Substance Abuse Treatment: Group Therapy

A Treatment Improvement Protocol TIP 41 Substance Abuse Treatment: Group Therapy

A Treatment Improvement Protocol TIP 41

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road Rockville, MD 20857 Acknowledgments Electronic Access and This publication was produced under the Printed Copies Knowledge Application Program (KAP) contract This publication may be ordered from or number 270-99-7072 with the Substance Abuse downloaded from SAMHSA’s Publications and Mental Health Services Administration Ordering Web page at http://store.samhsa.gov. (SAMHSA), U.S. Department of Health and Or, please call SAMHSA at 1-877-SAMHSA-7 Human Services (HHS). Karl D. White, Ed.D., (1-877-726-4727) (English and Español). and Andrea Kopstein, Ph.D., M.P.H., served as the Center for Substance Abuse Treatment (CSAT) Government Project Officers. Christina Currier served as the CSAT TIPs Task Leader. Recommended Citation Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Disclaimer Treatment Improvement Protocol (TIP) Series, No. 41. HHS Publication No. (SMA) The opinions expressed herein are the views 15-3991. Rockville, MD: Substance Abuse of the consensus panel members and do not and Mental Health Services Administration, necessarily reflect the official position of 2005. SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for the instruments or resources described are intended or should be inferred. Originating Office The guidelines presented should not be con- Quality Improvement and Workforce sidered substitutes for individualized client Development Branch, Division of Services care and treatment decisions. Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Public Domain Notice Cherry Road, Rockville, MD 20857. All materials appearing in this volume except HHS Publication No. (SMA) 15-3991 those taken directly from copyrighted sources Printed 2005 are in the public domain and may be repro- Revised 2009, 2011, 2012, 2014, and 2015 duced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publica- tion may not be reproduced or distributed for a fee without the specific, written authoriza- tion of the Office of Communications, SAMHSA, HHS.

ii Acknowledgments Contents

What Is a TIP?...... vii Consensus Panel...... ix KAP Expert Panel and Federal Government Participants ...... xi Foreword ...... xiii Executive Summary ...... xv Chapter 1—Groups and Substance Abuse Treatment ...... 1 Overview...... 1 Introduction ...... 1 Defining Therapeutic Groups in Substance Abuse Treatment ...... 2 Advantages of Group Treatment ...... 3 Modifying Group Therapy To Treat Substance Abuse...... 6 Approach of This TIP ...... 8 Chapter 2—Types of Groups Commonly Used in Substance Abuse Treatment ...... 9 Overview...... 9 Introduction ...... 9 Five Group Models ...... 12 Specialized Groups in Substance Abuse Treatment...... 29

Chapter 3—Criteria for the Placement of Clients in Groups...... 37 Overview ...... 37 Matching Clients With Groups ...... 37 Assessing Client Readiness for Group ...... 38 Primary Placement Considerations ...... 40 Stages of Recovery ...... 43 Placing Clients From Racial or Ethnic Minorities ...... 44 Diversity and Placement...... 52 Chapter 4—Group Development and Phase-Specific Tasks ...... 59 Overview ...... 59 Fixed and Revolving Membership Groups ...... 59 Preparing for Client Participation in Groups...... 61 Phase­Specific Group Tasks ...... 72 Chapter 5—Stages of Treatment ...... 79 Overview ...... 79 Adjustments To Make Treatment Appropriate...... 79 The Early Stage of Treatment ...... 80 The Middle Stage of Treatment ...... 85 The Late Stage of Treatment...... 88

iii Chapter 6—Group Leadership, Concepts, and Techniques...... 91 Overview ...... 91 The Group Leader ...... 92 Concepts, Techniques, and Considerations ...... 105 Chapter 7—Training and Supervision...... 123 Overview...... 123 Training...... 123 Supervision...... 131 Appendix A: Bibliography ...... 137 Appendix B: Adult Patient Placement Criteria...... 149 Appendix C: Sample Group Agreement ...... 151 Appendix D: Glossary ...... 153 Appendix E: Association for Specialists in Group Work Best Practice Guidelines ...... 159 Appendix F: Resource Panel ...... 165 Appendix G: Cultural Competency and Diversity Network Participants ...... 167 Appendix H: Field Reviewers...... 169 Appendix I: Acknowledgments ...... 175 Index ...... 177 SAMHSA TIPs and Publications ...... 183

iv Contents Figures 1­1 Differences Between 12­Step Self­Help Groups and Interpersonal Process Groups ...... 4 2­1 Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models ...... 11 2­2 Characteristics of Five Group Models Used in Substance Abuse Treatment ...... 13 2­3 Group Vignette: Joe’s Argument With His Roommate...... 26 2­4 Joe’s Case in an Individually Focused Group ...... 27 2­5 Joe’s Case in an Interpersonally Focused Group ...... 28 2­6 Joe’s Case in a Group­As­A­Whole Focused Group...... 29 2­7 The SageWind Model for Group Therapy...... 33 3­1 Eco­Map ...... 38 3­2 Client Placement by Stage of Recovery ...... 43 3­3 Client Placement Based on Readiness for Change...... 44 3­4 What Is Culture? ...... 45 3­5 Diversity Wheel ...... 46 3­6 When Group Norms and Cultural Values Conflict ...... 48 3­7 Three Resources on Culture and Ethnicity ...... 48 3­8 Guidelines for Clinicians on Evaluating Bias and Prejudice...... 49 3­9 Self­Assessment Guide ...... 50 3­10 Preparing the Group for a New Member From a Racial/Ethnic Minority...... 54 3­11 Culture and the Perception of Conflict ...... 57 4­1 Characteristics of Fixed and Revolving Membership Groups...... 62 4­2 The Family Care Program of the Duke Addictions Program ...... 66 4­3 SageWind...... 67 4­4 Examples of Agreements About Time and Attendance ...... 69 4­5 Examples of Agreements About Group Participation...... 71 4­6 Reminders for Each Group Session ...... 74 6­1 Shame ...... 95 6­2 Confidentiality and 42 C.F.R., Part 2 ...... 110 6­3 Jody’s Arm ...... 121 7­1 How Important Is It for a Substance Abuse Group Leader To Be in Recovery?...... 126 7­2 Does Online Communication Impede Attachment? ...... 132 7­3 Group Experiential Training ...... 133

Contents v

What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic-specific best-practice guidelines for the prevention and treat- ment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. If research supports a particular approach, citations are provided. When no citation is provided, the information is based on the collective clinical knowledge and experience of the consensus panel.

vii

Consensus Panel

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the individual's current affiliation.

Chair Charles Garvin, Ph.D. Professor of Social Work Philip J. Flores, Ph.D., COP, FAGPA School of Social Work Adjunct Clinical Supervisor University of Michigan Department of Psychology Ann Arbor, Michigan Georgia State University Atlanta, Georgia Panelists Co­Chair Marilyn Joan Freimuth, Ph.D. Psychologist/Faculty Member Jeffrey M. Georgi, M.Div., CGP, CSAC, The Fielding Institute LPC, CCS Bedford, New York Clinical Director Department of Behavioral Science Barbara Hardin-Perez, Ph.D. Duke School of Nursing and Duke University Director Medical Center Student Health and Mental Health Services Senior Clinician St. Mary’s University Duke Addictions Program San Antonio, Texas Duke University Medical Center Durham, North Carolina Frankie D. Lemus, Jr., M.A. Clinical Director Workgroup Leaders SageWind (Oikos, Inc.) Reno, Nevada David W. Brook, M.D., CGP Department of Community and Preventive Marilynn Morrical, CCDN, NCACII Medicine (Deceased 2002) Mount Sinai Medical Center Alcohol, Tobacco, and Drug Consultant New York, New York Marilynn Morrical Consulting and Rehabilitation Frederick Bruce Carruth, Ph.D., LCSW Reno, Nevada Private Practice Boulder, Colorado Tam K. Nguyen, M.D., LMSW, CCJS, DVC, MAC Sharon D. Chappelle, Ph.D., M.S.W., LCSW President President Employee & Family Resources Chief Executive Officer Polk City, Iowa Chappelle Consulting and Training Services, Inc. Candace M. Shelton, M.S., CADAC Middletown, Connecticut Clinical Director Native American Connections, Inc. David E. Cooper, Ph.D. Tucson, Arizona Psychologist/Psychoanalyst Chestnut Lodge Hospital Darren C. Skinner, Ph.D., LSW, CAC Chevy Chase, Maryland Director Gaudenzia, Inc. Gaudenzia House West Chester West Chester, Pennsylvania ix Judith S. Tellerman, Ph.D., MAT, M.Ed., Marsha Lee Vannicelli, Ph.D., FAGPA CGP Associate Clinical Professor Assistant Clinical Professor Department of Psychiatry College of Medicine Harvard Medical School University of Illinois Belmont, Massachusetts Chicago, Illinois

x Consensus Panel KAP Expert Panel and Federal Government Participants

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the individual's current affiliation.

Barry S. Brown, Ph.D. Renata J. Henry, M.Ed. Adjunct Professor Director University of North Carolina at Wilmington Division of Alcoholism, Drug Abuse, Carolina Beach, North Carolina and Mental Health Delaware Department of Health and Social Jacqueline Butler, M.S.W., LISW, LPCC, Services CCDC III, CJS New Castle, Delaware Professor of Clinical Psychiatry College of Medicine Joel Hochberg, M.A. University of Cincinnati President Cincinnati, Ohio Asher & Partners Los Angeles, California Deion Cash Executive Director Jack Hollis, Ph.D. Community Treatment and Correction Associate Director Center, Inc. Center for Health Research Canton, Ohio Kaiser Permanente Portland, Oregon Debra A. Claymore, M.Ed.Adm. Owner/Chief Executive Officer Mary Beth Johnson, M.S.W. WC Consulting, LLC Director Loveland, Colorado Addiction Technology Transfer Center University of Missouri—Kansas City Carlo C. DiClemente, Ph.D. Kansas City, Missouri Chair Department of Psychology Eduardo Lopez, B.S. University of Maryland Baltimore County Executive Producer Baltimore, Maryland EVS Communications Washington, DC Catherine E. Dube, Ed.D. Independent Consultant Holly A. Massett, Ph.D. Brown University Academy for Educational Development Providence, Rhode Island Washington, DC Jerry P. Flanzer, D.S.W., LCSW, CAC Diane Miller Chief, Services Chief Division of Clinical and Services Research Scientific Communications Branch National Institute on Drug Abuse National Institute on Alcohol Abuse Bethesda, Maryland and Alcoholism Bethesda, Maryland Michael Galer, D.B.A., M.B.A., M.F.A. Independent Consultant Westminster, Massachusetts

xi Harry B. Montoya, M.A. Consulting Members President/Chief Executive Officer of the KAP Expert Panel Hands Across Cultures Espanola, New Mexico Paul Purnell, M.A. Vice President Richard K. Ries, M.D. Social Solutions, L.L.C. Director/Professor Potomac, Maryland Outpatient Mental Health Services Dual Disorder Programs Scott Ratzan, M.D., M.P.A., M.A. Seattle, Washington Academy for Educational Development Washington, DC Gloria M. Rodriguez, D.S.W. Research Scientist Thomas W. Valente, Ph.D. Division of Addiction Services Director, Master of Public Health Program NJ Department of Health and Senior Services Department of Preventive Medicine Trenton, New Jersey School of Medicine University of Southern California Everett Rogers, Ph.D. Alhambra, California Center for Communications Programs Johns Hopkins University Patricia A. Wright, Ed.D. Baltimore, Maryland Independent Consultant Baltimore, Maryland Jean R. Slutsky, P.A., M.S.P.H. Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, Maryland Nedra Klein Weinreich, M.S. President Weinreich Communications Canoga Park, California Clarissa Wittenberg Director Office of Communications and Public Liaison National Institute of Mental Health Kensington, Maryland

xii KAP Expert Panel and Federal Government Participants Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of sub- stance abuse and mental illness on America's communities by providing evidence-based and best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementa- tion requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. Field reviewers then review and critique this panel’s work.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behav- ioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field. Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration Daryl W. Kade Acting Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

xiii

Executive Summary

With the recognition of addiction as a major health problem in this country, demand has increased for effective treatments of substance use disorders. Because of its effectiveness and economy of scale, group therapy has gained popularity, and the group approach has come to be regarded as a source of powerful curative forces that are not always experienced by the client in individual therapy. One reason groups work so well is that they engage therapeutic forces—like affiliation, support, and peer confrontation—and these properties enable clients to bond with a culture of recovery. Another advantage of group modalities is their effectiveness in treating problems that accompany addiction, such as depression, isolation, and shame.

Groups can support individual members in times of pain and trouble, and they can help people grow in ways that are healthy and creative. Formal therapy groups can be a compelling source of persuasion, stabilization, and support. In the hands of a skilled, well­trained group leader, the potential healing pow­ ers inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer reinforcement, act as a forum for self­expression, and teach new social skills. In short, group therapy can provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual ther­ apy.

Group therapy and addiction treatment are natural allies. One reason is that people who abuse sub­ stances are often more likely to stay sober and committed to abstinence when treatment is provided in groups, apparently because of rewarding and therapeutic benefits like affiliation, confrontation, support, gratification, and identification. This capacity of group therapy to bond patients to treatment is an impor­ tant asset because the greater the amount, quality, and duration of treatment, the better the client’s prog­ nosis (Leshner 1997; Project MATCH Research Group 1997).

The primary audience for this TIP is substance abuse treatment counselors; however, the TIP should be of interest to anyone who wants to learn more about group therapy. The intent of the TIP is to assist counselors in enhancing their therapeutic skills in regard to leading groups.

The consensus panel for this TIP drew on its considerable experience in the group therapy field. The panel was composed of representatives from all of the disciplines involved in group therapy and substance abuse treatment, including alcohol and drug counselors, group therapists, mental health providers, and State government representatives.

This TIP comprises seven chapters. Chapter 1 defines therapeutic groups as those with trained leaders and a primary intent to help people recover from substance abuse. It also explains why groups work so well for treating substance abuse.

xv Chapter 2 describes the purpose, main charac­ ly because substance abuse treatment profes­ teristics, leadership, and techniques of five sionals commonly use the term “substance group therapy models, three specialty groups, abuse” to describe any excessive use of addic­ and groups that focus on solving a single tive substances. In this TIP, the term refers to problem. the use of alcohol as well as other substances of abuse. Readers should attend to the context in Chapter 3 discusses the many considerations which the term occurs in order to determine that should be weighed before placing a client what possible range of meanings it covers; in in a particular group, especially keying the most cases, however, the term will refer to all group to the client’s stage of change and stage varieties of substance use disorders described of recovery. This chapter also concentrates on by DSM­IV. issues that arise from client diversity. The sections that follow summarize the content Chapter 4 compares fixed and revolving types in this TIP and are grouped by chapter. of therapy groups and recommends ways to prepare clients for participation: pregroup interviews, retention measures, and most Groups and Substance important, group agreements that specify clients’ expectations of each other, the leader, Abuse Treatment and the group. Chapter 4 also specifies the Because human beings by nature are social tasks that need to be accomplished in the early, beings, group therapy is a powerful therapeutic middle, and late phases of group development. tool that is effective in treating substance abuse. The therapeutic groups described in this Chapter 5 turns to the stages of treatment. In TIP are those groups that have trained leaders the early, middle, and late stages of treatment, and a specific intent to treat substance abuse. clients’ conditions will differ, requiring differ­ This definition excludes self­help groups like ent therapeutic strategies and approaches to Alcoholics Anonymous and Narcotics leadership. Anonymous. Chapter 6 is the how­to segment of this TIP. It Group therapy has advantages over other explains the characteristics, duties, and con­ modalities. These include positive peer sup­ cepts important to promote effective group port; a reduction in clients’ sense of isolation; leadership in treating substance abuse, includ­ real­life examples of people in recovery; help ing how confidentiality regulations for alcohol from peers in coping with substance abuse and and drug treatment apply to group therapy. other life problems; information and feedback Chapter 7 highlights training opportunities from peers; a substitute family that may be available to substance abuse treatment profes­ healthier than a client’s family of origin; social sionals. The chapter also recommends the skills training and practice; peer confrontation; supervisory group as an added measure that a way to help many clients at one time; struc­ improves group leadership and gives counselors ture and discipline often absent in the lives of in the group insights about how clients may people abusing substances; and finally, the experience groups. hope, support, and encouragement necessary to break free from substance abuse. Throughout this TIP, the term “substance abuse” has been used to refer to both sub­ stance abuse and substance dependence (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision [DSM­IV­TR] [American Psychiatric Association 2000]). This term was chosen part­

xvi Executive Summary Groups Commonly Appropriate placement begins with a thorough assessment of the client’s needs, desires, and Used in Substance ability to participate. Evaluators rely on forms Abuse Treatment and interviews to determine the client’s level of interpersonal functioning, motivation to Five group models are common in substance abstain, stability, stage of recovery, and expec­ abuse treatment: tation of success in the group.

•Psychoeducational groups, which educate Most clients can function in a group that is het­ clients about substance abuse erogeneous, that is, members may be mixed in •Skills development groups, which cultivate age, gender, culture, and so on. What is essen­ the skills needed to attain and sustain absti­ tial, however, is that all clients in a group nence, such as those needed to manage anger should have similar needs. Some clients, such or cope with urges to use substances as those with a severe personality disorder, will need to be placed in homogeneous groups, in •Cognitive–behavioral groups, which alter which members are alike in some way other thoughts and actions that lead to substance than their dependence problem. Such groups abuse may include people of a particular ethnicity, all •Support groups, which buoy members and women, or a particular age group. provide a forum to share pragmatic informa­ tion about maintaining abstinence and man­ Some clients probably are not suitable for aging day­to­day, chemical­free life certain groups, or group therapy in general, •Interpersonal process groups, which delve including into major developmental issues that con­ •People who refuse to participate tribute to addiction or interfere with recovery •People who cannot honor group agreements, Three other specialized types of groups that do including preserving privacy and confiden­ not fit neatly into the five­model classification tiality of group members in accordance with nonetheless are common in substance abuse the Federal regulations (42 C.F.R., Part 2) treatment. They are designed specifically to •People who make the therapist very uncom­ prevent relapse, to bring a specific culture’s fortable healing practices to bear on substance abuse, •People who are prone to dropping out or who or to use some form of art to express thoughts continually violate group norms that otherwise would be difficult to communi­ cate. Groups also can be formed to help clients •People in the throes of a life crisis who share a specific problem, such as anger or •People who cannot control impulses shyness, that contributes to their substance •People who experience severe internal abuse. discomfort in groups Professional judgment is also essential and Criteria for the should consider characteristics such as sub­ Placement of Clients stances abused, duration of use, treatment setting, and the client’s stage of recovery. For in Groups example, a client in a maintenance stage may Not everyone is suited to every kind of group. need to acquire social skills for interacting in Moreover, because recovery is a long, nonlin­ new ways, address emotional difficulties, or ear process, the type of therapy chosen always become reintegrated into a community or should be subject to re­evaluation. culture of origin. Ethnicity and culture can have a profound effect on treatment. The greater the mix of

Executive Summary xvii ethnicities in a group, the more likely it is that •Stability biases will emerge and require mediation. •Stage of recovery Special attention may be warranted, too, if •Expectation of success clients do not speak English fluently because they may be unable to follow a fast­flowing Throughout the initial group therapy sessions, discussion. Programs should ensure that group clients are particularly vulnerable to relapse members are fluent in the language for their and discontinuation of treatment. The first specific demographic area, which may or may month appears to be especially critical not be English. Further, while it might be desir­ (Margolis and Zweben 1998). Retention rates able to match the group leader and all group in a group are enhanced by client preparation, members ethnically, the reality is that it is sel­ maximum client involvement, feedback, dom feasible. Thus, it is crucial for the group prompts to encourage attendance, and the pro­ leader to understand how ethnicity affects vision of wraparound services (such as child substance abuse and group participation. care and transportation). The timing and duration of groups also affect retention. Group Development While group leaders have many responsibilities and Phase­Specific in preparing clients for participation in groups, clients have obligations, too. A group agree­ Tasks ment establishes the expectations that group members have of each other, the leader, and Group membership may be fixed, with a stable the group itself. It specifies the circumstances and relatively small number of clients. under which clients may be barred from group Alternatively, membership may revolve, with and explains policies regarding confidentiality, new members entering a group when they are physical contact, substance use, contact outside ready for the service it provides. Either type the group, group participation, financial can run indefinitely or for a set time. responsibility, and termination. A group mem­ The preparation of clients for group participa­ ber’s acceptance of the contract prior to enter­ tion commences when the group leader meets ing a group has been described as the single individually with each prospective group mem­ most important factor contributing to the suc­ ber to begin to form a therapeutic alliance, cess of outpatient therapy groups. reach consensus on what is to be accomplished The tasks in the beginning phase of a group in therapy, educate the client about group ther­ include introductions, review of the group apy, allay anxiety related to joining a group, agreement, establishment of an emotionally and explain the group agreement. In these pre­ safe environment and positive group norms, group interviews, it is important to be sensitive and focusing the group toward its work. In the to people who differ significantly from the rest middle phase, clients interact, rethink their of the group whether by age, ethnicity, gender, behaviors, and move toward productive disorder, and so on. It is important to assure change. The end phase concentrates on reach­ clients that a difference is not a deficit and can ing closure. be a source of vitality for the group.

