Tools & Tips for BH Spiritual Care Support Groups: Embracing Neurodiversity in Group Facilitation

Facilitating support groups within the realm of behavioral health (BH) presents a distinct set of challenges and opportunities, primarily stemming from the neurodivergent nature of the participants. This unique composition often leads to a spectrum of engagement, ranging from highly vocal and active participation to quiet and minimal interaction. Effective facilitation in this environment requires a nuanced understanding of these dynamics and an adaptive approach that prioritizes participant autonomy and a truly safe space.

At the outset, it is worth noting that having the support of behavioral techs and volunteers is invaluable in my role as a support group facilitator. This logistical assistance allows me to fully concentrate on leading the group, as I can delegate other concerns, such as restroom breaks or assisting a patient who needs to return to their unit or room, to the BT and/or volunteer.

Highly Engaged Participants
In many BH support groups, facilitators will encounter individuals (perhaps in manic episode) who are highly talkative, sometimes to the point of monopolizing the conversation. These "run-away trains" can be frustrating for facilitators who are accustomed to neuronormative communication patterns in groups, wherein participants are capable of tracking the time length of their sharing. In such instances, proactive and empathetic intervention from the facilitator is not just beneficial, but crucial for maintaining group cohesion and ensuring equitable participation.

To manage highly engaged participants effectively, facilitators should employ these strategies:

• Utilizing a Talking Object: Implementing a designated talking object, such as a stress ball or a small decorative item (such as an electric candle), can serve as a powerful visual and tactile cue. Only the person holding the object is permitted to speak. This tangible rule provides a clear boundary and helps to slow down the pace of conversation, allowing others to prepare their thoughts and find their voice. 
• Reinforcing Group Guidelines on "Shared Conversation Space": From the outset, group guidelines should explicitly emphasize the concept of a "shared conversation space." This means reminding participants that everyone deserves an opportunity to contribute and that no single individual should dominate the discussion. When a participant becomes overly talkative, a gentle but firm reminder, such as, "Thank you for your valuable insights. Let's ensure everyone has a turn in our shared conversation space," can be effective.
• Intentionally Ensuring All Participants Have an Opportunity to Share: Beyond simply setting boundaries, facilitators must actively create opportunities for quieter members to speak. This might involve directly inviting individuals to share their thoughts, "Sarah, we haven't heard from you yet, would you like to add anything?" or setting a timer for each person's sharing time. It's important to do this in a way that feels supportive rather than pressuring, always offering the option to pass.

Low-Functioning Participants
Conversely, some BH support groups may be non-conversational, exhibiting a pervasive quietness, with participants sharing minimally or even declining to speak when directly invited. This can stem from various factors, including participants being in the midst of a depressive episode, experiencing heightened anxiety, experiencing psychosis, catatonia, or simply being in a state of low functioning due to their neurodivergence. It's crucial for facilitators not to interpret this silence as a lack of engagement or disinterest, but as a valid form of presence and processing given their current mental state. 

Autonomy: Redefining "Good Participation" in BH Support Groups
In BH support groups, it is absolutely vital to discard traditional, neuronormative expectations of "good participation." In conventional settings, this often translates as assumptions that participants should be capable of stillness, articulate and coherent sharing, deep self-reflection, and strict adherence to the topic at hand. While neuronormative group discussions may sometimes still happen in BH support groups, neurodiverse contexts demand a much wider and more inclusive spectrum of participation, acknowledging that engagement manifests in varied and unique ways.

• Self-Regulation through Body Movement (Stimming and Walking): Many neurodivergent individuals utilize movement, known as "stimming" (self-stimulatory behavior), as a crucial self-regulation mechanism. This might involve fidgeting, rocking, or even walking around the periphery of the group. Facilitators should recognize these behaviors not as disruptive, but as essential tools for participants to manage sensory input, anxiety, or internal states. Rather than attempting to suppress these movements, a supportive environment embraces them, understanding that a comfortable and regulated participant is more likely to process information and feel safe. (Also, work with you BH team to see if a particular patient needs a self-regulation object or sensory tool, and how that person can access it while participating your group session).
• When Sharing Goes Off Topic (Tangential Sharing): In neurodiverse groups, sharing might veer off-topic. What may seem like a "tangent" to a neuronormative observer can, for a neurodivergent individual, be a highly relevant connection or a necessary pathway to expressing a core feeling or experience. In their intervention, facilitators should adopt a calm, non-judgemental and affirming tone: 

                  (1) Acknowledge and Affirm: "Thank you for sharing that, I appreciate you opening up." Or “Thank you so much
                        for your sharing - that seems to be very important to you.”
                  (2) Gently Redirect: "That's an interesting point. Bringing it back to our topic of coping strategies, how does that
                        relate to what we're discussing?" This approach validates the participant's contribution while gently guiding
​                        the group's focus back to the conversation.

