it, Mr. Blake. I can't tell you my reason. I never want to see you again, Bob, Carson. Oh, Mary. What is it, my boy? Why don't you confide in me? I planned a bright future for you here. I'm sorry, Mr. Blake. I can't tell you. I'll be leaving the bank as soon as possible. Good day. A short time after the arrival of the stage that afternoon, Jim Carson, dressed in clothes, cut in Eastern style and wearing eyeglasses, entered the cafe and went to the bar. Good to meet you. What do you have, stranger? This you have. More one for yourself. Yes, sir. Staying in town long, Mr. Not very long. Here, sir. Well, I saw you getting off the stage. Staying at the hotel, ain't ya? Yes, sir. Yes, I didn't catch your name. Then I'm going by the name of Hunter, Jim Hunter. A cattle buyer, maybe? No. Came this way in a little business. Matter of fact, I had a brother who died out this way some time ago. Old Pete Hunter. He sent me half a map showing where he buried his gold. What good to have a map? Then he gave the other half to a friend of his. That's who I'm looking for. What's a friend's name? I don't know. He didn't say in his letter. I guess he forgot. Then he died, so I never found out. If any of ya here, if anybody wandering around with half a map, some gold, you're sending to me at the hotel. Room 102, huh? I'll be there after 8 o'clock. You really think there is gold? Of course it is. He had plenty hit over in Pickett's County. I'd go over there later to hunt for the friend who has the other half of the map. Well, I'll see ya later. Yes, sir. Man, fellas, did you hear that? If any one of you armories has that other half of the map, just take it to room 102 at the hotel after 8 o'clock tonight. He's out lookin' for a needle in a haystack. It was after 8 o'clock when Tonto approached the Lone Ranger in the shadows alongside the hotel. Come to hotel desk. Hear him ask for room 102. He may be the one, Tonto. You know what to do. I'll go around to the window 102 in case of trouble. Hurry, Tonto, there isn't much time. Jim Carson, if anyone came to keep him waiting for at least 10 minutes, meet me under that window when you get back. Now, may do it. A short time later, Jim Carson heard the knock for which he was waiting. Come in. That's the name of Guba, eh? I'm Tom Chinson. How did you do? I understand you got part of a map from your brother, old Pete Hunter, who died some years ago. That's right. I'm the friend he gave the other half to. Yeah. Sure. And right here. I see you keep one hand on your gun, mister. I don't take any chances. Now, if you really have the other half, maybe I'll show it. Sure, why not? Let's compare them, see if they match up. That's a good idea.  I can't read with these on. So you were Pete's friend, eh? Friend enough to know you couldn't be his brother? What do you mean by that? I thought there was something familiar about your voice. But now with the glasses off, I know who you really are. Jim Carson. All right, now you know, Tom. But I know this much. Your pain with that map proves that you murdered old Pete that night. It does, eh? You're the one they've been looking for, Carson. Now I'm taking both halves of the map, and then I'm turning in. I'll be quite a hero for catching a killer who's been at large as long as you have. You mean you really did shoot old Pete and come back and blame me, and I feel for it? Yeah. I was just guessing before, but, well, it doesn't seem possible. Yeah, that's just what did happen, Carson. You butted in at the wrong time, so I had to beat it. But when I saw who it was, I knew I could scare you into leaving for Arizona. Of course, telling you this doesn't mean anything, because nobody would believe you. You're the one they want. Yeah, you rotten killer. You ruined my life once, but you're not going to spoil the rest of it? Why, you? I'll get it prettier now. I'll get praise for shooting a murderer. Listen on the outside, Tom, Jensen. We got the whole story.  Oh, my arm! That shot came through the window. In just in time, too. Take Jensen to the jail, boy.  Any kind of Molly and Bob Carson strangers? Yes, yes. Molly is my wife. Young Bob's your son, huh? You'd better get over to see him. From what we overheard, you've been away for a long, long time. Later at the Carson home. Howdy, stranger. Who did you wish to see? Don't you... Don't you know me? Gee! Now, Molly, everything's all right. Who is it, ma? What are you crying for? Bob. Bob, this is your father. Your father? What, I thought... Well, that is Uncle Tom. Your Uncle Tom made a bit of a mistake, shall I? There he is, Mr. Blake. So, you're Bob's father, huh? When the whole town's talking about what you've accomplished, single-handed. Let me shake your hand. Sure, Mr. Blake. Mrs.  Tom? Tom did that? Well, Molly, don't get the feeling. Well, after... After what he did to us, Jim, he deserves whatever punishment he gets. Bob, son. Don't stand there looking. Mary's in the doorway there. Hello, Father. Oh, Mary. Mary, now it's all right. I have a dad and he is a hero, so... You two run along and talk things over. All right, ma. Come on, honey. Tell me, Jim. However, did you get to prove Tom did the killing? Well, I had help, Molly. A businessman. He planned it all. Because of him, we're together again. And I can give Bob a wedding gift. The golden old peed left.  Well, I can tell you who that is. Yeah, sure. Who? He's the Lone Ranger. The story you have just heard is a copyrighted feature of the Lone Ranger Incorporated.


Adaptive Sports really helps you push yourself to recover. It's competition and we're trying to do our best for our team, but we're also rooting for the competitors we're competing against. Good to meet people that understood that you were able to actually compete and do things.  It's embarrassing so I just wouldn't go and I hear I am at a camp and everybody gets you. So it's sort of like a family. I think it gives them hope that they can do other things than just sit at home. This changes people's lives. Some people, this has saved their lives. And I think it's made mine. This program makes me want to go on and continue to actually do work in this kind of community and help the people that are getting out to get to the level that the people in this program are on.