Selection of group members is based on the client’s fit with a specific group modality. Stages of Treatment Considerations include the client’s As clients move through different stages of recovery, treatment must move with them. That •Level of interpersonal functioning, including is, therapeutic strategies and leadership roles impulse control will change with the condition of the clients. •Motivation to abstain from drug or alcohol abuse In the early phase of treatment clients tend to be ambivalent about ending substance use,

xviii Executive Summary rigid in their thinking, and limited in their abil­ identity, confidence, spontaneity, integrity, ity to solve problems. Resistance is a challenge trust, humor, and empathy. for the group leader at this time. Leaders should be able to The art of treating addiction in the early phase is in the defeat of denial and resistance. Groups •Adjust their professional styles to the are especially effective at this time since people particular needs of different groups with dependencies often have had adversarial •Model group­appropriate behaviors relationships with people in authority. Thus, •Resolve issues within ethical dimensions information from peers in a group is more •Manage emotional contagion easily accepted than that from a lone therapist. •Work only within modalities for which they People with addictions remain vulnerable are trained during the middle phase of treatment. Though •Prevent the development of rigid roles in the cognitive capacity usually begins to return to group normal, the mind can still play tricks. Clients •Avoid acting in different roles inside and out­ may remember distinctly the comfort of their side the group past use of substances, yet forget just how bad the rest of their lives were. Consequently, the •Motivate clients in substance abuse treatment temptation to relapse remains a concern. •Ensure emotional safety in the group Because people with dependencies usually are •Maintain a safe therapeutic setting (which isolated from healthy social groups, the group involves deflecting defensive behavior with­ helps to acculturate clients into a culture of out shaming the offender, recognizing and recovery. The leader draws attention to posi­ countering the resumption of substance use, tive developments, points out how far clients and protecting physical boundaries according have traveled, and affirms the possibility of to group agreements) increased connection and new sources of satisfaction. •Curtail emotion when it becomes too intense for group members to tolerate In the late phase of treatment clients are stable •Stimulate communication among group enough to face situations that involve conflict members or deep emotion. A process­oriented group may become appropriate for some clients who final­ Key concepts and techniques used in group ly are able to confront painful realities, such as therapy for substance abuse follow. being an abused child or an abusive parent. Other clients may need groups to help them Interventions are any action by a leader to build a healthier marriage, communicate more intentionally affect the processes of the group. effectively, or become a better parent. Some Interventions may be used, for example, to may want to develop new job skills to increase clarify understanding, redirect energy, or stop employability. a damaging sequence of interactions. Effective leaders do not overdo intervention. To do so would result in a leader­centered group, which Group Leadership, is undesirable because in therapy groups, the healing comes from the connections forged Concepts, and between group members. One type of interven­ Techniques tion, confrontation, deftly points out inconsis­ tencies in clients’ thinking. Effective group leadership requires a constellation of specific personal qualities and Confidentiality restricts the information that professional practices. The personal qualities providers can reveal about clients and that necessary are constancy, active listening, firm clients may reveal about each other. Group

Executive Summary xix leaders and clients should understand the exact Training and provisions of this important boundary. Supervision Diversity plays a highly important role in National professional organizations are a rich group therapy, for it may affect critical aspects source of training. Through conferences or of the process, such as what clients expect of regional chapters, national associations provide the leader and how clients may interpret other training—both experiential and direct instruc­ clients’ behavior. Clinicians should be open to tion—geared to the needs of a wide range of learning about other belief systems, should not persons, from graduate students to highly expe­ assume that every person from a specific group rienced therapists. More training options are shares the same characteristics, and should usually available in large urban areas. It is avoid appearing as if they are trying to persuade likely, however, that online training will make clients to renounce their cultural characteristics. some types of professional development accessi­ Many people in treatment for substance abuse ble to a greater number of counselors in remote have other complex problems, such as co­ areas. occurring mental disorders, homelessness, or Clinical supervision as it pertains to group involvement with the criminal justice system. therapy often is best carried out within the con­ For many clients, group therapy may be one text of group supervision. Group dynamics and element in a larger plan that also marshals group process facilitate learning by setting up a biopsychosocial and spiritual interventions to microcosm of a larger social environment. Each address important life issues and restore faith group member’s style of interaction will or belief in some force beyond the self. inevitably show up in the group transactions. Integrated care from diverse sources requires As this process unfolds, group members, guid­ cooperation with other healthcare providers. ed by the supervisor, learn to model effective For example, it is critical that all providers behavior in an accepting group context. working with clients with multiple disorders Supervisory groups reduce, rather than esca­ know what medications they are taking and why. late, the level of threat that can accompany Two aspects of group management relate to supervision. In place of isolation and alien­ conflict and subgroups. Properly managed, ation, group participation gives counselors a conflict can promote learning about respect for sense of community. They find that others different viewpoints, managing emotions, and share their worries, fears, frustrations, tempta­ negotiation. Part of the therapist’s job as a tions, and ambivalence. This reassurance is of conflict manager is to reveal covert conflicts particular benefit to novice group counselors. and expose repetitive and predictable argu­ ments. The therapist also reveals covert sub­ groups and intervenes to reconfigure negative subgroups that threaten the group’s progress.

Various types of disruptive behavior may require the group leader’s attention. Such problems include clients who talk nonstop, interrupt, flee a session, arrive late or skip ses­ sions, decline to participate, or speak only to the problems of others. The leader also should have skills to handle people with psychological emergencies or people who are anxious about disclosing personal information.

xx Executive Summary 1 Groups and Substance Abuse Treatment Overview In This The natural propensity of human beings to congregate makes group therapy a powerful therapeutic tool for treating substance abuse, one Chapter… that is as helpful as individual therapy, and sometimes more successful. One reason for this efficacy is that groups intrinsically have many Introduction rewarding benefits—such as reducing isolation and enabling members to witness the recovery of others—and these qualities draw clients into Defining a culture of recovery. Another reason groups work so well is that they Therapeutic are suitable especially for treating problems that commonly accompany Groups in substance abuse, such as depression, isolation, and shame. Substance Abuse Treatment Although many groups can have therapeutic effects, this TIP concen­ trates only on groups that have trained leaders and that are designed to Advantages of promote recovery from substance abuse. Great emphasis is placed on Group Treatment interpersonal process groups, which help clients resolve problems in Modifying Group relating to other people, problems from which they have attempted to Therapy To Treat flee by means of addictive substances. While this TIP is not intended Substance Abuse as a training manual for individuals training to be group therapists, it provides substance abuse counselors with insights and information that Approach of can improve their ability to manage the groups they currently lead. This TIP Introduction The lives of individuals are shaped, for better or worse, by their experi­ ences in groups. People are born into groups. Throughout life, they join groups. They will influence and be influenced by family, religious, social, and cultural groups that constantly shape behavior, self­image, and both physical and mental health.

Groups can support individual members in times of pain and trouble, and they can help people grow in ways that are healthy and creative. However, groups also can support deviant behavior or influence an individual to act in ways that are unhealthy or destructive.

1 Because our need for human contact is biologi­ The effectiveness of group therapy in the treat­ cally determined, we are, from the start, social ment of substance abuse also can be attributed creatures. This propensity to congregate is a to the nature of addiction and several factors powerful therapeutic tool. Formal therapy associated with it, including (but not limited to) groups can be a compelling source of persua­ depression, anxiety, isolation, denial, shame, sion, stabilization, and support. Groups orga­ temporary cognitive impairment, and charac­ nized around therapeutic goals can enrich ter pathology (personality disorder, structural members with insight and guidance; and during deficits, or an uncohesive sense of self). times of crisis, groups can comfort and guide Whether a person abuses substances or not, people who otherwise might be unhappy or these problems often respond better to group lost. In the hands of a skilled, well­trained treatment than to individual therapy (Kanas group leader, the potential curative forces 1982; Kanas and Barr 1983). Group therapy is inherent in a group can be harnessed and also effective because people are fundamentally directed to foster healthy attachments, provide relational creatures. positive peer rein­ forcement, act as a forum for self­ Defining Therapeutic expression, and Groups in Substance Groups provide teach new social skills. In short, Abuse Treatment group therapy can positive peer All groups can be therapeutic. Anytime some­ provide a wide range one becomes emotionally attached to other of therapeutic ser­ support and group members, a group leader, or the group vices, comparable as a whole, the relationship has the potential to in efficacy to those influence and change that person. Identifying a pressure to abstain delivered in individ­ group as “therapy” does not imply that other ual therapy. In some groups are not therapeutic. In preparing this from substances cases, group therapy TIP, the consensus panel debated at length can be more benefi­ what constitutes “group therapy” and what of abuse. cial than individual distinguishes therapy groups from other types therapy (Scheidlinger of groups. 2000; Toseland and Siporin 1986). Although many types of groups can have thera­ peutic elements and effects, the group types Group therapy and addiction treatment are included in this TIP are based on the goals and natural allies. One reason is that people who intentions of the groups, as well as the intended abuse substances often are more likely to audience of the TIP (especially substance abuse remain abstinent and committed to recovery treatment counselors and other substance when treatment is provided in groups, appar­ abuse treatment professionals). Thus, this TIP ently because of rewarding and therapeutic is limited to groups that (1) have trained lead­ forces such as affiliation, confrontation, sup­ ers and (2) intend to produce some type of port, gratification, and identification. This healing or recovery from substance abuse. This capacity of group therapy to bond patients to TIP describes (in chapter 2) five models of treatment is an important asset because the group therapy currently used in substance greater the amount, quality, and duration of abuse treatment: treatment, the better the client’s prognosis (Leshner 1997; Project MATCH Research •Psychoeducational groups, which teach about Group 1997). substance abuse.

2 Groups and Substance Abuse Treatment •Skills development groups, which hone the achieve that purpose. Figure 1­1 (see p. 4) skills necessary to break free of addictions. shows other differences between self­help •Cognitive–behavioral groups, which rear­ groups and interpersonal process groups. In range patterns of thinking and action that most aspects, the comparison would apply to lead to addiction. the other four group models as well. •Support groups, which comprise a forum where members can debunk each other’s Advantages of Group excuses and support constructive change. •Interpersonal process group psychotherapy Treatment (referred to hereafter as “interpersonal pro­ Treating adult clients in groups has many cess groups” or “therapy groups”), which advantages, as well as some risks. Any treat­ enable clients to recreate their pasts in the ment modality—group therapy, individual here­and­now of group and rethink the rela­ therapy, family therapy, and medication—can tional and other life problems that they have yield poor results if applied indiscriminately or previously fled by means of addictive sub­ administered by an unskilled or improperly stances. trained therapist. The potential drawbacks of group therapy, however, are no greater than Treatment providers routinely use the first four for any other form of treatment. models and various combinations of them. The last is not as widely used, chiefly because of the Some of the numerous advantages to using extensive training required to lead such groups groups in substance abuse treatment are and the long duration of the groups, which described below (Brown and Yalom 1977; demands a high degree of commitment from Flores 1997; Garvin unpublished manuscript; both providers and clients. All the same, many Vannicelli 1992). people enter substance abuse treatment with a long history of failed relationships exacerbated •Groups provide positive peer support and by substance use. In these cases, an extended pressure to abstain from substances of abuse. period of therapy is warranted to resolve the Unlike AA, and, to some degree, substance client’s problems with relationships. The reality abuse treatment program participation, that extended treatment is not always feasible group therapy, from the very beginning, elic­ does not negate its desirability. its a commitment by all the group members to attend and to recognize that failure to attend, This TIP does not discuss multifamily and mul­ to be on time, and to treat group time as spe­ ticouple groups, which are discussed in TIP 39, cial disappoints the group and reduces its Substance Abuse Treatment and Family effectiveness. Therefore, both peer support Therapy (Center for Substance Abuse and pressure for abstinence are strong. Treatment 2004). Even though multifamily and •Groups reduce the sense of isolation that multicouple groups typically are made up of most people who have substance abuse disor­ unrelated groups of families, they focus on ders experience. At the same time, groups family relations as they affect and are affected can enable participants to identify with oth­ by a member with a substance use disorder. ers who are struggling with the same issues. This TIP concentrates on therapy groups, Although AA and treatment groups of all which have a distinctively different focus. types provide these opportunities for sharing, for some people the more formal and deliber­ Also outside the scope of this TIP is the use of ate nature of participation in process group peer­led self­help groups such as Alcoholics therapy increases their feelings of security Anonymous (AA) or group activities like social and enhances their ability to share openly. events, religious services, sports, and games. Any or all may have one or more therapeutic •Groups enable people who abuse substances effects, but are not specifically designed to to witness the recovery of others. From this

Groups and Substance Abuse Treatment 3 Figure 1­1

Differences Between 12­Step Self­Help Groups and Interpersonal Process Groups Self-Help Group Interpersonal Process Group Size Unlimited (often large) Small (8–15 members) • Peer leader or individual in recovery • Trained professional • Leadership is earned over time • Appointed leader Leadership • Implicit hierarchical leadership • Formal hierarchical leadership structure structure Participation Voluntary Voluntary and involuntary

Group Self­governing Leader governed Government • Environmental factors, no • Examination of intragroup behavior examination of group interaction and extragroup factors • Emphasis on similarities among • Emphasis on differences and Content members similarities among members • Here­and­now focus • Here­and­now focus plus historical focus

Screening None Always Interview Universality, empathy, affective sharing, Cohesion, mutual identification, self­disclosure (public statement of education, catharsis, use of group Group problem), mutual affirmation, morale pressure to encourage abstinence Processes building, catharsis, immediate positive and retention of group membership, feedback, high degree of persuasiveness outside socialization (depending on the group contract or agreement) • Positive goal setting, behaviorally • Ambitious goals: immediate problem Group oriented plus individual personality issues Goals • Focus on the group as a whole and • Individual as well as group focus the similarities among members • Educator/role model, catalyst • Responsible for directing Leader for learning therapeutic group experience Activity • Less member­to­leader distance • More member­to­leader distance

Use of Psycho- No Yes dynamic Techniques Anonymity strongly emphasized and Confiden- Anonymity preserved includes everything that occurs in the tiality group, not just the identity of group members

4 Groups and Substance Abuse Treatment Self-Help Group Interpersonal Process Group Sponsorship Program Yes (usually same sex) None • Members may leave group at their own • Predetermined minimal term of group Determina- choosing membership tion of Time in Group • Members may avoid self­disclosure or • Avoidance of discussion seen as discussion of any subject possible “resistance”

Involvement Yes—eclectic models in Other Yes Therapies No—psychodynamic models Time Unlimited group participation possible Often time­limited group experiences Factors over years Frequency Active encouragement of daily Meets less frequently (often once or of Meetings participation twice weekly)

Source: Adapted from Spitz 2001. Used with permission.

inspiration, people who are addicted to cantly during different stages of treatment substances gain hope that they, too, can and recovery and often reveals the set of maintain abstinence. Furthermore, an inter­ traits that makes the system of a person’s self personal process group, which is of long as altogether unique. duration, allows a magnified witnessing of •Groups provide feedback concerning the both the changes related to recovery as well values and abilities of other group members. as group members’ intra­ and interpersonal This information helps members improve changes. their conceptions of self or modify faulty, • Groups help members learn to cope with distorted conceptions. In terms of process their substance abuse and other problems by groups in particular, as specific themes allowing them to see how others deal with emerge in a client’s group experience, repeti­ similar problems. Groups can accentuate this tive feedback from multiple group members process and extend it to include changes in and the therapist can chip away at those how group members relate to bosses, parents, faulty or distorted conceptions in slightly spouses, siblings, children, and people in different ways until they not only are general. correctable, but also the very process of •Groups can provide useful information to correction and change is revealed through clients who are new to recovery. For exam­ the examination of the group processes. ple, clients can learn how to avoid certain •Groups offer family­like experiences. Groups triggers for use, the importance of abstinence can provide the support and nurturance that as a priority, and how to self­identify as a may have been lacking in group members’ person recovering from substance abuse. families of origin. The group also gives mem­ Group experiences can help deepen these bers the opportunity to practice healthy ways insights. For example, self­identifying as a of interacting with their families. person recovering from substance abuse can be a complex process that changes signifi­

Groups and Substance Abuse Treatment 5 •Groups encourage, coach, support, and Modifying Group reinforce as members undertake difficult or anxiety­provoking tasks. Therapy To Treat •Groups offer members the opportunity to Substance Abuse learn or relearn the social skills they need to Modifying group therapy to make it applicable cope with everyday life instead of resorting to to and effective with clients who abuse sub­ substance abuse. Group members can learn stances requires three improvements. One is by observing others, being coached by oth­ specific training and education for therapists so ers, and practicing skills in a safe and sup­ that they fully understand therapeutic group portive environment. work and the special characteristics of clients •Groups can effectively confront individual with substance use disorders. The importance members about substance abuse and other of understanding the curative process that harmful behaviors. Such encounters are occurs in groups cannot be underestimated. possible because groups speak with the com­ bined authority of people who have shared Most substance abuse counselors have respond­ common experiences and common problems. ed by adapting skills used in individual therapy. Confrontation often plays a part of substance Counselors have also sought direction, clinical abuse treatment groups because group training, and practical suggestions. Despite members tend to deny their problems. individual efforts, however, group therapy often Participating in the confrontation of one is conducted as individual therapy in a group. group member can help others recognize and defeat their own denial. Individual therapy is not equivalent to group therapy. Some principles that work well with •Groups allow a single treatment professional individuals are inappropriate for group therapy. to help a number of clients at the same time. Using the wrong approach may lead to several In addition, as a group develops, each group undesirable results. First, the rich potential of member eventually becomes acculturated to groups––self­understanding, psychological group norms and can act as a quasi­therapist growth, emotional healing, and true intimacy–– himself, thereby ratifying and extending the will be left unfulfilled. Second, group leaders treatment influence of the group leader. who are unfamiliar with and insensitive to •Groups can add needed structure and disci­ issues that manifest themselves in group thera­ pline to the lives of people with substance use py may find themselves in a difficult situation. disorders, who often enter treatment with Third, therapists who think they are doing their lives in chaos. Therapy groups can group therapy when they actually are not may establish limitations and consequences, which observe the poor results and conclude that can help members learn to clarify what is group therapy is ineffective. Compounding all their responsibility and what is not. these difficulties is the fact that group therapy •Groups instill hope, a sense that “If he can is so ubiquitous. Thus, poorly conceived make it, so can I.” Process groups can approaches are being used frequently. expand this hope to dealing with the full Group therapy also is not equivalent to 12­Step range of what people encounter in life, program practices. Many therapists who lack overcome, or cope with. full qualifications for group work have adapted •Groups often support and provide encourage­ practices from AA and other 12­Step programs ment to one another outside the group set­ for use in therapeutic groups. To say that this ting. For interpersonal process groups, borrowing is inadvisable is not to say that the though, outside contacts may or may not be principles of AA are inadequate. On the con­ disallowed, depending on the particular trary, many people seem to be unable to recov­ group contract or agreements. er from dependency without AA or a program

6 Groups and Substance Abuse Treatment similar to it. For this reason, most effective A second major improvement needed if people treatment programs make attendance at AA or who have addictions are to benefit from group another 12­Step program a mandatory part of therapy is a clear answer to the question, the treatment process. By the same token, AA “Why is group therapy so effective for people and other 12­Step programs are not group with addictions?” We already have part of the therapy. Rather, they are complementary com­ answer, and it lies in the individual with addic­ ponents to the recovery process. Twelve­Step tion, a person whose character style often programs can help keep the individual who involves a defensive posture commonly referred abuses substances abstinent while group thera­ to as denial. Addiction is, in fact, frequently py provides opportunities for these individuals referred to as a disease of denial. to understand and explore the emotional and interpersonal conflicts that can contribute to The individual who is substance abuse. chemically dependent usually comes into Progress toward optimal group therapy has treatment with an also been hindered by the misconception that uncommonly complex Groups instill group therapy with clients who have addictions set of defenses and does not require specially qualified leaders. character pathology. hope, a sense that This notion is false. Therapy groups cannot Any group leader who just take care of themselves. Group therapy, intends to help people properly conducted, is difficult. One reason who have addictions “If he can make it, that it is challenging has to do with the nature benefit from treat­ of the clients; an addicted population poses ment should have a so can I.” unique problems for the group therapy leader. clear understanding A second reason is the complexity of group of each group mem­ therapy; the leader requires a vast amount of ber’s defensive pro­ specialized knowledge and skills, including a cess and character clear understanding of group process and the dynamics. More than stages of development of group dynamics. Such 20 years ago, John Wallace (1978) wrote about mastery only comes with extended training and this important issue in an informative essay on experience leading groups. the defensive style of the individual who is addicted to alcohol. He referred to these char­ Many groups led by untrained or poorly acter­related defensive features as the pre­ trained leaders have not fulfilled their potential ferred defense system of the individual addict­ and may even have had negative effects on a ed to alcohol. client’s recovery. It matters little whether the inadequately trained group therapist is a per­ A third major modification needed is the adap­ son who once abused substances or someone tation of the group therapy model to the treat­ who developed knowledge in a traditional ment of substance abuse. The principles of course of academically based training. Where group therapy need to be tailored to meet the problems exist, they usually relate to one of two realities of treating clients with substance use deficiencies: a lack of effective group therapy disorders. training or use of a group therapy model that is inadequate for clients who are chemically For the most part, group therapy has been dependent. Additional training and education based on a model derived from outpatient ther­ is needed to produce therapists who are well apy for clients whose problems may or may not qualified to lead therapy groups composed pri­ include substance abuse. The theoretical marily of individuals who are chemically underpinnings and practical applications of dependent. general group therapy are not always applica­ ble to individuals who abuse substances.