• Quiet, Non-Conversational Participants: Perhaps one of the most significant shifts in perspective for facilitators is understanding that participants have the absolute autonomy to decline to speak. Their silence does not necessarily signify a lack of internal processing, engagement, or benefit from the group. For some, merely being present, listening to others' experiences, and feeling a sense of belonging is a form of participation and healing. As a facilitator, it is crucial to emphasize that their mere presence is sufficient. A gentle phrase like, "It's perfectly okay if you don't feel like sharing today. Your presence here is valuable, and perhaps you're here to simply listen, and that's just as important," can be incredibly affirming.
• When the Group is Silent During Reflection/Sharing Rounds: On occasion, you as a facilitator, may get a silent response from your group. When this happens you may continue to encourage participants in this manner: “I encourage you to continue to reflect on this particular theme, either through the worksheets, or by checking in with me in a 1-on-1 visit. Also, you could always return to this story and theme at a later time in your journey - even after you get discharged.”
• Freedom to Choose Where to Sit: While participants are encouraged to sit in a group circle, they have the agency to choose where and how to sit in the meeting space. Some may find sitting on the floor more relaxing and grounding, while others might feel safer outside the circle. For those who opt for distance, I always check in: "You're welcome to stay where you are. Can you hear me and the group from that distance? I want to ensure you can see and hear the conversation or activity." Moreover, during reflection rounds I make sure to invite them to share/speak even if they are outside of the circle. This approach respects individual comfort and safety needs while maintaining inclusivity.
• Choice to Exit - Self-Care as a Priority: BH support group participants should have the agency to prioritize their well-being above all else. If a participant feels unwell, overwhelmed, or triggered, they should be free to exit the group. The choice to exit should be viewed and framed not as a failure or a sign of weakness, but as a vital act of self-care. Facilitators can communicate this proactively by stating, "Remember, if at any point you feel the need to step out and take a break, please feel free to do so. This is a space for self-care, and sometimes that means knowing when to step back." Bear in mind that a participant's decision to leave a behavioral health support group doesn't necessarily reflect on your abilities as a facilitator. BH patients are often dealing with internal (mental-emotional) illnesses that have non-physical or invisible symptoms.

Validation and Affirmation to Create Safe Space
Creating a truly "safe space" is paramount in BH support groups. This extends beyond merely setting boundaries and involves cultivating an atmosphere of radical acceptance and non-judgment. Group guidelines should explicitly state the importance of mutual respect. Put-downs, derogatory language, or any form of invalidation are never acceptable. While unforeseen triggers can occur despite best efforts, facilitators are crucial in clarifying miscommunications and facilitating reconciliation if necessary.

Beyond the "safe space" boundary, facilitators must actively avoid judging participants' sharing based on its perceived relevance to the topic or its level or depth of self-reflection. In a neurodiverse setting, literal interpretations, abstract connections, or seemingly unrelated sharing are not only acceptable but expected. Every unique thought process, every individual experience, and every distinct way of communicating is to be respected and affirmed. This unconditional acceptance is the bedrock upon which trust is built and healing can occur.

Avoid Exclusively Relying on Intellectual Discussions
In the diverse neurobiological landscape of BH, I strongly encourage facilitators to move beyond the exclusive reliance on intellectual discussions and traditional group reflections as the primary methods of engagement. While these approaches undoubtedly hold a place in therapeutic settings, their singular focus can inadvertently exclude or limit the participation of many BH patients. For individuals with neurodevelopmental differences, trauma histories, or various cognitive processing styles, verbal processing and analytical reflection may not always be the most accessible or effective avenues for expression and healing.

Instead, it is paramount to create opportunities for BH patients to engage in a variety of ways, fostering a more inclusive and effective support group environment. This multi-modal approach acknowledges that healing and connection can manifest through various forms of expression and sensory experience. Consider integrating the following tools and modalities:

(A) Music: The power of music transcends words, offering a direct pathway to emotions, memories, and a sense of shared experience. Facilitators can utilize music in numerous ways:

• Thematic Songs/Music: Playing selected pieces that resonate with common group themes, encouraging participants to reflect on how the music makes them feel or what it brings to mind. In my sessions, I invite people to choose a song based on a few options or selections related to the spiritual theme. 
• Informal "lectio divina": After a song is sung or played, invite your participants to share a word of phrase that resonated with them based on the lyrics, and if they would like, briefly share why that world/phrase might be meaningful to them.
• Rhythmic Engagement: Incorporating simple rhythm exercises or drumming circles to promote grounding, connection, and a sense of unity.
• Native Flute: Sometimes playing a musical instrument (like a native flute) for short minute helps ground and regulate the whole group emotionally.  

(B) Poetry: Poetry, with its evocative language and metaphorical depth, can provide a powerful yet often less direct means of communication.

• Shared Readings: Reading poems aloud that touch upon themes relevant to the group (e.g., resilience, grief, hope, self-discovery).
• Writing Prompts: Encouraging participants to write their own short poems, haikus, or free verse on a given theme, without pressure for perfection or performance.
• Informal "lectio divina": After reading a poem, invite your participants to share a word of phrase that resonated with them, and if they would like, briefly share why that world/phrase might be meaningful to them.

(C) Art: Visual arts offer a potent non-verbal language that allows individuals to externalize internal experiences, emotions, and thoughts without the need for linguistic articulation.

• Drawing/Journaling: Providing materials for free drawing or structured art prompts to reflect on the focused spiritual theme(s) of the session.
• Collage: Utilizing magazines, newspapers, and other materials to create visual representations of feelings, goals, or challenges.
• Sculpture/Clay Work: Engaging with tactile materials can be particularly grounding and expressive, allowing for the formation of three-dimensional representations.
• Process, Not Product: Emphasize that the value lies in the creative process and expression, not in producing a "good" piece of art.

(D) Meditative Breathing Tools: These techniques are foundational for self-regulation, grounding, and cultivating present-moment awareness, which are crucial for emotional well-being.

• Guided Breathwork: Leading participants through simple breathing exercises like diaphragmatic breathing, box breathing, or alternate nostril breathing.
• Mindful Awareness: Focusing attention on the sensation of the breath as an anchor to the present moment, helping to reduce anxiety and intrusive thoughts.
• Body Scans: Guiding participants to bring awareness to different parts of their body, noticing sensations without judgment, which can be particularly helpful for individuals with trauma.
• Singing (Meditation) Bowl: When facilitating breathing exercises, I have found the meditation bowl effective in inviting participants to take a deep breath. It serves as a gentle reminder to return to their breath after intellectual reflections or conversations.

In my groups, when appropriate I insert in between reflection rounds a non-cognitive activity (say, a song, or a breathing tool using a meditative bowl, or a flute). This gives the group the opportunity to pause and move away from intellectual analysis mode. Integrating these diverse modalities makes the support group space inclusive to neurodivergent participants whose natural and preferred ways of participation often do not fit neuronormative expectations. By offering different engagement options, facilitators can ensure that every individual has the opportunity to connect, process, express, and heal in a manner that honors their unique neurological wiring and personal comfort level, ultimately fostering a more supportive, empathetic, and effective therapeutic environment. This approach recognizes and celebrates the inherent diversity in human experience and expression, moving beyond a one-size-fits-all model to truly meet participants where they are.

On Spiritual Care Notes for Epic
While I strive to foster an environment of radical welcome, inclusivity, and acceptance in spiritual care support groups, it is also important to observe patient behaviors during sessions that can offer valuable insights to physicians for their mental health assessments. Positive behaviors are straightforward to document in Epic. However, when challenging behaviors warrant particular attention, I detail them in my notes, such as these examples:

• "The patient exhibited disruptive tendencies, frequently interrupting others, but was receptive to redirection."
• "The patient's physical actions indicated active engagement with their hallucinations."
• "The patient shared very little, declining opportunities to speak during group reflections."
• "The patient departed from the group well before its conclusion."

When appropriate I also include notes about the participants healing intentions and goals. 

Closing Remarks
I have seen low functioning patients in psychosis dance and sing to the song and music related to the reflection theme. A patient who was very quiet and non-conversational produced a vibrant and colorful reflection drawing of the session's spiritual theme. A patient with increasing anxiety in his body stepped out of the group circle for a couple of minutes to self-regulate using tai-chi movements. While having disorganized speech, a patient diagnosed with schizophrenia expressed appreciation for the songs and music, especially the native flute. During the day of his discharge, a seemingly disinterested teen, who consistently kept his distance from the group circle, requested a brief meeting to share his appreciation for the wisdom stories he heard during the support group sessions.

This means that embracing these values and adopting these facilitation techniques enhances a facilitator's ability to lead groups in the neurodiverse environments of BH. This approach goes beyond mere tolerance; it actively empowers neurodivergent individuals to participate authentically, without the pressure of conforming to neuronormative social expectations and standards. For facilitators, these principles offer a liberating opportunity to release ingrained assumptions about "correct" behavior and instead embrace the rich tapestry of human experience and expression that defines neurodiversity. By fostering environments where every individual feels seen, heard, and valued for who they are, we can truly unlock the transformative power of behavioral health support groups.

---

WISDOM STORIES: A WAY TO RISE ABOVE

4 SPIRITUAL THEMES FOR BH SUPPORT GROUPS