Groups and Substance Abuse Treatment 7 Substance abuse treatment sometimes is imple­ A further negative result is that the clients who mented as a grab bag of strategies, approaches, have addictions may be unfairly viewed as poor and techniques that were not tailored for peo­ treatment risks—people resistant to treatment ple with substance use disorders. Further, the and unmotivated to change. common characteristics and typical dynamics seen in this population have not always been Time also is an important factor in a person’s evaluated adequately, and this lapse has inhib­ recovery. What a group leader does in group ited the development of effective methods of therapy with clients in an inpatient setting in a treatment for these clients. hospital during the first few days or weeks of recovery will differ dramatically from what This model suitability problem is further com­ that same group therapist will do with the same plicated by the fact that clients with substance recovering person in a continuing care group 6 use disorders, and even staff members, often months into abstinence with the expectation become confused about the different types of that the person will remain in the group at least group treatment modalities. For instance, in another 6 to 12 months. the course of their treatment, clients may engage in AA, Narcotics Anonymous, other 12­Step groups, discussion groups, educational Approach of This TIP groups, continuing care groups, and support While this TIP does not provide the training groups. Given this mix, clients often become needed to become an interpersonal process confused about the group therapist, the point of view, attitudes, purpose of group and considerations of these group therapists therapy, and the infuse the discussions throughout this TIP. The treatment staff some­ panel hopes that this TIP will help counselors This TIP will help times underestimates expand their awareness and comprehension the impact that of dynamics that might be going on in their counselors expand group therapy can current substance abuse treatment groups. make on an individ­ These insights will help counselors become bet­ their awareness ual’s recovery. ter prepared to manage their groups and their individual members, inform group members’ The upshot of these and comprehen­ individual therapists of possible issues that problems has been need resolution, record dynamics and issues partial or complete for use in treatment during later stages of sion of dynamics failure; that is, the recovery, and improve retention by appropri­ techniques and ately acknowledging issues that are outside the occurring in their strategies that usual­ scope of the group. The TIP will achieve its ly work with the gen­ purpose to the extent that it assists counselors treatment groups. eral psychiatric pop­ as they juggle immediate client needs, interac­ ulation often do not tions in groups, tasks leading to recovery, and work with people sheer human complexity. abusing substances.

8 Groups and Substance Abuse Treatment 2 Types of Groups Commonly Used in Substance Abuse Treatment

Overview In This This chapter presents five models of groups used in substance abuse treatment, followed by three representative types of groups that do not Chapter… fit neatly into categories, but that, nonetheless, have special significance in substance abuse treatment. Finally, groups that vary according to Five Group Models specific types of problems are considered. The purpose of the group, Psychoeducational Groups its principal characteristics, necessary leadership skills and styles, and Skills Development Groups typical techniques for these groups are described. Cognitive–Behavioral Groups Support Groups Introduction Interpersonal Process Group Psychotherapy Substance abuse treatment professionals employ a variety of group treatment models to meet client needs during the multiphase process of Specialized Groups recovery. A combination of group goals and methodology is the primary in Substance Abuse way to define the types of groups used. This TIP describes five group Treatment therapy models that are effective for substance abuse treatment: Relapse Prevention • Psychoeducational groups Communal and Culturally Specific Groups • Skills development groups Expressive Groups • Cognitive–behavioral/problemsolving groups Groups Focused on • Support groups Specific Problems • Interpersonal process groups Each of the models has something unique to offer to certain populations; and in the hands of a skilled leader, each can provide powerful thera­ peutic experiences for group members. A model, however, has to be matched with the needs of the particular population being treated; the goals of a particular group’s treatment also are an important determi­ nant of the model that is chosen.

This chapter describes the group’s purpose, principal characteristics, leadership requisites, and appropriate techniques for each type of group. Also discussed are three specialized types of groups that do not fit

9 into the five model categories, but that function •Recurrence. Many clients will relapse and as unique entities in the substance abuse treat­ return to an earlier stage, but they may move ment field: quickly through the stages of change and may have gained new insights into problems that •Relapse prevention treatment groups defeated their former attempts to quit sub­ •Communal and culturally specific treatment stance abuse (such as unrealistic goals or groups frequenting places that trigger relapse). •Expressive groups (including art therapy, For a detailed description of the stages of dance, psychodrama) change, see TIP 35, Enhancing Motivation for Figure 2­1 lists some groups commonly used in Change in Substance Abuse Treatment (Center substance abuse treatment and classifies them for Substance Abuse Treatment [CSAT] 1999b). into the five­model framework used in this TIP. The client’s stage of change will dictate which This list of groups is by no means exhaustive, group models and methods are appropriate at a but it demonstrates the variety of groups found particular time. If the group is composed of in substance abuse treatment settings. members in the action stage who have clearly Occasionally, discussions in this TIP refer to identified themselves as substance dependent, the stages of change delineated by Prochaska the group will be conducted far differently and DiClemente (1984). They examined 18 psy­ from one composed of people who are in the chological and behavioral theories of how precontemplative stage. Priorities change with change occurs, including the components of a time and experience, too. For example, a group biopsychosocial framework for understanding of people with substance use disorders on their substance abuse. Their result was a continuum second day of abstinence is very different from of six categories for understanding client moti­ a group with 1 or 2 years of sobriety. vation for changing substance abuse behavior. Theoretical orientations also have a strong The six stages are: impact on the tasks the group is trying to •Precontemplation. Clients are not thinking accomplish, what the group leader observes about changing substance abuse behavior and responds to in a group, and the types of and may not consider their substance abuse interventions that the group leader will initiate. to be a problem. Before a group model is applied in treatment, the group leader and the treating institution •Contemplation. Clients still use substances, should decide on the theoretical frameworks to but they begin to think about cutting back or be used, because each group model requires quitting substance use. different actions on the part of the group lead­ •Preparation. Clients still use substances, but er. Since most treatment programs offer a vari­ intend to stop since they have recognized the ety of groups for substance abuse treatment, it advantages of quitting and the undesirable is important that these models be consistent consequences of continued use. Planning for with clearly defined theoretical approaches. change begins. In practice, however, groups can, and usually •Action. Clients choose a strategy for discon­ do, use more than one model, as shown in tinuing substance use and begin to make the Figure 2­1. For example, a therapy group in an changes needed to carry out their plan. This intensive early recovery treatment setting might period generally lasts 3–6 months. combine elements of psychoeducation (to show •Maintenance. Clients work to sustain how drugs have ravaged the individual’s life), abstinence and evade relapse. From this skills development (to help the client maintain stage, some clients may exit substance use abstinence), and support (to teach individuals permanently. how to relate to other group members in an honest and open fashion). Therefore, the

10 Types of Groups Commonly Used in Substance Abuse Treatment Figure 2­1

Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models

Group Types æ Group Model or Combination of Models Skills Cognitive– Inter- Support Specialized Psycho- Develop- Behavioral personal Group* educa- ment Therapy Process tional Anger/feelings management • • • Co­occurring disorders • • Skills­building • • Conflict resolution • • • Relapse prevention • • • • 12­Step psychoeducational • • Psychoeducational • Trauma (abuse, violence) • • • Early recovery • • • • Substance abuse education • Spirituality­based • Cultural • • Psychodynamic • • Ceremonial healing practices • Support • Family roles (psychoeducational) • Expressive therapy • Relaxation training • Meditation • Multiple­family • • • Gender specific • • Life skills training • • Health and wellness • Cognitive–behavioral • • • Psychodrama • Adventure­based • Marathon • Humanistic/existential • •

Source: Consensus Panel. *See “Specialized Groups in Substance Abuse Treatment” on p. 29.

Types of Groups Commonly Used in Substance Abuse Treatment 11 descriptions of the groups in this chapter are of prompt people using substances to take action ideal, pure forms that rarely stand alone in on their own behalf, such as entering a treat­ practice. It must be acknowledged, too, that ment program. While psychoeducational the terms used to describe groups are not alto­ groups may inform clients about psychological gether clear­cut and consistent. In different issues, they do not aim at intrapsychic change, treatment settings, programs, and regions of though such individual changes in thinking and the country, a term like “support group” may feeling often do occur. be used to refer to different types of treatment groups, including a relapse prevention group. Purpose. The major purpose of psychoeduca­ tional groups is expansion of awareness about Despite such discrepancies between neat theory the behavioral, medical, and psychological con­ and untidy practice, little difficulty will arise if sequences of substance abuse. Another prime the group leader exercises sound clinical judg­ goal is to motivate the client to enter the recov­ ment regarding models and interventions to be ery­ready stage (Martin et al. 1996; Pfeiffer et used. One exception to this assurance, however, al. 1991). Psychoeducational groups are pro­ should be noted. Close adherence to the theory vided to help clients incorporate information that dictates the way an interpersonal process that will help them establish and maintain group should be conducted has crucial implica­ abstinence and guide them to more productive tions for its success. choices in their lives.

These groups also can be used to counteract Five Group Models clients’ denial about their substance abuse, increase their sense of commitment to contin­ Figure 2­2 summarizes the characteristics of ued treatment, effect changes in maladaptive five therapeutic group models used in sub­ behaviors (such as associating with people who stance abuse treatment. Variable factors actively use drugs), and supporting behaviors include the focus of group attention, specificity conducive to recovery. Additionally, they are of the group agenda, heterogeneity or homo­ useful in helping families understand substance geneity of group members, open­ended or abuse, its treatment, and resources available determinate duration of treatment, level of for the recovery process of family members. facilitator or leader activity, training required for the group leader, length of sessions, and Some of the contexts in which psychoeducation­ preferred arrangement of the room. al groups may be most useful are

•Helping clients in the precontemplative or Psychoeducational Groups contemplative level of change to reframe the Psychoeducational groups are designed to edu­ impact of drug use on their lives, develop an cate clients about substance abuse, and related internal need to seek help, and discover behaviors and consequences. This type of group avenues for change. presents structured, group­specific content, •Helping clients in early recovery learn more often taught using videotapes, audiocassette, or about their disorders, recognize roadblocks lectures. Frequently, an experienced group to recovery, and deepen understanding of the leader will facilitate discussions of the material path they will follow toward recovery. (Galanter et al. 1998). Psychoeducational •Helping families understand the behavior of groups provide information designed to have a a person with substance use disorder in a direct application to clients’ lives—to instill way that allows them to support the individu­ self­awareness, suggest options for growth and al in recovery and learn about their own change, identify community resources that can needs for change. assist clients in recovery, develop an under­ •Helping clients learn about other resources standing of the process of recovery, and that can be helpful in recovery, such as

12 Types of Groups Commonly Used in Substance Abuse Treatment Figure 2­2

Characteristics of Five Group Models Used in Substance Abuse Treatment

Group model Group/ Specificity of the Heterogeneous Open-ended/ Level of facili- leader focus group agenda or homogeneous determinate tator activity Psycho­ Leader Specific Either Either High educational focused Skills Leader Specific Either Either High development focused (depending on topic) Cognitive– Mixed/ Either Either Either High behavioral balanced Support Group focus Nonspecific Either Open Low to moderate Interpersonal Group focus Nonspecific Heterogeneous Open Low to process moderate Group Level of facili- Duration of Length of Space and Leader model tator activity treatment session arrangement training Psycho­ High Limited by 15 to 90 Horseshoe Basic educational program minutes or circle requirements Skills High Variable 45 to 90 Horseshoe Basic with development minutes or circle some special­ ized training Cognitive– High Variable and 60 to 90 Circle Specialized behavioral open­ended minutes training Support Low to Open­ended 45 to 90 Circle Specialized moderate minutes training with process­ oriented skills Interpersonal Low to Open­ended 1 to 2 hours Circle Specialized Process moderate training in interpersonal process groups

meditation, relaxation training, anger coping skills (such as anger management or the management, spiritual development, and use of “I” statements) normally taught in a nutrition. skills development group often accompany this Principal characteristics. Psychoeducational learning. groups generally teach clients that they need to Psychoeducational groups are considered learn to identify, avoid, and eventually master a useful and necessary, but not sufficient, com­ the specific internal states and external circum­ ponent of most treatment programs. For stances associated with substance abuse. The instance, psychoeducation might move clients

Types of Groups Commonly Used in Substance Abuse Treatment 13 in a precontemplative or perhaps contempla­ may need special considerations. Psycho­ tive stage to commit to treatment, including educational groups also have been shown to be other forms of group therapy. For clients who effective with clients with co­occurring mental enter treatment through a psychoeducational disorders, including clients with schizophrenia group, programs should have clear guidelines (Addington and el­Guebaly 1998; Levy 1997; about when members of the group are ready Pollack and Stuebben 1998). For more infor­ for other types of group treatment. mation on making accommodations for clients with disabilities, see TIP 29, Substance Use Often, a psychoedu­ Disorder Treatment for People With Physical cational group inte­ and Cognitive Disabilities (CSAT 1998b). grates skills devel­ Psychoeducational opment into its pro­ Leadership skills and styles. Leaders in psy­ gram. As part of a choeducational groups primarily assume the groups are highly larger program, roles of educator and facilitator. Still, they psychoeducational need to have the same core characteristics as structured and groups have been other group therapy leaders: caring, warmth, used to help clients genuineness, and positive regard for others. often follow a reflect on their own behavior, learn new Leaders also should possess knowledge and skills in three primary areas. First, they should manual or a ways to confront problems, and understand basic group process—how people interact within a group. Subsets of this knowl­ preplanned increase their self­ esteem (La Salvia edge include how groups form and develop, 1993). how group dynamics influence an individual’s curriculum. behavior in group, and how a leader affects Psychoeducational group functioning. Second, leaders should groups should work understand interpersonal relationship dynam­ actively to engage ics, including how people relate to one another participants in the group discussion and in group settings, how one individual can influ­ prompt them to relate what they are learning to ence the behavior of others in group and some their own substance abuse. To ignore group basic understanding of how to handle problem­ process issues will reduce the effectiveness of atic behaviors in group (such as being with­ the psychoeducational component. drawn). Finally, psychoeducational group lead­ ers need to have basic teaching skills. Such Psychoeducational groups are highly struc­ skills include organizing the content to be tured and often follow a manual or a pre­ taught, planning for participant involvement in planned curriculum. Group sessions generally the learning process, and delivering information are limited to set times, but need not be strictly in a culturally relevant and meaningful way. limited. The instructor usually takes a very active role when leading the discussion. Even To help clients get the most out of psychoeduca­ though psychoeducational groups have a for­ tional sessions, leaders need basic counseling mat different from that of many of the other skills (such as active listening, clarifying, sup­ types of groups, they nevertheless should meet porting, reflecting, attending) and a few in a quiet and private place and take into advanced ones (such as confronting and termi­ account the same structural issues (for nating) (Brown 1998). It also helps to have instance, seating arrangements) that matter in leadership skills, such as helping the group other groups. get started in a session, managing (though not necessarily eliminating) conflict between group As with any type of group, accommodations members, encouraging withdrawn group mem­ may need to be made for certain populations. bers to be more active, and making sure that Clients with cognitive disabilities, for example,

14 Types of Groups Commonly Used in Substance Abuse Treatment all group members have a chance to participate. standing of the content before expressing their As the group unfolds, it is important that group views. Techniques such as role playing, group leaders are nondogmatic in their dealings with problemsolving exercises, and structured experi­ group members. Finally, the group leader ences all foster active learning. should have a firm grasp of material being communicated in the psychoeducational group. Second, the leader should encourage group participants to take responsibility for their During a session, the group leader should be learning rather than passing on that responsi­ mindful both of the group’s need and the spe­ bility to the group leader. From the outset of cific needs of each member. The group leader the group, the leader can emphasize group self­ will need to understand group member roles ownership by allowing members to participate and how to manage problem clients. Except in in setting agreements and other group bound­ unusual circumstances, efforts should be made aries. The leader can emphasize member to increase members’ comfort and to reduce responsibility for honest, respectful interaction anxiety in the group. Leaders will use a variety among all members and can de­emphasize the of resources to impart knowledge to the group, leader role in determining group life. so each session also requires preparation and familiarization with the content to be delivered. Third, because many people have pronounced preferences for learning through a particular Group leaders should have ongoing training sense (hearing, sight, touch/movement), it is and formal supervision. Supervision benefits essential to use a variety of learning methods all group leaders of all levels of skill and train­ that call for different kinds of sensory experi­ ing, as it helps to assure them that people in ence. Excellent material on adapting instruc­ positions of authority are interested in their tion to learning styles is available through the development and in their work. If direct super­ Association for Supervision and Curriculum vision is not possible (as may be the case in Development Web site. To access the many arti­ remote, rural areas), then Internet discussions cles and book chapters, enter “learning styles” or regular telephone contact should be used. into the search function and click the “Go” button. Techniques. Techniques to conduct psychoedu­ cational groups are concerned with (1) how Most people, at one time or another, have had information is presented, and (2) how to assist unpleasant experiences in traditional, formal clients to incorporate learning so that it leads to classroom environments. The resulting shame, productive behavior, improved thinking, and rejection, and self­deprecation strongly moti­ emotional change. Adults in the midst of crises vate people to avoid situations where these in their lives are much more likely to learn experiences might be brought back into aware­ through interaction and active exploration than ness. Therefore it is critically important for the they are through passive listening. As a result, it group leader to be sensitive to the anxiety that is the responsibility of the group leader to can be aroused if the client is placed in an envi­ design learning experiences that actively engage ronment that replicates a disturbing scene from the participants in the learning process. Four the past. To allay some of these concerns, lead­ elements of active learning can help. ers can acknowledge the anxieties of partici­ pants, prevent all group participants from First, the leader should foster an environment mocking others’ comments or ideas, and show that supports active participation in the group sensitivity to the meaning of a participant’s and discourages passive note taking. withdrawal in the group. Overall, leaders Accordingly, leader lecturing should be limited should create an environment where partici­ in duration and extent. The leader should con­ pants who are having difficulty with the centrate instead on facilitating group discussion, psychoeducational group process can express especially among clients who are withdrawn and their concerns and receive support. have little to say. They need support and under­

Types of Groups Commonly Used in Substance Abuse Treatment 15 Fourth, people with alcoholism and other becomes a natural treatment of choice for skills addictive disorders are known to have subtle, development. Members can practice with each neuropsychological impairments in the early other, see how different people use the same stage of abstinence. Verbal skills learned long skills, and feel the positive reinforcement of a ago (that is, crystallized intelligence) are not peer group (rather than that of a single profes­ affected, but fluid intelligence, needed to learn sional) when they use skills effectively. some kinds of new information, is impaired. As a result, clients may seem more able to learn Principal characteristics. Because of the than they actually are. Therapists who are degree of individual variation in client needs, teaching new skills should be mindful of the particular skills taught to a client should this difficulty. depend on an assessment that takes into account individual characteristics, abilities, and background. The suitability of a client for Skills Development Groups a skills development group will depend on the unique needs of the individual along with the Most skills development groups operate from a skills being taught. Most clients can benefit cognitive–behavioral orientation, although from developing or enhancing certain general counselors and therapists from a variety of skills, such as controlling powerful emotions or orientations apply skills development tech­ improving refusal skills when around people niques in their practice. Many skills develop­ using alcohol or illicit drugs. Skills might also ment groups incorporate psychoeducational be highly specific to certain clients, such as elements into the group process, though skills relaxation training. development may remain the primary goal of the group. Skills development groups usually run for a limited number of sessions. The size of the Purpose. Coping skills training groups (the group needs to be limited, with an ideal range most common type of skills development group) of 8 to 10 participants (perhaps more, if a attempt to cultivate the skills people need to cofacilitator is present). The group has to be achieve and maintain abstinence. These skills small enough for members to practice the skills may either be directly related to substance use being taught. (such as ways to refuse offers of drugs, avoid triggers for use, or cope with urges to use) or While skills development groups often incorpo­ may apply to broader areas relevant to a rate elements of psychoeducation and support, client’s continued sobriety (such as ways to the primary goal is on building or strengthening manage anger, solve problems, or relax). behavioral or cognitive resources to cope better in the environment. Psychoeducational groups Skills development groups typically emerge tend to focus on developing an information base from a cognitive–behavioral theoretical on which decisions can be made and action approach that assumes that people with sub­ taken. Support groups, to be discussed later in stance use disorders lack needed life skills. this chapter, focus on providing the internal and Clients who rely on substances of abuse as a environmental supports to sustain change. All method of coping with the world may never are appropriate in substance abuse treatment. have learned important skills that others have, While a specific group may incorporate elements or they may have lost these abilities as the of two or more of these models, it is important to result of their substance abuse. Thus, the maintain focus on the overall goal of the group capacity to build new skills or relearn old ones and link methodology to that goal. is essential for recovery. In skills develop­ Since many of the skills that people with Leadership skills and styles. ment groups, as in psychoeducation, leaders substance abuse problems need to develop are need basic group therapy knowledge and skills, interpersonal in nature, group therapy such as understanding the ways that groups

16 Types of Groups Commonly Used in Substance Abuse Treatment grow and evolve, knowledge of the patterns Furthermore, many that show how people relate to one another in behavioral changes group, skills in fostering interaction among that seem straightfor­ members, managing conflict that inevitably ward on the surface Skills development arises among members in a group environment, have powerful effects and helping clients take ownership for the at deeper levels of groups typically group. psychological func­ tioning. For instance, emerge from a cog­ In addition, group leaders should know and be assertiveness may able to demonstrate the set of skills that the touch feelings of participants are trying to develop. Leaders also shame and unworthi­ nitive–behavioral will need significant experience in modeling ness. Thus, new behavior and helping others learn discrete ele­ assertive competence approach. ments of behavior. Other general skills, such as may be incompatible sensitivity to what is going on in the room and with and over­ cultural sensitivity to differences in the ways whelmed by deep feel­ people approach issues like anger or assertive­ ings of inadequacy ness, also will be important. Depending on the and low self­esteem. As a result, a client may skill being taught, there may be certain educa­ learn a new behavior, but be unable to incor­ tional or certification requirements. For exam­ porate it into a repertoire of positive action. ple, a nurse might be needed to teach specific Counselors should not automatically assume, health maintenance skills, or a trained facilita­ therefore, that a newly learned skill inevitably tor may be needed to run certain meditation or will translate into action. Feedback from par­ relaxation groups. ticipants on their progress since the last group is a good way to assess both learning and the Techniques. The specific techniques used in a incorporation of skills. skills development group will vary greatly depending on the skills being taught. (For more An often unstated and underrecognized diffi­ information on the techniques used in cogni­ culty in leading skills groups is that a leader tive–behavioral coping skills training see chap­ teaching the same material week after week can ter 4 of TIP 34, Brief Interventions and Brief become bored with the content. In due course, Therapies for Substance Abuse Treatment the boredom will creep into the teaching. To [CSAT 1999a].) retain energy and teaching effectiveness, lead­ ers can switch topics, or one leader can teach It is useful to keep in mind that most skills, different topics over time. When feasible, it such as riding a bicycle or swimming, seem rel­ also may help to provide feedback to leaders atively simple, straightforward, and easy once by making video or audio recordings of their incorporated into one’s repertoire of behavior. presentations. The process of learning and incorporating new skills, however, may be difficult, especially if Other specific techniques for skills develop­ the previous approach has been used for a long ment groups depend on the nature of the time. For instance, individuals who have been group, topic, and approach of the group lead­ passive and nonassertive throughout life may er. Before undertaking leadership of a skills have to struggle mightily to learn to stand up development group, it is wise for the leader to for themselves. As a consequence, it is crucial have previously participated in the specific for leaders of skills development groups to be kind of skills development group to be led. sensitive to the struggles of group participants, Often special training programs are available hold positive expectations for change, and not for leaders of these kinds of groups. demean or shame individuals who seem over­ whelmed by the task.

Types of Groups Commonly Used in Substance Abuse Treatment 17 Cognitive–Behavioral Groups decisions, opinions, and assumptions. A num­ ber of thoughts and beliefs are affected by an Cognitive–behavioral groups are a well­ individual’s substance abuse and addiction. established part of the substance abuse treat­ Some common errant beliefs of individuals ment field and are particularly appropriate in entering recovery are early recovery. The term “cognitive–behavioral therapy group” covers a wide range of formats •“I’m a failure.” informed by a variety of theoretical frame­ •“I’m different.” works, but the common thread is cognitive restructuring as the basic methodology of •“I’m not strong enough to quit.” change. •“I’m unlovable.” •“I’m a (morally) bad person.” The word Purpose. Cognitive–behavioral groups concep­ “morally” carries the implication of a “shame tualize dependency as a learned behavior that script” and feeling defective as a person. is subject to modification through various “Bad” alone refers more to behavior, or interventions, including identification of condi­ doing “bad things.” tioned stimuli associated with specific addictive behaviors, avoidance of such stimuli, develop­ Changing such cognitions and beliefs may lead ment of enhanced contingency management to greater opportunities to maintain sobriety strategies, and response­desensitization and live more productively. (McAuliffe and Ch’ien 1986). The etiologies of dependency include neurobehavioral factors Principal characteristics. In cognitive– (Rawson et al. 1990), biopsychosocial (Nunes­ behavioral groups for people who abuse Dinis and Barth 1993; Wallace 1990), and the substances, the group leader focuses on pro­ disease model (Miller and Chappel 1991), in viding a structured environment within which which the key etiological determinants of group members can examine the behaviors, dependency are genetic and physiological fac­ thoughts, and beliefs that lead to their mal­ tors, ones that the person with dependency adaptive behavior. Treatment manuals— cannot control. providing specific protocols for intervention techniques—may be helpful in some, though Cognitive–behavioral therapy groups work to not all, cognitive–behavioral groups. In any change learned behavior by changing thinking case, most cognitive–behavioral groups patterns, beliefs, and perceptions. The groups emphasize structure, goal orientation, and a also work to develop focus on immediate problems. Problem social networks that solving groups often have a specific protocol support continued that systematically builds problemsolving abstinence so the skills and resources. person with depen­ Cognitive– dency becomes One example is a model cognitive–behavioral aware of behaviors group for women with posttraumatic stress dis­ behavioral groups that may lead to order (PTSD) and substance abuse designed to relapse and develops •Educate clients about the two disorders are particularly strategies to contin­ ue in recovery •Promote self­control skills to manage over­ whelming emotions appropriate in (Matano et al. 1997). •Teach functional behaviors that may have Cognitive processes deteriorated as a result of the disorders early recovery. include a number of different psychologi­ •Provide relapse prevention training (Najavits cal elements, such as et al. 1996) thoughts, beliefs,

18 Types of Groups Commonly Used in Substance Abuse Treatment The group format is an important element of cognition (beliefs, judgments, and perceptions) the model, given the importance of social sup­ and the behavior that flows from it. Some port for PTSD and substance use disorders. In approaches focus more on behavior, others on addition, group treatment is a well­established, core beliefs, still others on developing problem­ relatively low­cost modality, so it can success­ solving capabilities. Regardless of the particu­ fully reach a large number of clients. Some key lar focus, the group therapist conducting cogni­ characteristics of this program are that it tive–behavioral groups should have a solid grounding in the broader theory of •Uses a model designed for 24 sessions, in cognitive–behavioral therapy. This basis is the which 3–10 members meeting twice each week framework from which specific interventions for 3 months in 90­minute group meetings can be drawn and implemented. Training in •Is early­recovery–oriented, with a strong cognitive–behavioral theory is available in focus on coping skills to gain control over many workshops on counseling skills and in symptoms many alcohol and drug training programs for •Has homogeneous membership (for example, counselors. For instance, over a 2­week period all women) in 2002, the Rutgers Summer Schools of Alcohol and Drug Studies offered seven week­ •Includes a six­session unit on relationships long courses that concentrated specifically on and themes, such as Safety and Self­ cognitive counseling theory and methods. Many protection and Reaching Out for Help books are available on the theory of cogni­ •Uses educational devices to promote rapid tive–behavioral therapy (Beck 1976; Ellis and and sustained learning of material, such as MacLaren 1998; Glasser 2000; Leahy 1996) as visual aids, role preparation, memory well as self­help manuals with a cognitive– improvement techniques, written summaries, behavioral focus (Burns 1999; Greenberger review sessions, homework, and audiotapes and Padesky 1995). See chapter 7 for more of each session information about training sources. •Focuses on both disorders, with instruction The level of interaction by the therapist in cog­ on stages of recovery to motivate members to nitive–behavioral groups can vary from very achieve abstinence and control over PTSD directive and active to relatively nondirective symptoms (Najavits et al. 1996) and inactive. It also can vary from highly con­ Another cognitive–behavioral model was frontational with group members to relatively employed to reduce the anger that can trigger nonconfrontational demeanor. Perhaps the renewed use of cocaine among 59 men and 32 most common leadership style in cognitive– women diagnosed with cocaine dependence. behavioral groups is active engagement and a The model assumed that angry responses are consistently directive orientation. learned behavior that can be changed. Clients A cautionary note: In cognitive–behavioral in the pilot program were taught to gauge their groups, the leader may be tempted to become anger levels and to use anger management the expert in how to think, how to express that strategies like time­outs and conflict resolution. thinking behaviorally, and how to solve prob­ During the 12 weeks of treatment, participants lems. It is important not to yield to such a were able to reduce and control their anger temptation, but instead to allow group mem­ more effectively than they had in the past, and bers to use the power of the group to develop these gains held at the follow­up 3 months after their own capabilities in these areas. treatment. Violent behavior also decreased sig­ nificantly (Reilly and Shopshire 2000). Techniques. Specific techniques may vary Leadership skills and styles. Cognitive–behav­ based on the particular orientation of the lead­ er, but in general, techniques include those ioral therapies encompass a variety of method­ which (1) teach group members about self­ ological approaches, all focused on changing

Types of Groups Commonly Used in Substance Abuse Treatment 19 destructive behavior and thinking that leads to cies sustain abstinence without necessarily maladaptive behavior, (2) focus on problem­ understanding the determinants of their depen­ solving and short­ and long­term goal setting, dence (Cooper 1987). and (3) help clients monitor feelings and behav­ ior, particularly those associated with drug use. The focus of support groups can range from More experienced leaders will have a wider strong leader­directed, problem­focused groups range of specific techniques to engage partici­ in early recovery, which focus on achieving pants and more comfort with a wider range of abstinence and managing day­to­day living, to client needs and expectations. group­directed, emotionally and interpersonal­ ly focused groups in middle and later stages of An important element of conducting cognitive– recovery. behavioral groups is recognizing that behav­ ioral change and intellectual insight gained in Purpose. Support groups bolster members’ the group can be provocative and upsetting for efforts to develop and strengthen the ability to clients with a poor sense of self, low self­ manage their thinking and emotions and to esteem, and fear of emotional and interperson­ develop better interpersonal skills as they al inadequacy. As a result, resistance to change recover from substance abuse. Support group inevitably will occur as the group evolves and members also help each other with pragmatic behavioral changes begin to become routine. concerns, such as maintaining abstinence and Experienced leaders learn to recognize, managing day­to­day living. These groups are respect, and work with the resistance instead of also used to improve members’ general self­ simply confronting it. Clinical supervision is esteem and self­confidence. The group—or quite beneficial in learning a variety of styles of more often, the group leader—provides specific working with resistance generated by growth kinds of support, such as being sure to help and change. clients avoid isolation and finding something positive to say about each participant’s contri­ Many specific approaches to cognitive–behav­ bution. In some programs, support groups ioral therapy, including rational emotive thera­ might be considered process (therapy) groups, py (Ellis 1997), reality therapy (Glasser 1965) but the main interest of support groups is and the work of Aaron Beck and colleagues not in the intrapsychic world, and the goal (1993), incorporate various techniques specific is not character change. Process issues may to each approach. Substance abuse treatment be involved, but support groups are less counselors may find it useful to explore these complex, more direct, and narrower in focus approaches for techniques appropriate to their than process groups. specific client populations. Principal characteristics. Many people with substance use disorders avoid treatment Support Groups because the treatment itself threatens to increase their anxiety. Because of support The widespread use of support groups in the groups’ emphasis on emotional sustenance substance abuse treatment field originated in providing a safe environment, these groups are the self­help tradition in the field. These groups especially useful for apprehensive clients, also have roots in the realization that signifi­ indeed, for any client new to abstinence. The cant lifestyle change is the long­term goal in adjective “support” itself may be a way of treatment and that support groups can play a destigmatizing the activity. For this reason, a major role in such life transitions. Self­help “support” group may be more attractive to groups share many of the tenets of support someone less committed to recovery than a groups—unconditional acceptance, inward “therapy” group. reflection, open and honest interpersonal inter­ action, and commitment to change. These Not all support groups, however, are intended groups attempt to help people with dependen­ just for clients new to recovery. Support groups

20 Types of Groups Commonly Used in Substance Abuse Treatment can be found for all stages of treatment in all this TIP is mainly concerned with groups led sorts of settings (inpatient, outpatient, continu­ by a trained, professional group leader. ing care, etc.). While a support group always Support group leaders need a solid grounding will have a clearly stated purpose, the purpose in how groups grow and evolve and the ways varies according to its members’ motivation in which people interact and change in groups. and stage of recovery. Many of these groups are It is also critical that group leaders have a open­ended, with a changing population of theoretical framework for counseling (such as members. As new clients move into a particular cognitive–behavioral therapy) that informs stage of recovery, they may join a support their approach to support group development, group appropriate for that stage until they are the therapeutic goals for group members, the ready to move on again. Groups may continue guidance of group members’ interactions, and indefinitely, with new members coming in and the leader’s imple­ old members leaving, and occasionally, return­ mentation of specific ing. Program differences will also alter how this intervention methods. type of group is used. A support group will be In a support different in a 4­ to 6­week daily treatment pro­ Since the leader gram from the way it is used in a 1­year treat­ should help build con­ group, members ment community. nections between members and empha­ In a support group, members typically talk size what they have in typically talk about their current situation and recent prob­ common, it is useful lems that have arisen. Discussion usually focus­ for the leader to have about their cur­ es on the practical matters of staying abstinent; participated in a sup­ for example, ways to deal with legal issues or port group and to rent situation and avoid places that tempt people to use sub­ have been supervised stances. Group members are encouraged to in support group problems that share and discuss their common experiences. work before under­ taking leadership of have recently Issues that do not specifically relate to the such a group. focus of the group are often considered extra­ Training and supervi­ neous, so discussion of them is limited. Support sion focused on how arisen. groups provide guidance through peer feed­ individuals develop back, and group members generally require psychologically, typi­ accountability from each other. The group cal psychological con­ leader, however, will try to minimize confronta­ flicts, and the way these conflicts may appear tion within the group so as to keep anxiety lev­ in group therapy settings also may help the els low. In cohesive, highly functioning support support group leader function more effectively, groups, member­to­member or leader­to­mem­ since such considerations help the leader ber confrontation does occur. understand individual members’ behavior in the group. Support groups can work from a variety of the­ oretical positions. Many reflect the 12­Step tra­ The leadership style for someone running a dition in the substance abuse field, but other support group typically will be less directive recovery tools, such as relapse prevention, can than for psychoeducational, skills develop­ form the basis of a support group. Some sup­ ment, or cognitive–behavioral groups because port groups are based on theoretical frame­ the support group is generally group­focused works such as cognitive therapies or spiritual rather than leader­focused. The leader’s pri­ paths. Programs may even design a support mary role is to facilitate group discussion, help­ group by combining theories or philosophies. ing group members share their experiences, grapple with their problems, and overcome dif­ Leadership skills and styles. Some support ficult challenges. The group leader also pro­ groups may be peer­generated or peer­led, but vides positive reinforcement for group mem­

Types of Groups Commonly Used in Substance Abuse Treatment 21 bers, models appropriate interactions between experience. Understanding some of the history individuals in the group, respects individual of each person in the group, the leader also and group boundaries, and fosters open and watches to see whether the group is providing honest communication in the group setting. In each individual with emotional and interper­ a most general way, the leader is active but not sonal experiences that build success and skills directive. that apply to life arenas outside the group. In addition to monitoring individuals in the Techniques. The techniques of leading support group, the leader also monitors the progress of groups vary with group goals and member the group as a whole, making sure that group needs. In general, leaders need to actively development proceeds through its predictable facilitate discussion among members, maintain stages and does not become blocked at any appropriate group boundaries, help the group stage of its evolution. work though obstacles and conflicts, and pro­ vide acceptance of and regard for members. In Finally the leader is responsible for recognizing a support group, the leader exercises the role interpersonal blocks or struggles between of modeler of appropriate behaviors. In this group members. It is not necessarily the way, the leader helps members grow and responsibility of the leader to resolve these change. blocks, or even to point them out to group members, but to ensure that such struggles Specific group techniques may appear to be do not hinder the development of the group or less important for the leader of a support any member of the group. group, since the leader is usually less active in group direction and leadership. The techniques used in support groups, however, are simply Interpersonal Process Group less obvious. Psychotherapy Interventions, for example, are likely to be The interpersonal process group model for more interpretive and observational and less substance abuse treatment is grounded in an directive than in many other groups. The extensive body of theory (Brown 1985; Brown observations are generally limited to support and Yalom 1977; Flores 1988; Flores and for the progress of the group and facilitating Mahon 1993; Khantzian et al. 1990; Matano supportive interac­ and Yalom 1991; Vannicelli 1992; Washton tion among group 1992). Even this sharply defined area of pro­ members. The goal cess­oriented group therapies is widely diverse. is not to provide Psychodynamic group therapies can be thought Process­oriented insight to group of as a generic name encompassing several ways members, but to of looking at the dynamics that take place in group therapy facilitate the evolu­ groups. Originally, these dynamics were consid­ tion of support with­ ered in Freudian psychoanalytic terms that in the group. placed a heavy emphasis on sexual and aggres­ uses the process of sive drives, and conflicts and attachments The support group between parents and children. Over the past the group as the leader is also respon­ half century many researchers, such as Jung, sible for monitoring Adler, Bion, Noreno, Rogers, Perls, Yalom, primary change each individual’s and others, expanded or changed the Freudian progress in group emphasis. As a result, current dynamic concep­ mechanism. and ensuring that tualizations include heavy emphasis on the individuals are par­ social nature of human attachment, rivalry and ticipating (in their social hierarchies, and cultural and spiritual own way) and bene­ concerns (i.e., existential issues and questions fiting from the group

22 Types of Groups Commonly Used in Substance Abuse Treatment of faith). This therapeutic approach focuses on •Sometimes perceptions distort reality. People healing by changing basic intrapsychic (within often draw generalizations from their life a person) or interpersonal (between people) experiences and apply the generalizations to psychological dynamics. the current environment, even when doing so is inappropriate or counterproductive. These Thus, a student of process­oriented group ther­ “cognitive distortions” may serve to maintain apy, a group treatment approach that uses the habits people would otherwise like to change. process of the group as the primary change •Psychological and cognitive processes outside mechanism, soon learns that the way Bion awareness influence behavior. As clients (1961) taught group therapy will be far differ­ become conscious of some formerly subcon­ ent from the way other recognized authorities, scious processes supporting a behavior they such as Wolf and Schwartz (1962), taught. want to change, this information can be used These theorists in turn differ from the process­ to alter dysfunctional relationships. orientation exemplified by Durkin (1964) or Glatzer (1969). The many theoretical variants •Behaviors are chosen to adapt to situations differ in what they pay most of their attention and protect people from harm. A specific to as group members interact. behavior is a person’s best effort to adapt to a particular situation given individual make­ Purpose. Interpersonal process groups use up, environment, and personal history. In a psychodynamics, or knowledge of the way peo­ sense, people come to therapy because of ple function psychologically, to promote change their solutions, not their problems. and healing. The psychodynamic approach rec­ ognizes that conflicting forces in the mind, Within the interpersonal process model, the some of which may be outside one’s awareness, objects of interest are the here­and­now inter­ determine a person’s behavior, whether healthy actions among members. Of less importance is or unhealthy. Attachment to others is one of what happens outside the group or in the past. the contending forces. From a psychodynamic All therapists using a “process­oriented group point of view, starting in early childhood, therapy” model continually monitor three developmental issues are a key concern, as are dynamics: environmental influences, to which certain peo­ •The psychological functioning of each group ple are particularly vulnerable because of their member (intrapsychic dynamics) genetic and other biological characteristics. For those people who have been drawn to substance •The way people are relating to one another in abuse, the interpersonal process group raises the group setting (interpersonal dynamics) and re­examines fundamental developmental •How the group as a whole is functioning issues. As faulty relationship patterns are per­ (group­as­a­whole dynamics) ceived and identified, the group participant can begin to change dysfunctional, destructive A group leader conducting an interpersonal patterns. The group member becomes increas­ process group, however, will tend to pay more ingly able to form mutually satisfying relation­ attention to the interpersonal dynamics and ships with other people, so alcohol and drugs concentrate less on each member’s individual lose much of their power and appeal. psychological dynamics and the workings of the group as a whole. The section that follows Basic tenets of the psychodynamic approach includes illustrations (Figures 2­3 to 2­6) of how include the following groups might differ according to their focus on intrapsychic, interpersonal, and group­as­a­ •Early experience affects later experience. whole dynamics. Individuals bring their histories—personal, cultural, psychological, and spiritual—to The experienced group leader knows that the therapy. intervention chosen at any moment in the group will have an impact on all three dynamics and

Types of Groups Commonly Used in Substance Abuse Treatment 23 that a delicate balance must be struck in the or authoritarian leader. The IPGP model per­ attention given to each. A too­intense focus on mits a group experience that is neither leader­ group members’ interaction, to the exclusion of dependent nor leader­centered. This general­ attention to individual psychological needs or ly egalitarian setting helps to reduce resis­ the needs of the group as a whole, blunts the tance. effectiveness and relevance of group develop­ •Synergistic. IPGP and substance abuse treat­ ment. ment complement each other, reciprocally setting the scene for the establishment of the Principal characteristics. Interpersonal pro­ crucial components of effective treatment. cess group therapy delves into major develop­ The combination of IPGP and substance mental issues, searching for patterns that con­ abuse treatment allows the client to experi­ tribute to addiction or interfere with recovery. ence treatment as emotionally supportive. The group becomes a microcosm of the way This sparing of the client’s self­image enables group members relate to people in their daily the client to identify positively with treatment lives. and mutes any strong reactions to the coun­ The Interpersonal Process Group Psychothe­ selor. Further, the combination of these two rapy (IPGP) model links the abstinence­based treatment approaches can ease the client’s treatment approach with current psychological handling of shame, the need to change principles of treatment, while still remaining aspects of self, the uncomfortable newness of compatible with 12­Step theory and practice. the recovery period, and the therapeutic IPGP and substance abuse treatment both rec­ experience itself. Recovery can proceed as ognize that a person’s capacity for healthy clients experience and re­experience deep interpersonal relationships supports solid attachment dynamics and use the experience recovery from substance abuse. IPGP is easy to to craft major changes in character and understand and adapt because it is behavior. •Pragmatic. IPGP is a practical, nuts and Leadership skills and styles. In interpersonal bolts, hands­on type of group treatment. It process groups, content is a secondary con­ focuses on results, not abstract concepts and cern. Instead, leaders focus on the present, all­encompassing theories, and its results­ori­ noticing signs of people recreating their past in ented nature is especially satisfying to a pop­ what is going on between and among members ulation that needs some swift, positive out­ of the group. If, for example, a person has a comes. This feature is especially important problem with anger, this problem eventually during the early phases of treatment, when will be re­enacted in the group. When an angry the window of opportunity for influencing group member, “George,” explodes at clients is small and open only briefly. “Charlie,” the therapist might say, “George, you seem to be having a strong response to •Applicable. IPGP is a very adaptable model. Charlie right now. Who does Charlie remind Because it can so readily be modified, it can you of? Does this feel familiar? Has anything be applied in diverse sets of difficulties and like this happened to you before?” under various circumstances. IPGP furnish­ es the group leader with a set of strategic On one hand, the interpersonal process group tools that are easy to acquire and use. The leader monitors how group members are relat­ IPGP model provides enough structure to ing, how each member is functioning psycholog­ prevent unproductive discussion. This is ically or emotionally, and how the group as a especially desirable because few will tolerate a whole is functioning. On the other hand, the passive group leader who waits for issues to interpersonal process group leader observes a evolve out of the flow of the group. On the variety of group dynamics, such as the stages of other hand, many people who abuse sub­ group development, how leadership is emerging stances will react negatively to a domineering in the group, the strengths each individual is

24 Types of Groups Commonly Used in Substance Abuse Treatment bringing to the group as a whole, and how indi­ to be more or less vidual resistances to change are interacting active in the group with and influencing group functioning. The life. They might also interventions of the leader are dependent on choose, based on the In interpersonal his or her perceptions of this mix. needs of the group, to make more or fewer Since the group leader’s theoretical persuasion, interpretations of process groups, training, experience, and personality determine individual and group the level of intervention that takes priority at a dynamics to the group leaders focus on particular time, it is rare to find two interper­ as a whole. Likewise sonal process group leaders who will conduct a they might choose to the present. group in exactly the same manner. Even so, show more warmth leaders in this type of group are not fonts of and supportiveness information, skill builders, problemsolving toward group mem­ directors, or client boosters. In interpersonal bers or take a more process group therapy, the leader’s job is to aloof position. For promote and probe interactions that carry instance, in contrast to leading a support a point. group, where the leader is likely to be uncondi­ tionally affirming, the process leader might Most group leaders who apply a process­orient­ make a conscious decision to allow clients to ed approach to group therapy with people who struggle to affirm themselves, rather than abuse substances recognize the theoretical essentially doing it for them. influence of the Interactional Model (Yalom 1975). Yalom recommends an adaptable Such choices should be based on the needs of approach to group treatment, one that allows group members and the needs of the group as a easily applied modifications across the continu­ whole, rather than the style that is most com­ um of the recovery needs of an individual who fortable for the group leader. Obviously such abuses substances. His model can be tightened tactical decisions require a high degree of (to have more structure) early in treatment and understanding and insight about group dynam­ can subsequently be loosened (to relax struc­ ics and individual behavior. For this reason, ture) as more abstinent time passes, recovery is almost all leaders of process groups will seek solidified, and the danger of relapse decreases. supervision and consultation to guide them in making the best tactical decisions on behalf of Techniques. In practice, group leaders may use the group and its members. different models at various times, and may simultaneously influence more than one focus level at a time. For example, a group that Three group dynamics focuses on changing the individual will also in practice have an impact on the group’s interpersonal When deciding on a model for a substance relations and the group­as­a­whole. Groups abuse treatment group, programs need to con­ will, however, have a general orientation that sider their resources, the training and theoreti­ determines the focus the majority of the time. cal orientation of group leaders, and the needs This focus is an entry point for the group lead­ and desires of clients in order to determine er, helping to provide direction when working what approaches are feasible. While it is with the group. beyond the scope of this TIP to provide Specific techniques of the process group leader detailed instruction on how to run each of the will vary, not only with the type of process different models of groups, the following figures group, but also with the developmental stage of do illustrate the basic differences among the the group. Early on in group development, psychodynamic emphases. Figure 2­3 describes process group leaders might consciously decide an argument drawn from a problem­focused

Types of Groups Commonly Used in Substance Abuse Treatment 25 Figure 2­3

Group Vignette: Joe’s Argument With His Roommate

Before the first meeting of a new problem­focused group, Joe had been arguing with his roommate because the roommate had forgotten to pay the phone bill the previous month. Joe had told his roommate, Mike, that he might remember to pay the bills on time if he were not smoking pot every day, and they began an angry discussion about the roommate’s drug use. Joe tells the group that he wants to talk about his distrust of his roommate. Joe is not currently using drugs, but he is still struggling with attempts to control his drinking. Group members are generally supportive of Joe in his argument with his roommate. They express concern that he is living with someone who is actively using marijuana and other drugs. One group member, Jane, voices strong objections, however, to Joe’s lack of trust for his roommate. Jane is struggling with her own abuse of prescription tranquilizers, and she is typically rather quiet and anxious in group. Nonetheless, she attacks Joe verbally with uncharacteristic vehemence.

Source: Adapted from Flores 1997. group, which assists people in resolving a spe­ and psychodrama as well as the glossary in cific problem in their lives. (For additional appendix D). information on this type of group, see the last section in this chapter. The reader also may The group is conceived as an aggregate of indi­ refer to appendix B of TIP 34, Brief viduals in which the group leader generally Interventions and Brief Therapies for works sequentially with one group member at Substance Abuse [CSAT 1999a], for a list of a time. While one individual’s issues are resources that can provide further training and addressed, the other group members serve as information about the theoretical orientations observers, contributors, alter egos, or signifi­ that influence these groups.) cant others. Generally, however, more than one group member will be involved in the con­ versation at one time, and all group members Individually focused groups will be encouraged to actively help each other The individually focused group concentrates on and learn from each other’s experiences. This individual members of the group and their dis­ model of group does not require a client to tinctive internal cognitive and emotional pro­ have insight into a problem but does require cesses. How the client interacts in the world at awareness of behavior and its immediate caus­ large is not on the agenda. The group instead es and consequences. Some individually orient­ strives to modify clients’ behavior. This model ed approaches will use group members in a is used with a range of technical and theoretical structured/directive way, such as in a role­ approaches to group therapy, including cogni­ playing exercise. tive therapy, expressive therapies, psychodra­ ma, transactional analysis, redecision therapy, In the more cognitively oriented approaches, Gestalt, and reality therapy (see section below clients will focus on their behaviors in relation for further discussion of expressive therapies to thoughts. The more expressive form of indi­ vidually oriented groups is particularly bene­

26 Types of Groups Commonly Used in Substance Abuse Treatment ficial for clients who need a structured envi­ group include sensitivity training, or T­groups ronment or have so much contained, powerful (Bradford et al. 1964), and L. Ormont’s emotion that they need some creative way of Modern Analytic Approach (Ormont 1992). In releasing it. groups that follow this model, emphasis is placed primarily on current interactions Individually focused groups are useful to iden­ between and among group members. Clients tify the first concrete steps in coping with sub­ are urged to explore how they behave, how this stance abuse. They can help clients become behavior affects others, and how more aware of behavior and its causes, and at others’ behavior affects them. the same time, they increase the client’s range of options as to how to behave. The ideal end In interpersonally focused groups, the group result is the client’s freedom from an unpro­ leader serves as a role model, but does not ductive or destructive behavior. explicitly assess the clients’ behavior. That task is left to other group members, who evaluate Figure 2­4 describes how an individually each other’s behavior. The group leader moni­ focused group might respond to the conflict tors the way clients relate to one another, and described in Figure 2­3. reinforces therapeutic group norms, such as members responding to each other in an Interpersonally focused emphatic way. The leader also steps in to groups extinguish contratherapeutic norms that might damage group cohesion or to point out behav­ Interpersonally focused groups generally work ior that could inhibit empathic relationships from a theory of interactional group therapy, within the group. most often associated with the work of Irving Yalom (1995). Other examples of this model of

Figure 2­4

Joe’s Case in an Individually Focused Group

The group leader in an individually focused group might work first with Joe and then Jane (or vice versa, depending on who seemed to have the more pressing issues). The group leader might ask Joe to tell the group more about his anger and how he experiences it and might ask him to say why he has difficulty trust­ ing his roommate. Joe could be urged to see how this situation might relate to other circumstances and how his reaction to his roommate’s substance abuse might help him understand his own problems with drinking. The leader might use role­playing techniques with Joe so that he can practice how he will interact with his roommate and better understand his reaction to his roommate’s behav­ ior. Jane might be asked why Joe’s reaction to his roommate made her so angry. The group leader could try to help her see if Joe reminded her of anyone and whether she identified with the roommate because she too had been judged. Her fears of being judged might be related to her own substance abuse, and the group could explore that possibility.

Source: Adapted from Flores 1997.

Types of Groups Commonly Used in Substance Abuse Treatment 27 Figure 2­5

Joe’s Case in an Interpersonally Focused Group

A group leader working from an interpersonally focused group model would direct the group’s attention to what is going on between Joe and Jane. The lead­ er might ask Jane if she can tell Joe directly how his statements have made her feel, and then ask Joe to say how he feels about what she said. The group leader might also ask Joe if he sees any parallel in his response to both his roommate and Jane. The leader might ask him if Jane could have reported what she felt in a way that would make him feel less defensive. Jane might tell Joe that she is reacting to his judgmental behavior toward his roommate and his evasiveness about his own drinking. This interaction confronts Joe’s denial. If Jane discloses the reasons behind her response to Joe, namely that her husband distrusts her in a similar manner, the group leader would turn the issue over to the group, perhaps asking Jane how she thinks Joe feels about her. Another group member who has worked on issues concerning trust may interpret what is really going on between Joe and Jane. The goal is to help Joe and Jane deal authentically and realistically with one another, and strengthen the attachment between them. This analysis of relationships within the group may ultimately transfer to set­ tings outside the group and improve Joe’s and Jane’s relationships with others outside the group.

Source: Adapted from Flores 1997.

Figure 2­5 describes how an interpersonally as a single unit with its own ways of operating focused group might respond to the conflict in the world. described in Figure 2­3. This model generally is inappropriate for clients with substance use disorders—at least Group­as­a­whole focused as the sole approach to treatment. It can be groups harmful, especially to clients new to recovery, The theoretical approaches most often associat­ and can add to their problems without helping ed with the group­as­a­whole orientation are them manage their substance abuse. Certain Tavistock’s Group­as­a­Whole (Bion 1961; Rice techniques taken from this approach, however, 1965), Agazarian Systems­Centered Therapy may be used productively in an eclectic treat­ for Group (Agazarian 1992), Bion’s primary ment group. For example, when the entire assumption groups (Bion 1961), and the focal group seems to be sharing a mood, behavior, or conflict model (Whitaker and Lieberman viewpoint, a group leader may choose to use 1965). As the name suggests, in this model, the mass group process comments, such as “You all group leader focuses on the group as a single seem quiet today” or “Almost everyone is gang­ entity or system. While model variations may ing up on Jim.” recognize the group as an aggregate of individ­ Figure 2­6 describes how a group­as­a­whole uals (the Systems­Centered Therapy does, for focused group might handle Joe’s problem. instance), the emphasis remains on the group

28 Types of Groups Commonly Used in Substance Abuse Treatment Figure 2­6

Joe’s Case in a Group­As­A­Whole Focused Group

A group leader with a Bion orientation would notice a lot of conflict swirling around this incident and that the group is in a “fight mode.” The point of inter­ est would be the source of the tension and how it interferes with the work of the group, which is the recovery process. The leader might note that the group has become very involved in this discussion as a way of evading issues of trust com­ mon to the whole group. Is the group perhaps fleeing from dealing directly with trust? Looking at Jane’s response, the group leader would consider whether Jane’s response is carrying something for the group, that is, representing a group concern about whether the group will judge members for what they have to say. The discussion might be redirected toward how the group is coping with feelings of uncertainty about continued substance use.

Source: Adapted from Flores 1997.

Three cautionary notes Specialized Groups in These vignettes illustrate the different interven­ Substance Abuse tions available. No single approach necessarily is more appropriate than any other. The Treatment critical question is always, “Is this approach A variety of therapeutic groups that do not the most likely to succeed with this particular fit in the already­described group models may group in substance abuse treatment?” be employed in substance abuse treatment settings. Some of these specialized groups are In addition to making the right strategic choice unique to substance abuse treatment (like of approach, the interventions should be done at the right time. Treatment as a time­depen­ relapse prevention), and others are unique in format, group membership, or structure (such dent process should be the guiding principle when working with people with addictions as culturally specific groups and expressive therapy groups). It would be impossible to in group. describe all of the types of special groups that Finally, what works for the client without might be used in substance abuse treatment. addictions will not always work with a client The three that follow represent a cross­section with addictions. Consequently, the rest of this of special groups. TIP will be dedicated to exploring the modifi­ cations in group technique that need to be made when treating people with substance Relapse Prevention use disorders. Relapse prevention groups focus on helping a client maintain abstinence or recover from relapse. This kind of group is appropriate for clients who have attained abstinence, but who have not necessarily established a proven track record indicating they have all the skills to maintain a drug­free state. Relapse prevention

Types of Groups Commonly Used in Substance Abuse Treatment 29 also can be helpful for people in crisis or who skills development; other models tend to are in some way susceptible to a return to sub­ emphasize support. stance use. These approaches share a number of basic ele­ Purpose. Relapse prevention groups help ments, including teaching clients to recognize clients maintain their sobriety by providing high­risk situations that may lead to relapse, them with the skills and knowledge to “antici­ preparing them to meet those high­risk situa­ pate, identify, and manage high­risk situations” tions, and helping them develop balance and that lead to relapse into substance use “while alternative ways of coping with stressful situa­ also making security preparations for their tions. Many of these approaches also increase future by striving for broader life balance” group members’ feelings of self­ (Dimeff and Marlatt 1995, p. 176). Thus, control, so they feel capable of resisting relapse prevention is a double­level initiative. relapse. (More information on the techniques It aims both to upgrade a client’s ability to of relapse prevention appears in TIP 34, Brief manage risky situations and to stabilize a Interventions and Brief Therapies for client’s lifestyle through changes in behavior Substance Abuse [CSAT 1999a].) (Dimeff and Marlatt 1995). Research has demonstrated that relapse is com­ Principal characteristics. Relapse prevention mon and to be expected during the process of groups focus on activities, problemsolving, and recovery (Project MATCH 1997). In a meta­ skills­building. They also may take the form of analysis of 24 controlled clinical trials evaluat­ psychotherapy. For instance, Khantzian et al. ing relapse prevention programs delivered in (1992) assert that, because the same traits in both group and individual formats, Carroll personality and character predispose people (1996) found that relapse prevention groups to use substances initially and to relapse dur­ were effective in comparison to no­treatment ing recovery, psychodynamic approaches can controls for many substances of abuse; the mitigate psychological vulnerabilities. Because groups were most effective for smoking cessa­ relapse prevention groups may use techniques tion. Carroll also notes that relapse prevention drawn from all of these types of groups, they groups seem to reduce the intensity of relapse are considered a special type of group in when it occurs. Groups also appear to be more this TIP. effective than other approaches for clients who have “more severe levels of substance use, The different models greater levels of negative affect, and greater for relapse preven­ perceived deficits in coping skills” (1996, p. 52). tion groups Relapse (Donovan and Research also suggests that relapse prevention Chaney 1985) can be conducted in both group and one­on­ prevention groups include those devel­ one formats, with little measurable difference oped by Annis and in outcomes. Schmitz and colleagues (1997) Davis (1988), Daley compared relapse prevention for cocaine abuse focus on activities, (1989), Gorski and delivered in group and individual formats. Miller (1982), and Both demonstrated favorable outcomes; no problemsolving, Marlatt (1982). All significant difference was detected in cocaine of these models are use as measured by urine tests. Clients treated and skills­ derived from princi­ in groups, however, reported fewer cocaine­ ples of cognitive related problems than those treated in individ­ building. therapy. Some, such ual sessions. Further, McKay et al. (1997) as that of Marlatt, found that 6 months after intensive outpatient classify relapse pre­ treatment for cocaine abuse, subjects treated vention as a form of in a group setting displayed higher rates

30 Types of Groups Commonly Used in Substance Abuse Treatment of sustained abstinence than those treated Techniques. Relapse prevention groups draw individually. on techniques used in a variety of other types of groups, especially the cognitive–behavioral, Relapse prevention carried out in group set­ psychoeducational, skills development, and tings enables clients to explore the problems of process­oriented groups. Because the purpose daily life and recovery together and to work of a relapse prevention group is to help mem­ collaboratively to isolate and overcome prob­ bers develop new ways of living and relating to lems. Because of these dual goals, relapse pre­ others, thereby undercutting the need to return vention groups may improve clients’ quality of to substance use or abuse, potential group life. However, as Schmitz and colleagues note, members need to achieve a period of abstinence it may also be the case that the group experi­ before joining a relapse prevention group. ence makes members less willing to report the severity of their problems or cause them to feel that their problems are less severe by compari­ Communal and Culturally son to those of others (Schmitz et al. 1997). Specific Groups Leadership skills and styles. Leaders of Restoring lost cultural ties or providing a sense relapse prevention groups need to have a set of of cultural belonging can be a powerful thera­ skills similar to those needed for a skills devel­ peutic force in substance abuse treatment, and opment group. However, they also need experi­ in important ways, substance abuse is intimate­ ence working in relapse prevention, which ly intertwined with the cultural context in requires specialized training, perhaps in a par­ which it occurs. Cultural prohibitions against ticular model of relapse prevention. Leaders substance use and cultural patterns of permis­ also sible use define, in part, what is reasonable use need a well­developed ability to work on group and what is abuse of substances (Westermeyer process issues. 1995). Risk factors such as cultural displace­ ment or discrimination cause substance abuse Group leaders need to be able to monitor client rates to rise drastically for a given population. participation to determine risk for relapse, to Problems that pervade particular cultures, perceive signs of environmental stress, and to such as racism, poverty, and unemployment, know when a client needs a particular interven­ have an impact on the incidence of substance tion. Above all, group leaders should know how abuse and are appropriate focuses for inter­ to handle relapse and help the group process vention in substance abuse treatment (Taylor such an event in a nonjudgmental, nonpunitive and Jackson 1990; Thornton and Carter 1988). way—clients, after all, need to feel safe in the group and in their recovery. Leaders should Communal and culturally specific wellness know how to help the group manage the absti­ activities and groups include a wide range of nence violation effect, in which a single lapse activities that use a specific culture’s healing leads to a major recurrence of the addiction. practices and adjust therapy to cultural values. For instance, Hispanics/Latinos generally share Additionally, the leader of a relapse prevention a value of personalismo, a preference for per­ group should understand the range of conse­ son­to­person contact. Effective substance quences a client faces because of relapse. These abuse treatment providers thus build personal consequences can be culturally specific relationships with clients before turning to the responses, criminal justice penalties, child tasks of treatment. Also, at the outset of treat­ protective services actions, welfare­to­work ment, personal relationships do not yet exist. setbacks, and so on. The group leader, like any At this point, a client’s hesitation should not counselor, should know the confidentiality be mistaken for resistance (Millan and Ivory rules (42 C.F.R. Part 2) and the legal reporting 1994). requirements relating to client relapse.

Types of Groups Commonly Used in Substance Abuse Treatment 31 Three common ways to integrate such their own background, cope with prejudice, strengths­focused activities into a substance and resolve other problems related to minori­ abuse treatment program are ty status. Groups described in this TIP fall into this category. •Culturally specific group wellness activities may be used in a treatment program to help Purpose. Groups and practices that accentuate clients heal from substance abuse and prob­ cultural affinity help curtail substance abuse lems related to it. by using a particular culture’s healing practices •Culturally specific practices or concepts can and tapping into the healing power of a com­ be integrated into a therapeutic group to munal and cultural heritage. Many have instruct clients or assist them in some aspect commented on the usefulness of these types of of recovery. For example, a psychoeducation­ groups (Trepper et al. 1997; Westermeyer al group formed to help clients develop a bal­ 1995), and clinical experience supports their ance in their lives might use an American utility. As this TIP is written, little research­ Indian medicine wheel diagram or the seven based evidence has accumulated to confirm the principles of Kwanzaa. The medicine wheel effectiveness of this approach. Research is represents four dimensions of wellness: needed to evaluate the effectiveness of cultural­ belonging, independence, mastery, and gen­ ly specific groups and ascertain the primary erosity. These four concepts promote wellness indications for their use. for the individual and collective good of the Principal characteristics. Different cultures American­Indian tribal group and humani­ have developed their own views of what consti­ ty/environments. Kwanzaa is based on a tutes a healthy and happy life. These ideas may value system of seven principles called the prove more relevant and understandable to Nguzo Saba. The Kwanzaa paradigm is a members of a minority culture than do the val­ nonreligious, nonheroic ritual that has been ues of the dominant culture, which sometimes widely embraced by the national African­ can alienate rather than heal. All cultures also American community. The Nguzo Saba and have specific processes for promoting wellness other Kwanzaa symbols and practices can be among their members. used therapeutically in the regrounding and reconnecting process for African­American In using a culture’s healing practices or group clients. activities, whether in heterogeneous or homoge­ •Culturally or community­specific treatment neous groups (that is, all one culture or a mix groups may be developed within a services of cultures), treatment providers should be program or in a substance abuse treatment careful to show respect for the culture and its program serving a heterogeneous population healing practices. As long as respect and with a significant minority population of a awareness are evident, the use of such prac­ specific type. Examples might include a tices will not harm the members of a particular group for people with cognitive disabilities, culture. or a bilingual group for recent immigrants. Leadership characteristics and style. Group Such groups typically are process­ or sup­ leaders always need to strive to be culturally port­oriented, though they also may have competent with members of the various popula­ psychoeducational components. The groups tions who enter their programs.1 Substance help minority group members understand

1 See chapter 3 of this TIP and the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (SAMHSA in development a) for more information on cultural competence. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998b), contains information on being sensitive and respon­ sive to the needs of people with disabilities, and A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001) has information on working with gay and lesbian populations.

32 Types of Groups Commonly Used in Substance Abuse Treatment abuse treatment counselors first need to be and practices of the cultural group. The group aware of the demographics in their program leader should pay attention to a number of fac­ areas, and to be aware as well that there are tors, all of which should be considered in any many people from mixed ethnic backgrounds group but which will be particularly important who do not necessarily know or recognize their in culturally specific groups. Clinicians should cultural heritage. Clinicians should actively avoid stereotyping clients based on their looks, •Be aware of cultural attitudes and resistances and instead allow them to self­identify. Clients toward groups. should be asked what it means to them to •Understand the dominant culture’s view of belong to a particular group. Clinicians also the cultural group or community and how should be sensitive to self­identification issues that affects members of the group. such as sexual orientation, gender identifica­ •Be able to validate and acknowledge past and tion, and disability. When in doubt, clinicians current oppression, with a goal of helping to should discuss the issue privately with the empower group members. client. •Be aware of a cultural group’s collective grief A group leader for a culturally specific group and anger and how it can affect counter­ will need to be sensitive and creative. How transference issues. much authority leaders will exercise and how interactive they will be depends on the values

Figure 2­7

The SageWind Model for Group Therapy

In programs that have the resources, the capacity to offer a variety of types of groups addressing a range of client needs is preferred. SageWind in Reno, Nevada, offers more than 100 groups each week.

To assess each client’s unique needs, SageWind’s comprehensive biopsychosocial assessment evaluates the severity of a client’s substance abuse. In addition, the clinical team, the client, and any others concerned (such as probation or parole officers, parents or legal guardians, or social workers) determine the best course of group therapy formats.

Group intervention ranges in intensity from one group per week to more than 20. The large number of weekly groups offered in SageWind’s menu of options covers a continuum of treatment options from psychoeducational to skills­build­ ing to experiential to process­oriented. In a structured program similar to that of a university, where fundamental courses are required before more advanced ones may be taken, clients attend the groups they need, then change to others and progress through the program. Clients complete groups, moving to more advanced formats until they have met discharge criteria based on the American Society of Addiction Medicine (ASAM) Patient Placement Criteria­2R (PPC­2R) (ASAM 2001).

Types of Groups Commonly Used in Substance Abuse Treatment 33 •Focus on what is held in common among states that play therapy and art therapy are members of the group, being sensitive to particularly useful for substance abuse treat­ differences. ment clients who have been incest victims. Play and art therapies enable these clients to The SageWind Model for group therapy, work through their trauma and substance discussed in Figure 2­7 (see p. 33), provides abuse issues using alternatives to verbal individually tailored interventions for its communication (Glover 1999). clients. Although a number of articles have theorized Techniques. Different cultures have specific about the usefulness of various types of expres­ activities that can be used in a treatment sive therapy for clients with substance use dis­ setting. Some common elements in treatment orders, little study on the subject has used rig­ include storytelling, rituals and religious prac­ orous research methods. Clinical observation, tices, holiday celebrations, retreats, and rites however, has suggested benefits for female of passage practice (these may be particularly clients involved in dance therapy (Goodison useful for adolescent clients). and Schafer 1999). Client self­reports suggest the value of psychodrama for female clients in Culturally specific groups work best if all mem­ treatment for alcoholism, particularly for high­ bers of the population become involved in the ly educated women and those who are inclined activity, even the clients who are not familiar to be extroverted and verbally expressive with their cultural heritage. In fact, the reasons (Loughlin 1992). for that lack of familiarity can become a topic of discussion. Helping clients understand what As Galanter and colleagues note, expressive they have lost by being separated from their therapy groups—which they called “activity cultural heritage, whether because of substance groups”—often can be “the source of valuable abuse or societal forces, can provide one more insight into patients’ deficits and assets, both of reason to continue in sobriety. which may go undetected by treatment staff members concerned with more narrowly Expressive Groups focused treatment interventions” (Galanter et al. 1998, p. 528). This category includes a range of therapeutic activities that allow clients to express feelings Principal characteristics. The actual charac­ and thoughts—conscious or unconscious—that teristics of an expressive therapy group will they might have difficulty communicating with depend on the form of expression clients are spoken words alone. asked to use. Expressive therapy may use art, music, drama, psychodrama, Gestalt, bioener­ Purpose. Expressive therapy groups generally getics, psychomotor, play (often with children) foster social interaction among group members games, dance, free movement, or poetry. as they engage either together or independently in a creative activity. These groups therefore Leadership characteristics and style. can improve socialization and the development Expressive group leaders generally will have a of creative interests. Further, by enabling highly interactive style in group. They will need clients to express themselves in ways they might to focus the group’s attention on creative activi­ not be able to in traditional talking therapies, ties while remaining mindful of group process expressive therapies can help clients explore issues. The leader of an expressive group will their substance abuse, its origins, the effect it need to be trained in the particular modality to has had on their lives, and new options for cop­ be used (for example, art therapy). ing. These groups can also help clients resolve Expressive therapies can require highly skilled trauma (like child abuse or domestic violence) staff, and, if a program does not have a trained that may have been a progenitor of their sub­ staff person, it may need to hire an outside stance abuse. For example, Glover (1999) consultant to provide these services. Any con­

34 Types of Groups Commonly Used in Substance Abuse Treatment sultant working with the group should be in cific form of cogni­ regular communication with other staff, since tive–behavioral group expressive activities need to be integrated into used to eliminate or the overall program, and group leaders need to modify a single par­ Expressive know about each client if they are to under­ ticular problem, such stand their work in the group. as shyness, loss of a therapy groups loved one, or sub­ Expressive therapies can stir up very powerful stance abuse. In foster social feelings and memories. The group leader sheer numbers, these should be able to recognize the signs of reac­ groups are the most interaction as tions to trauma and be able to contain clients’ widespread. emotional responses when necessary. Group Additionally, prob­ members engage leaders need to know as well how to help clients lemsolving groups are obtain the resources they need to work though directed from a cogni­ their powerful emotions. tive–behavioral in a creative framework. They Finally, it is important to be sensitive to a focus on problems of activity. client’s ability and willingness to participate in daily life for people in an activity. To protect participants who may be early and middle in a vulnerable emotional state, the leader recovery, helping should be able to set boundaries for group group members learn members’ behavior. For example, in a move­ problemsolving skills, cope with everyday diffi­ ment therapy group, participants need to be culties, and develop the ability to give and aware of each other’s personal space and receive support in a group setting. As clients understand what types of touching are not discuss problems they face, these problems are permissible. generalized to the experience of group mem­ Techniques. The techniques used in expressive bers, who offer support and insight. groups depend on the type of expressive thera­ Purpose. Problem­focused groups’ primary py being conducted. Generally, however, these purpose is to “change, alter, or eliminate a groups set clients to work on an activity. group member’s self­destructive or self­defeat­ Sometimes clients may work individually, as in ing target behavior. Such groups are the case of painting or drawing. At other times, usually short­term and historically have been they may work as a group to perform music. used with addictive types of behavior (smoking, After clients have spent some time working on eating, taking drugs) as well as when the focus this activity, the group comes together to dis­ is on symptom reduction…or behavioral cuss the experience and receive feedback from rehearsal” (Flores 1997, p. 40). the group leader and each other. In all expres­ sive therapy groups, client participation is a Principal characteristics. Problem­focused paramount goal. All clients need to be involved groups are short (commonly 10 or 12 weeks), in the group activity if the therapy is to exert highly structured groups of people who share a its full effect. specific problem. This type of group is not intended to increase client insight, and little or Groups Focused on Specific no emphasis is placed on self­exploration. Instead, the group helps clients develop effec­ Problems tive coping mechanisms to enable them to meet In addition to the five models of therapeutic social obligations and to initiate recovery from groups and three specialized types of groups substance abuse. The group’s focus, for the discussed above, groups can be classified by most part, is on one symptom or behavior, and purpose. The problem­focused group is a spe­ they use the cohesiveness among clients to

Types of Groups Commonly Used in Substance Abuse Treatment 35 increase the rate of treatment compliance and cific problem or loss (such as breast cancer or change. A problem­focused group commonly is suicide in the family), help people alter a par­ used in the early stages of recovery to help ticular behavior or trait (like overeating or shy­ clients engage in treatment, learn new skills, ness), or learn a new skill or behavior (for and commit to sobriety. This kind of group is instance, conflict resolution or assertiveness helpful particularly for new clients; its homo­ training). geneity and simple focus help to allay feelings of vulnerability and In practice, group leaders may use different anxiety. models at various times, and may simultane­ ously influence more than one focus level at a Leadership charac- time. For example, a group that focuses on The leader in a teristics and styles. changing the individual will also have an The group leader impact on the group’s interpersonal relations problem­focused usually is active and and the group­as­a­whole. Groups will, however, directive. have a general orientation that determines the group usually Interaction within focus the majority of the time. This focus is an the group is limited entry point for the group leader, helping to is active and typically to provide direction when working with the group. exchanges between When deciding on a model for a substance directive. individual clients and the group lead­ abuse treatment group, programs will need er; the rest of the to consider their resources, the training and group acts to theoretical orientation of group leaders, and confront or support the needs and desires of clients in order to the client according to the leader’s guidance. determine what approaches are feasible. The reader may also refer to appendix B of TIP 34, Techniques. Many traditional recovery groups Brief Interventions and Brief Therapies for fall into the problem­focused category, which Substance Abuse (CSAT 1999a), for a list of includes abstinence maintenance, relapse pre­ resources that can provide further training and vention, support, behavior management, and information about the theoretical orientations many continuing care groups. Other examples that influence these groups. are groups that help support people with a spe­

36 Types of Groups Commonly Used in Substance Abuse Treatment 3 Criteria for the Placement of Clients in Groups

Overview In This Before any client is placed in a group, readiness for particular groups must be assessed. Techniques such as eco­maps and resources like Chapter… American Society of Addiction Medicine (ASAM) criteria (see the “Primary Placement Considerations” section of this chapter) can be Matching Clients very helpful. The clinician must also determine the client’s current stage With Groups of recovery and stage of change.

Assessing Client Culture and ethnicity considerations also are of primary importance. Readiness for This chapter explains ways to facilitate the placement of people from Group minority cultures and ease such clients into existing groups. From this Primary Placement discussion, clinicians can also assess their readiness to deal with other Considerations cultures and become aware of processes that occur in multiethnic Stages of Recovery groups. Placing Clients From Racial or Matching Clients With Groups Ethnic Minorities Diversity in a Broad Sense Therapy groups, designed to treat substance abuse by resolving persis­ tent life problems, are used frequently, but the individual success of this Leader Self­Assessment group experience depends in important respects on appropriate place­ Diversity and Placement ment. Matching each individual with the right group is critical for suc­ Ethnic and Cultural Matching cess. Before placing a client in a particular group, the provider should Other Considerations for consider Practice •The client’s characteristics, needs, preferences, and stage of recovery •The program’s resources •The nature of the group or groups available The placement choice, moreover, should be considered as constantly subject to change. Recovery from substance abuse is an ongoing process and, if resources permit, treatment may continue in various forms for some time. Clients may need to move to different groups as they progress through treatment, encounter setbacks, and become more or less com­ mitted to recovery. A client may move, for example, from a psychoedu­ cational group to a relapse prevention group to an interpersonal process group. The client also may participate in more than one group at the same time. 37 Assessing Client eco­map (sometimes called a sociogram) is a graphic representation that depicts interper­ Readiness for Group sonal relationships (Garvin and Seabury 1997; Hartman 1978). The client occupies the center Placement should begin with a thorough assess­ of the page. Then, circles are added to show ment of the client’s ability to participate in the each significant relationship. The closer the group and the client’s needs and desires regard­ relationship, the closer it is to the center circle. ing treatment. This assessment can begin as A solid line between circles indicates a strong, part of a general assessment of clients entering nurturing relationship, while a dotted line the program, but the evaluation process should depicts a conflicted connection. Arrows drawn continue after the initial interview and through on the lines can represent the direction of the as long as the first 4 to 6 weeks of group. relationship. An arrow from the center out Assessment should inquire about all drugs used means “I care about this person.” An incoming and look for cross­addictions. It also is impor­ arrow means “This person cares about me.” tant to match groups to clients’ current needs. Clients who are inarticulate or withdrawn may In addition to these and other assessment con­ welcome the opportunity to present informa­ siderations, clients should be asked about the tion visually, and clinicians can gather useful composition of their social networks, types of information from these diagrams. If the dia­ groups they have been in, their experience in gram indicates few, distant, and conflicted rela­ those groups, and the roles they typically have tionships, the client may require a group that is played in those groups (Yalom 1995). very structured. To help assess clients’ relationships and their The eco­map is indicative, but not comprehen­ ability to participate productively in a group, sive. It only provides the client’s viewpoint. the clinician can have the client draw an Though it is a useful tool, leaders should be eco­map (see an example in Figure 3­1). An

Figure 3­1

Eco­Map

Brother Mother Boss

Father

Client Wife

Drinking Brother Buddy Joe Sister #2 Ex­wife

Source: Adapted from Garvin and Seabury 1997; Hartman 1978. Used with permission.

38 Criteria for the Placement of Clients in Groups wary of basing placement decisions on this or months. A group usually can be heterogeneous any other single source of information. Clinical in demographic composition, including men observation and judgments, information from and women, younger and older clients, and collateral resources, and other assessment people of different races and ethnicities, but instruments all should contribute to a decision clients should be placed in groups with people on a client’s readiness and appropriateness for with similar needs. group treatment. Either the group leader or another trained staff person should meet with a People with significant character pathology (for client before assignment to a group. In this example, a personality disorder) placed in a interview, it is important to evaluate how the group of people who do not have a similar dis­ client reacts to the group leader and to assess order almost certainly would violate the bound­ current and past interpersonal relationships. aries of the group and of individuals in the The group leader also may hold an orientation group. As a result, both the clients who have group (perhaps educational in nature) to and who lack the character disorder would observe how the client relates to others. The have a negative group experience and limited client also may be observed in a waiting room opportunity for growth. Clients with a person­ with other clients or in a similar social situation ality disorder generally need a group that can to gain insight into how each person relates place significant limits on their behavior both to others. in and beyond the group setting. In groups treating clients with active psychoses, special The clinician pays such careful attention to the adaptations would need to be made for possible relationships clients can manage at their cur­ psychotic symptoms, delusions, and paranoia. rent stage of recovery because this capacity has Once such adaptations in technique are made everything to do with how able the client is to to fit the special circumstances of the popula­ participate in a group. Whatever their diagno­ tion being treated, group therapy—in the sis, clients in groups—especially interpersonal hands of a skilled group leader—can be an process groups—need to be able to engage with effective, appropriate form of treatment. other people. They need motivation to change, creativity, and dogged perseverance (Brown Other types of clients who may be inappropri­ 1991). Furthermore, the group leader should ate for group therapy include continue to assess clients as treatment progress­ • Clients who refuse to participate. No one es. The clients’ needs and abilities are apt to should be forced to participate in group change––change is part of successful treat­ therapy. ment––and the appropriate type of group or the suitability for group in general may shift • People who can’t honor group agreements. dramatically. Sometimes, as noted, these clients may have a disqualifying pathology. In other instances, Not all clients are equally suited for all kinds of they cannot attend for logistical reasons, groups, nor is any group approach necessary such as a work schedule that conflicts with or suitable for all clients with a history of sub­ that of regular group meetings. stance abuse. For instance, a person who • Clients who, for some reason, are unsuitable relapses frequently probably would be inap­ for group therapy. Such people might be propriate in a support group of individuals prone to dropping out, getting and remaining who have attained significant abstinence and stuck, or acting in ways contrary to the inter­ who have moved on to resolving practical life ests of the group. problems. It would be equally disadvantageous • People in the throes of a life crisis. Such to place a person in the throes of acute with­ clients require more concentrated attention drawal from crack cocaine in a group of people than groups can provide. with alcoholism who have been abstinent for 3

Criteria for the Placement of Clients in Groups 39 • People who can’t control impulses. Such Women. Recent studies have shown that clients, however, may be suitable for women do better in women­only groups than in homogeneous groups. mixed gender groups. When women have single­ • People whose defenses would clash with the gender group therapy, retention is improved dynamics of a group. People who can’t toler­ (Stevens et al. 1989). They also are more likely ate strong emotions or get along with others to complete their treatment programs (Grella are examples. 1999), use more services during the course of their treatment, and are more likely to feel they • People who experience severe internal are doing well in treatment (Nelson­Zlupko et discomfort in groups. al. 1996).

The primary reason same­sex groups are more Primary Placement effective for women is that women have distinct Considerations treatment needs that are different from those of men. Women are more likely than men to A formal selection process is essential if clini­ have experienced traumatic events, which often cians are to match clients with the groups best lead to depression, anxiety, and posttraumatic suited to their needs and wants. For each stress disorder. About three­quarters of the group, different filters are appropriate. Some women in treatment have been child or adult groups may require only that members be par­ victims of sexual, physical, or emotional abuse ticipants in a particular program. Others may (Roberts 1998). Statistically, women with sub­ require a multidisciplinary panel review of the stance use disorders also have experienced client’s case history. For many groups, espe­ more severe types of abuse (such as incest), cially interpersonal process groups, pregroup and perpetrators have abused them for longer interviews and client preparation are essential. periods of time in comparison to women with­ out substance use disorders. The perpetrators Client evaluators should not rely solely on the are most often male partners, male family review of forms, but should meet with each members, or male acquaintances. Women candidate for group placement. The interview­ are less willing to disclose and discuss their er should listen carefully to the client’s hopes, victimization in mixed­gender groups (Hodgins fears, and preferences. Ideally, clients should et al. 1997). be offered a menu of appropriate options, since people will be more likely to remain committed Women further are more likely to be caretakers to courses of treatment that they have chosen. for minor children or elderly parents and need Client choice also may strengthen the therapeu­ to balance these family responsibilities with tic alliance and thereby increase the likelihood their own treatment needs. They face greater of a positive treatment outcome (Emrick 1974, challenges in securing employment, are more 1975; Miller and Rollnick 1991). Naturally, likely to have co­occurring mental illness, and appropriate clinical guidance should also play encounter greater stigma for their substance a part in placement decisions. use disorders than men.

After specifying the appropriate treatment Because women are relational by nature and level, a therapist meets with the client to identi­ develop a sense of self and self­worth in rela­ fy options consistent with this level of care. tion to others (Miller 1986), groups specifically More specific screens are needed to determine for women are advisable, particularly in early whether, within the appropriate level of care, treatment. Gender­specific treatment groups the client is appropriate for treatment in a provide both the safety women often need to group modality. If so, further screens are need­ resolve the problems that fuel their substance ed to determine the most helpful type of group. use disorders and the healing environment they Considerations include the following.

40 Criteria for the Placement of Clients in Groups need to develop a healthier development of self (Lawson and Lawson and connections to other women. 1992), especially the chapter on group psy­ It is important to help female clients make the chotherapy with ado­ transition from an environment supportive of lescents by Shaw. In placement, their specific needs to one that is less sensitive Last, a journal article to them. Following treatment, they will need an (Pressman et al. 2001) both the client’s effective support network in their communities relates the special dif­ to help them sustain the gains of treatment. ficulties group psy­ (See the forthcoming TIP Substance Abuse chotherapy presents and the group’s Treatment: Addressing the Specific Needs of for adolescents with Women [Center for Substance Abuse both psychiatric best interests need Treatment (SAMHSA) in development b].) and substance abuse problems—another Adolescents. Planning, designing, and operat­ to be considered. common complexity ing group therapy services for adolescent of providing group clients is a complex undertaking. Adolescents therapy for adoles­ are strikingly different from adults, both psy­ cents with substance chosocially and developmentally, and require abuse disorders. decidedly different services. Local, State, and Federal laws related to confidentiality; infec­ The client’s level of interpersonal function- tious disease control; parental permissions and ing, including impulse control. Does the client notifications; child abuse, neglect, and endan­ pose a threat to others? Is the client prepared germent; and statutory rape all can come into to engage in the give and take of group dynam­ play when substance abuse treatment services ics? The client’s “level of psychological func­ are delivered to minors. Add the complications tioning and integration” should be considered, related to scheduling around school and the as should “the kinds of defenses [used] to need to include family in the treatment process, maintain abstinence, and the rigidity of [those] and it is no surprise that most group therapy defenses” (Vannicelli 1992, p. 31). A client who for teens occurs in the context of an overall has not moved beyond sloganism, including treatment program or as part of highly special­ “avoid strong feelings,” may not do well in a ized, targeted programs (e.g., see the discussion group that has evolved more sophisticated ways of Cognitive Behavioral Therapy group sessions to maintain abstinence (Vannicelli 1992). in Sampl and Kadden 2001). Indeed, to serve as a substance abuse counselor or clinician in Motivation to abstain. Clients with low levels the delivery of group therapy to adolescents of motivation to abstain should be placed in typically requires prior training and experience psychoeducational groups. They can help the with the particular age group to be served. client make the transition into the recovery­ ready stage. The complexities related to adolescents and group therapy lie outside the scope of the TIP. Stability. In placement, both the client’s and Suggested reading for those interested in the group’s best interests need to be considered. rationale for group therapy with adolescents For example, bringing a new member who is in includes, but is not limited to, Sampl and crisis into treatment may tax the group beyond Kadden 2001 or textbooks such as Group its ability to function effectively, yet the group Therapy with Children and Adolescents might easily manage a person in similar crisis (Kymissis and Halperin 1996), including the who already is part of the group (Vannicelli chapter by Spitz and Spitz on adolescents who 1992). Group stability counts as well. An ongo­ abuse substances, or Adolescent Substance ing group of clients who have gained insight Abuse: Etiology, Treatment, and Prevention into the management of their feelings can sup­

Criteria for the Placement of Clients in Groups 41 port a new member, mary factor to consider regarding continued helping that person participation in group should be a client’s abili­ solve problems with­ ty to get something out of the experience, it is Every effort out getting caught also important to determine how each person’s up in feelings of cri­ participation affects the group as a whole. A should be made to sis themselves. client who, for whatever reason, cannot partici­ pate may have a profoundly adverse effect on Stage of recovery. the group’s ability to coalesce and function place the client in The five stages of cohesively. If a client does not interfere with Prochaska and group progress, however, sometimes it is appro­ a group in which DiClemente’s trans­ priate to keep a nonparticipant in the group theoretical model of and simply allow that person to sit and listen. the client can change (discussed briefly in chapter 2 A number of different assessment models can be succeed. and in greater detail used to allow meaningful dialog between client in TIP 35, and program representatives during the screen­ Enhancing ing and placement phase, even when resources Motivation for are limited. The ASAM PPC­2R treatment cri­ Change in teria (ASAM 2001) commonly are used for client Substance Abuse placement. The criteria are arranged in two Treatment [CSAT 1999b]) map the route that a sets, one for adults and one for adolescents. person abusing substances must travel during Each set covers five levels of service: the transition from abuse to recovery. The stages of change are best conceived as a cycle, • Level 0.5 Early Intervention but movement through the cycle is not always a • Level I Outpatient Treatment tidy, forward progression. Clients can––and • Level II Intensive Outpatient Treatment/ often do––move backward as they struggle with Partial Hospitalization dependence. Varying types of groups will be • Level III Residential/Inpatient appropriate for clients at different stages of Treatment recovery. For example, an interpersonal pro­ cess group might be overstimulating for some • Level IV Medically Managed Intensive clients in early stages of recovery, particularly Inpatient Treatment those undergoing detoxification. They would On each level of care ASAM’s criteria benefit most from a group with a strong prima­ describe appropriate treatment settings, staff ry focus on achieving and maintaining absti­ and services, admission, continued service, and nence. Once abstinence and attachment to the discharge criteria for six “dimensions”: recovery process are established, the client is ready to work on such issues as awareness and •Potential for acute intoxication or withdrawal communication of feelings, conflict resolution, •Biomedical conditions and complications healthy interdependence, and intimacy. •Emotional and behavioral conditions or Expectation of success. Every effort should be complications made to place the client in a group in which the •Treatment acceptance or resistance client, and therefore, the program, can succeed. •Relapse and continued use potential A poor match between group and client is not •Recovery environment always apparent at the outset. Monitoring can ensure that clients are in groups in which they On the five levels of care, ASAM also provides can learn and grow without interfering with the a brief overview of the services available for learning and growth of others. Although the pri­ particular severities of addiction and related

42 Criteria for the Placement of Clients in Groups problems. Another commonly used assessment judgment. Actual client placement should take tool, the Addiction Severity Index, can be into account characteristics such as substances found in appendix D of TIP 38, Integrating abused, duration of use, treatment setting, and Substance Abuse Treatment and Vocational the client’s stage of change. For example, a Services (CSAT 2000). client in a maintenance stage may need to acquire social skills to interact in new ways, Some States require providers to use the ASAM may need to address emotional difficulties, or PPC­2R for patient placement, continuing stay, may need to be reintegrated into a community and discharge decisions. For placement in and culture of origin. Only an additional level group therapy, a provider can also consider of assessment will determine which of these groups (or combination of groups) is best for •A client’s stage of recovery (see next section) the client. •The progression of the disease •The client’s stage of readiness for change Stages of Recovery Although no single set of criteria is sufficient to A number of classification systems have been evaluate a client’s proper placement, this docu­ applied to the stages of recovery from sub­ ment presents a chart (see Figure 3­2) that stance abuse. The most common, however, summarizes the types of group treatment most classifies clients as being in an early, middle, or appropriate for clients at different stages of late stage of recovery: recovery. Clinicians can use the chart as a guide to determine the type of group most • Early recovery. The client has moved into appropriate for a client. treatment, focusing on becoming abstinent and then on staying sober. Clients in this When different dimensions of evaluation con­ stage are fragile and particularly vulnerable flict in their placement indications, the clini­ to relapse. This stage generally will last from cian will need to break the impasse with clinical 1 month to 1 year.

Figure 3­2

Client Placement by Stage of Recovery Psycho- Skills- Cognitive– Support Inter- Relapse Ex- Culture- educa- Building Behavioral personal Preven- pressive Specific tion Process tion Early +++ ++ + +++ + + * Middle + ++ ++ ++ +++ +++ + * Late and ++ + +++ * Maintenance

Key: Blank Generally not appropriate + Sometimes necessary ++ Usually necessary +++ Necessary and most important

Source: Consensus Panel.

Criteria for the Placement of Clients in Groups 43 Figure 3­3

Client Placement Based on Readiness for Change Psycho- Skills- Cognitive– Support Inter- Relapse Ex- Culture- educa- Building Behavioral personal Preven- pressive Specific tion Process tion

Precontem­ + + + + plation Contem­ + + + + + + + plation Preparation + + + + + + + Action + + + + + + + + Maintenance + + + + + + + Recurrence + + + + + + +

Source: Consensus Panel; Prochaska and DiClemente 1984.

•Middle recovery. The client feels fairly secure Placing Clients From in abstinence. Cravings occur but can be recognized. Nonetheless, the risk of relapse Racial or Ethnic remains. The client will begin to make signifi­ Minorities cant lifestyle changes and will begin to change personality traits. This stage generally will take at least a year to complete, but can last Diversity in a Broad Sense indefinitely. Some clients never progress to In all aspects of group work for substance abuse the late recovery/maintenance stage. Some­ treatment, clinicians need to be especially mind­ times they relapse and revert to an early ful of diversity issues. Such considerations are stage of recovery. key in any form of substance abuse treatment, • Late recovery/maintenance. Clients work to but in a therapeutic group composed of many maintain abstinence while continuing to make different kinds of people, diversity considera­ changes unrelated to substance abuse in their tions can take on added importance. As group attitudes and responsive behavior. The client therapy proceeds, feelings of belonging to an also may prepare to work on psychological ethnic group can be intensified more than in issues unrelated to substance abuse that have individual therapy because, in the group pro­ surfaced in abstinence. Since recovery is an cess, the individual may engage many peers who ongoing process, this phase has no end. are different, not just a single therapist who is different (Salvendy 1999). Figure 3­3 uses Prochaska and DiClemente’s stages of change model to relate group While the word “diversity” often is used to placements to the client’s level of motivation refer to cultural differences, it is used here in a for change. broader sense. It is taken to mean any differ­ ences that distinguish an individual from others and that affect how an individual identifies himself and how others identify him. Considerations such as age, gender, cultural

44 Criteria for the Placement of Clients in Groups background, sexual orientation, and ability It is important for clinicians to realize that level are all extremely important, as are less diversity issues affect everyone. All individuals apparent factors such as social class, education have unique characteristics. Further, how level, religious background, parental status, people view themselves and how the dominant and justice system involvement. Figure 3­4 culture may view them are frequently different. provides several definitions around culture. In any event, no one should be reduced to a sin­ gle characteristic in an attempt to understand To help clinicians understand the range of diver­ that person’s identity. All people have multiple sity issues and the importance of these issues, characteristics that define who they are. this volume adapts a diversity wheel from Loden and Rosener (1991) (see Figure 3­5 on p. 46). While ideas of difference are social construc­ The wheel depicts two kinds of characteristics tions, they do have a real­world effect. For that can play an important role in understand­ example, members of groups tend to act in dif­ ing client diversity: The inner wheel includes ferent ways when with members of their own permanent characteristics such as age or race; group than they would in a heterogeneous the outer wheel lists a number of secondary group. Further, the dominant culture’s atti­ characteristics that can be altered. Note that tudes and beliefs about people (based on age, primary characteristics are not necessarily race, sexual preference, and so on) influence more important than secondary ones and that everyone. this figure does not include a comprehensive list of secondary characteristics. A culturally homogeneous group quite natural­ ly will tend to adopt roles and values from its

Figure 3­4

What Is Culture?

Culture: Integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group.

Cultural knowledge: Familiarity with selected cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group.

Cultural awareness: Developing sensitivity to and understanding of another ethnic group. This usually involves internal changes of attitudes and values. Awareness and sensitivity also refer to the qualities of openness and flexibility that people develop in relation to others. Cultural awareness should be supplemented with cultural knowledge.

Cultural competence: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable them to work effectively in cross­cultural situations.

Source: Giachello 1995; Office of Minority Health 2001.

Criteria for the Placement of Clients in Groups 45 Figure 3­5

Diversity Wheel

SECONDARY CHARACTERISTICS

level of accultaration, religion, PRIMARY learning style, socioeconomic CHARACTERISTICS language, class, race, gender, ethnicity, age, accent, education sexual orientation, criminal justice physical/mental system involvement ability

geographic location, time orientation, appearance, marital status, parental status, military status, immigrant status

Source: Adapted from Loden and Rosener 1991. Used with permission.

46 Criteria for the Placement of Clients in Groups culture of origin (Tylim 1982). These ways ethnicity, and gender identity mean to that should be understood, accepted, respected, person. If a leader believes that cultural tradi­ and used to promote healing and recovery. tions might be a factor in a client’s participation However, group leaders should also be aware in group or in misunderstandings among group of the possibility that these group roles and val­ members, the leader should check the accuracy ues might conflict with treatment requirements, of that perception with the client involved. and therefore clinicians need to be prepared to Therapists should be aware, however, that indi­ provide more direction to group members when viduals may not always be able to perceive or required (Salvendy 1999). For example, a articulate their cultural assumptions. group composed of Southeast Asian refugees might give authority to older men in the group, Group leaders should be able to anticipate a who may never be challenged, contradicted, or particular group’s characteristics without auto­ disagreed with because to do so would show matically assigning them to all individuals in disrespect (Kinzie et al. 1988). These older, that group. It would be a mistake, for instance, adult males can assist in group leadership. if an institution assigned all immigrants or peo­ However, the opinions of female group mem­ ple of color to a single group, assuming they bers, particularly younger ones, might be would be more comfortable together. Members ignored, and a group leader should be able to of such groups may not have anything in com­ compensate for this tendency. As another mon. An Asian­American woman assigned to example, many Hispanics/Latinos may be sus­ the only Asian­American therapist in the insti­ picious of rules and the people who enforce tution might resent her placement and protest them. Consequently, group leaders regarded as in strong terms. She would want the best thera­ authority figures (that is, not compadres) pist for her, not an automatic matchmaking unwittingly may represent discrimination and based on ethnicity. encroachments on freedom (Torres­Rivera et Clinicians working primarily with other cultur­ al. 1999). al or ethnic groups should be open and ready Cultural practices also affect communication to learn all they can about their clients’ cul­ among group members. Many traditionally ture. For example, a therapist working with raised Asians, for example, will be reluctant to Salvadoran immigrants should be prepared to disagree openly with their elders or even voice learn not only about the country and culture of a personal opinion in their presence (Chang El Salvador, but also about all the events and 2000). Gender­specific cultural roles, too, may influences that have shaped this population’s be played out in groups. For example, women experience, including social conditions in El may hold emotional energy for men or nurture Salvador and the experience of immigration. them. Therapists should be alert to assump­ Accommodating cultural and ethnic character­ tions and roles that may inhibit the develop­ istics is not a simple matter. These adaptations ment of individuals or the group as a whole. should be made, however, because ethnicity Unfortunately, little research reveals how and culture can have a profound effect on group therapy should be adapted to meet such many aspects of treatment. For instance, differences, and many of the findings that do pressures to conform to the dominant culture exist are contradictory. Further, any general­ represented in the group can be intense. The izations about cultural groups may not apply to norms of the group may also be in painful individuals because of variance in levels of conflict with an individual’s traditional cultural acculturation and other experiential factors. A values. An example is shown in Figure 3­6 (see particular Latino youth, for example, may p. 48). Figure 3­7 (see p. 48) provides three identify with the dominant culture and not suggested resources on culture and ethnicity; think of himself as Latino. The client is always however, this list is by no means exhaustive. to be considered the expert on what culture,

Criteria for the Placement of Clients in Groups 47 Figure 3­6

When Group Norms and Cultural Values Conflict

A middle­aged, single professional woman of Philippine background who, in one group session, recounted death wishes toward an elder sister whom she perceived as domineering, remained silent the following week in the group. When other members tried to engage her, wanting her to follow up, she complained of debili­ tating migraines and refused to talk. Months later, she was able to share with the group that she felt ashamed and disloyal to her sister, a great transgression in her culture. The client believed she was punished for her “naughtiness” with crippling headaches.

Source: Adapted from Salvendy 1999, p. 441.

Figure 3­7

Three Resources on Culture and Ethnicity

Culture and Psychotherapy: A Guide to Clinical Practice is a resource for men­ tal health professionals treating people of widely varying cultural backgrounds. Case studies include the story of an American­Indian woman who could not escape her “spirit song,” a Latina who feared “losing her soul,” and an Arab woman whose psychological conflicts were related to cultural changes in her soci­ ety that involved the social status of women. Other chapters describe treatment techniques for various racial and ethnic groups and models of therapy (Tseng and Streltzer 2001). Ethnic Sensitivity in Social Work provides a section on cross­cultural orientation and one on specific cultures, including African­American, Hispanic/Latino, American­Indian, and Asian and Pacific Island cultures. The second part of the book is a psychocultural overview of several major ethnic groups in the United States. For each group, the authors discuss work and economic systems, family life and kinships, political structures and stratification, intergroup relations and ideological structures, identity, social interaction rules, and health behaviors (Winkelman 1995). Readings in Ethnic Psychology contains several chapters on substance abuse and treatment among several ethnic and racial groups and describes culturally appropriate interventions used in therapy, including group therapy (Organista et al. 1998).

48 Criteria for the Placement of Clients in Groups Leader Self­Assessment all members equally, regardless of gender. Clinicians also need to evaluate how competent Group leaders should be aware that their own they are managing issues of cultural diversity. ethnicities and standpoints can affect their In cases where cultural or language barriers are interpretation of group members’ behavior. very strong, a group leader may need to refer a The group leader brings to the group a sense of client to another group or make special accom­ identity, as well as feelings, assumptions, modations to allow the client to participate. thoughts, and reactions. Leaders should be conscious of how their own backgrounds affect Reed and her colleagues (1997) have developed their ability to work with particular popula­ a list of principles for group leaders to evalu­ tions. For example, a female therapist who has ate their own attitudes about diversity (see survived domestic violence may have severe Figure 3­8). Figure 3­9 (see pp. 50–52) is a self­ difficulties working with spouse abusers. assessment guide for group counselors working Another example is that male group leaders with diverse populations. may be inclined to call on male members more often than female members of the group. If so, they need to make a conscious effort to call on

Figure 3­8

Guidelines for Clinicians on Evaluating Bias and Prejudice

• The processes of gaining knowledge about the workings of discrimination and oppression and for guarding against bias should be ongoing and lifelong. • Clinicians should learn about their own culturally shaped assumptions so as to refrain from unconsciously imposing them on others and should exhibit a pro­ fessional’s values, standards, and actions. • Clinicians should work harder to recognize institutionalized racism than they do to perceive individual prejudice; that is, they should recognize how bias is structured into policies, practices, and norms in program relations. • Clinicians should question the knowledge base and theories that underlie their practice in order to eliminate prejudice and bias in that practice. • Clinicians should look at their own feelings and reactions and listen to the feed­ back of others to recognize how their own ideas have been unconsciously shaped by discriminatory social dynamics. • Clinicians can use their knowledge of how their personal characteristics are likely to affect a range of others to reduce communication problems and dis­ putes between group members.

Source: Adapted from Reed et al. 1997. Used with permission.

Criteria for the Placement of Clients in Groups 49 Figure 3­9

Self­Assessment Guide The questions that follow can serve as a guide and self­assessment for group leaders working with clients of diverse cultures.

Are you familiar with a broad range of special populations, particularly those in your community?

• What cultural customs and health beliefs, practices, and attitudes of ethnic/racial groups would affect treatment in a group situation? • Would tensions within any broad cultural group––say one that includes Cubans, Mexicans, and Puerto Ricans––pose problems in therapy? • What languages are spoken within the community? • What are the typical communication styles, including body language, of various racial/ethnic groups? Are clients likely to speak in a group setting? Would they speak only with others of their same culture? Would they speak in an ethnically mixed group? • How do clients think about the cultures of the world? Do they have pronounced prejudices? How do they understand the major and minor cultural subgroups that make up the community? • How do language, social class, race/ethnicity, and gender affect the outward signs and symptoms of substance abuse, emotional distress, and mental illness? • In any local cultures, do specific social stresses, such as homelessness or uncer­ tain immigration status, complicate the problem of coping with substance abuse and psychiatric disorders? • What are community views about different kinds of substances? Is alcohol more acceptable than marijuana? Marijuana more acceptable than cocaine? Are males with addictions tolerated more than females? • How do various cultural subgroups perceive women in the community? The elderly? Lesbian, gay, and bisexual persons? Do you understand your own thoughts, feelings, and experiences regarding other cultures?

• With what cultural groups other than your own do you have frequent contact? • With what ethnic groups do you have contact? How frequently? • What are some of the key characteristics of these groups? • What do you know about the principal cultural groups in the country? In your community? • What are the main ethnic groups in the United States? • What are the important characteristics of your own culture? • How does your culture affect the way you interact with others? What is your culture’s style of interaction?

50 Criteria for the Placement of Clients in Groups Figure 3­9

Self­Assessment Guide (continued)

• Do you have a personal style that differs from your culture’s norms? • Toward which cultural groups do you feel positive? Which groups make you feel uneasy or uncomfortable?

• Are you comfortable counseling persons with sexual orientations different from yours? • Have you worked with a variety of age groups? • Do you have substantial knowledge of any particular population’s key attributes and values regarding child rearing, marriage, financial matters, and other major matters of life? • Do you know any other group’s social and political history well enough to predict its impact on group dynamics around a given issue? What resources in the community are available to meet the needs of special populations?

• Are cofacilitators with special expertise, such as fluency in other languages, available to assist with groups? • Are services available in other languages? Have support groups been designed for racial/ethnic groups? Lesbians and gay men? Women? Elderly people? • What State­ and community­based organizations provide social services for people from nonmainstream cultures? What systemic barriers and staff attitudes and beliefs inhibit cultural sensitivity and competence in your programs?

• Is cross­cultural training available to group leaders? • Are any staff members fluent in languages spoken by potential clients in group? • Is there someone in your agency or organization who assists clients with social services support, including Medicaid? What are the characteristics of the person about to be placed?

• Are the client’s language skills adequate to permit participation in this group? • To what degree is the client acculturated? For example, how long has a Salvadoran been in this country? • Is the client discriminated against? • Does this client share traits (for example, educational attainment, socioeconom­ ic status, motivation level) with others in the group who are not from the same population? • How familiar is the client with the goals of therapy? With group therapy?

Criteria for the Placement of Clients in Groups 51 Figure 3­9

Self­Assessment Guide (continued)

• How does the client currently relate to the therapist? To treatment in general? • How would the client fit into an existing group? Would the client be the only representative of that culture in the group? What is the current makeup of the group with respect to cultural diversity? What views do current members hold toward the prospective member’s culture? • How long has the person been a resident of your community? Is the client trav­ eling from another community for therapy? How long has the person been a resident of this geographical area? • Would the client fit in better with a homogeneous group; for example, a single­ sex group for a woman who has been a victim of sexual abuse or incest? • How does the client’s family handle issues of power and control? Independence and autonomy? Trust? Communication of feelings? • Does the culture of origin provide traditional healing practices that could be used in the group? • Might specific cultural issues affect the recovery process? • To what extent will the new client adapt to an existing group’s norms? • Will changes that satisfy the group’s norms alienate the client from the culture of origin? • What are the alternatives to placing the person in a specific group? What accommodations may have to be made?

Source: Adapted from Winkelman 1995. Used with permission.

Diversity and Placement ings, or attitudes. Rather, group members are encouraged to share these feelings and beliefs In many groups, the composition of members verbally and overtly, even if this may be upset­ will be heterogeneous; for example, a majority ting to some or all of the group’s members” of Caucasians placed with a minority of ethni­ (Brook et al. 1998, p. 77). Although therapists cally or racially different members. The may be uncomfortable when group members greater the mix of ethnicities, the more likely talk about subjects like racism and discrimina­ that biases will emerge and require mediation tion, such expression sometimes is an impor­ (Brook et al. 1998). Whatever a client’s belief tant part of an individual’s recovery process. system or origin, “neither the therapist nor the group should ask any group member to give up First­generation immigrants who speak little or or renounce any ethnic/cultural beliefs, feel­ no English usually are underrepresented in

52 Criteria for the Placement of Clients in Groups group therapy because of their limited fluency. Assess the behaviors While an immigrant may be able to communi­ and attitudes of cur­ cate adequately in individual therapy with a rent group members Understanding the single healthcare professional, that newcomer to ascertain whether may be unable to follow a fast­flowing group the new client would cultural character­ discussion. match the group. From the start of a istics of major As previously mentioned, before placing a multicultural therapy client in a particular group, the therapist needs group, members racial and ethnic to understand the influence of culture, family should feel that race is structure, language, identity processes, health a safe topic to discuss populations will beliefs and attitudes, political issues, and the (Salvendy 1999). stigma associated with minority status for each Because group mem­ permit better­ client who is a potential candidate for a group. bers are less restricted In addition, the therapist will need to do the to their usual social following: circles and customary informed decisions ethnic and cultural Address the substance abuse problem in a man­ boundaries, the group about placement. ner that is congruent with the client’s culture. is potentially a social Each culture incorporates beliefs and values microcosm within that guide the behavior of everyone identified which members may with the culture and that govern experiences safely try out new ways of relating (Matsukawa related to the use of substances. Some cultures, 2001). Even so, potential problems between a for instance, use chemical substances as part of candidate and existing group members should rituals, some of them religious. This entwine­ be identified and counteracted to prevent ment of substance use and culture does not dropout and promote engagement cohesion mean that the therapist cannot discuss the issue among members. of this substance use with a client. Some clients, of their own volition, will reduce or Understand personal biases and prejudices eliminate the use of substances once they exam­ about specific cultural groups. A group leader ine their beliefs and experiences. should be conscious of personal biases to be aware of countertransference issues, to serve as Appreciate that particular cultures use sub­ a role model for the group, and to create group stances, usually in moderation, at specified norms that permit discussion of prejudice and types of social occasions. For many people, other topics relevant to a multicultural setting. occasional, moderate use of substances might be part of a meaningful social/cultural ritual, Understanding the cultural characteristics of but for people with substance use disorders major racial and ethnic populations—particu­ such use, even when culturally accepted, is larly their history, acculturation level, family contraindicated because it might provoke and community roles and relationships, health relapse, binges, or other destructive reactions. beliefs, and attitudes toward substance abuse— Again, a culturally sensitive discussion of this will permit better­informed decisions about the issue with clients may result in individual deci­ placement of individuals from these popula­ sions to abstain on these occasions, despite con­ tions into existing therapy groups. Naturally, siderable cultural pressure to use substances of no group leader can know everything about abuse. In contrast, some cultures have beliefs every culture, but a good counselor can be in direct opposition to the client’s use of sub­ aware of major characteristics of cultural stances. Helping the client redirect behavior to groups. This knowledge can guide the place­ come into accord with these beliefs may be an ment of clients into appropriate groups and important treatment approach.

Criteria for the Placement of Clients in Groups 53 Figure 3­10

Preparing the Group for a New Member From a Racial/Ethnic Minority

To promote cohesion, a positive group quality stemming from a sense of solidarity within the group, the group leader should

• Inform the group members in advance that people from a variety of back­ grounds and racial and ethnic groups will be in the group. • Discuss the differences at appropriate times in a sensitive way to provide an atmosphere of openness and tolerance. • Set the tone for an open discussion of differences in beliefs and feelings. • Help clients adapt to and cope with prejudice in effective ways, while maintain­ ing their self­esteem. • Integrate new clients into the group slowly, letting them set their own pace. • When new members start to make comments about others or to accept feed­ back, encourage more participation.

help a leader anticipate relationships and ten­ woman who showed her craft work without sions that may arise within a group. comment) are used to communicate indirect­ ly and acceptably. In such a situation, Figure 3­10 provides tools to prepare both the Matsukawa says, the therapeutic approach group and the minority client for the client’s is modified to perceive and permit a entry and integration into an established thera­ Japanese­American woman to present peutic group. herself tacitly without pressing for verbal elaboration. Therapists also should One researcher cites four major dynamic pro­ intervene if nonverbal communications are cesses that occur within a multiethnic group misinterpreted. (Matsukawa 2001). Identifying these processes as they function in a group may help a thera­ 2. Cultural transference of traits from one per­ pist predict whether a possible placement will son of a certain culture to another person of support a cohesive social microcosm or create a that culture. If a group member has had threatening and disruptive environment. experiences (usually negative) with people of the same ethnicity as the therapist, the 1. Symbolism and nonverbal communication. group member may transfer to the therapist In some cultural groups, direct expression the feelings and reactions developed with of thoughts and feelings is considered others of the therapist’s ethnicity. In short, unseemly. Matsukawa (2001) points out that Matsukawa (2001) says, the group member among the Japanese, a highly valued trait is jumps to conclusions and assigns traits to the ability to sense what another person the therapist based on ethnicity alone. The wants without explicitly stated cues. In such therapist first should detect these miscon­ a culture, symbolic gestures (a gift, perhaps) or nonverbal signals (the author describes a

54 Criteria for the Placement of Clients in Groups ceptions and then reveal them for what they treated may have some merit, the reality is that are to dispel them. such a course seldom is feasible. Health care 3. Cultural countertransference, the thera­ providers from culturally and linguistically pist’s (often subconscious) emotional reac­ diverse groups are underrepresented in the tion to a client. Therapists also can jump to current service delivery system, so it is likely conclusions. Countertransference of culture that a group leader will be from the main­ occurs when a therapist’s response to a cur­ stream culture (Cohen and Goode 1999). While rent group member is based on experience it might be ideal to match all participants by with a former group member of the same ethnicity in a therapeutic group, the most ethnicity as the new client. Matsukawa important determinants of success are the val­ (2001) cautions therapists to exercise ues and attitudes shared by the therapist and restraint when in the middle of a “counter­ group members (Brook et al. 1998). transference storm.” It should be noted that recent research suggests 4. Ethnic prejudice. “Stereotypes become prej­ that an ethnic match between therapist and udice,” Matsukawa (2001, p. 256) writes, client does not “consistently improve out­ “when they are hard to modify and when comes” (Salvendy 1999, p. 437). Other one’s interactions, or lack thereof, with research (Atkinson and Lowe 1995) suggests another person are based on preconceived that, while the ethnicity of the therapist is a feelings and judgments about the person’s factor that can influence treatment, it is by no race, without enough knowledge, under­ means the most important factor. Culturally standing, or experience.” In multiethnic specific homogeneous groups should be used groups, it is vital to develop an environment only when someone’s “cultural, religious, or in which it is safe to talk about race. Not to political beliefs are very different from the do so will result in scapegoating or division mainstream and they are not open to adjust­ along racial lines (Matsukawa 2001). ments,” as, for example, with recent immi­ grants or refugees (Brook et al. 1998; Ivey et In practice, people connect and diverge in ways al. 1993; Salvendy 1999, p. 457; Silverstein that cannot be predicted solely on the basis of 1995; Takeuchi et al. 1995; Yeh et al. 1994). ethnic or cultural identity. Two people from different ethnic backgrounds may share many If less acculturated people with limited lan­ other common experiences that provide a basis guage skills are treated in groups, the program for identification and mutual support. All the should provide bilingual clinicians who are sen­ same, it is possible to rule out some combina­ sitive to gender and culture. Therapists should tions. For example, two elderly men, one focus on problem­oriented, short­term treat­ Korean and the other Japanese, may not blend ment; should consider employing a proactive well since their cultures have clashed in the therapeutic style; and should be aware that past many times. Similarly, a single 17­year­old clients may view them as authority figures girl would not mix well with a group made up (Brook et al. 1998). primarily of middle­aged males. Potentially undesirable and distracting group dynamics In culturally specific groups, a member of the could easily be foreseen. Leaders are responsi­ focus culture usually runs the group, although ble for considering carefully the positions of this ideal situation is not always possible. If a people who are different in some way, especial­ trained clinician who also belongs to the group ly when planning fixed­membership groups. is not available, it may be advantageous to add a cofacilitator who belongs to the population, understands the population’s specific problems Ethnic and Cultural Matching and strengths, and can serve as a role model to Although arguments for matching the ethnicity assist the clinician. Of course, if the program is of the therapist with that of the group members not specifically focused on cultural or communi­

Criteria for the Placement of Clients in Groups 55 ty issues and is simply incorporating some cul­ Americans look to leaders as problemsolvers. In tural elements, the staffing requirements are Hispanic/Latino culture, people are equals until not as stringent. In such cases, the presence of a proven otherwise––roles do not automatically member of the culture that developed the prac­ constitute a supervisor/subordinate relationship tice or knowledge is desirable, but not vital. (Wilbur and Roberts­Wilbur 1994).

“Children often accompany their parents to Differences that may influence an individual’s therapeutic encounters to translate and provide perception of a leader’s role should be explored support” for immigrant parents, but relying on in the pregroup interview. The interviewer can “the children in this way actually perpetuates explain how the leader’s role may differ from isolation and decreases pressure to build a net­ what the client might expect. Later, in group, work of supports. Finding an interpreter who leaders need to be alert to unexpected differ­ not only speaks the language but also who may ences in interpretation of their actions. For share the values and the migration experience is example, a group member who expects the crucial to further the acculturation and therapy leader to exercise authority might view a lead­ process” (Nakkab and Hernandez 1998, p. 98). er’s attempt to empower the group as shirking responsibility. The leader can help by being explicit about his or her role and responsibili­ Other Considerations for ties in the group. Practice Group leaders also should be aware that people Groups may include people who have varying manage conflict in culturally diverse ways. A native New Yorker might have an in­your­face • Expectations of leaders approach to conflict, while some Asian • Experience in decisionmaking and conflict Americans may find a raised voice offensive. resolution Cultural factors may frame a client’s percep­ • Understanding of gender roles, families, and tion of conflict in a way not readily apparent to community the group. For an example, see Figure 3­11. • Values For more detailed information on cultural All these differences, and many others, will diversity in client placement, see the forth­ affect individual and group experiences. Group coming TIP Improving Cultural Competence leaders should be keenly aware of ways in in Substance Abuse Treatment (SAMHSA in which ethnicity and culture can affect participa­ development a). tion in interactive therapy. One of the most pro­ Once placement decisions are completed, group found ways that different cultural backgrounds development begins. Chapter 4 explains this may affect individuals in groups is in expecta­ process. tions of the leader. For example, many African

56 Criteria for the Placement of Clients in Groups Figure 3­11

Culture and the Perception of Conflict

A 33­year­old single, second­generation Chinese­Canadian woman joined a group after proper preparation. She was one of two non­Caucasians in this long­term, interpersonally focused, slow­turnover group. Unfortunately, in her first session, the group forcefully confronted an elderly man, who was emotionally abusive to his spouse and shirked responsibility for it. The new member froze throughout the session and was clearly very anxious. The therapist acknowledged her dis­ comfort and the stressfulness of the situation for her. Nevertheless, the following day this client wanted to discontinue group, feeling very threatened by the directness of the confrontation and its target, the elderly father figure. Her anxi­ ety was accepted as genuine and not seen as resistance by the therapist, who pro­ vided several individual sessions parallel to the group to clarify that this was not an attack on all fathers (including her own) in the group, and that it was done to help the elderly group member. This Chinese­Canadian client also was reassured that the other group members would be informed about the sociocultural reasons for her being upset, and that they would be empathic to her feelings on this mat­ ter. This intervention facilitated her integration in the group and her perception of the therapist as culturally credible and competent.

Source: Adapted from Salvendy 1999, p. 451.

Criteria for the Placement of Clients in Groups 57

4 Group Development and Phase­Specific Tasks

Overview In This This chapter begins by discussing the varying uses of fixed or revolving groups. Fixed groups generally stay together for a long time, while Chapter… members in revolving groups remain only until they accomplish their goals. Each is used for different purposes, and each requires different Fixed and leadership. Revolving Membership As treatment and recovery have stages, group development also changes Groups over time. The first phase pays attention to orientation and establishing Fixed Membership Groups safe, effective working relationships. In the middle (and longest) phase, Revolving Membership the actual work of the group is done. The end phase is a deliberate, Groups positive termination of group business. Each phase requires attention to specific tasks. Preparing for Client Participation in Groups Fixed and Revolving Membership Pregroup Interviews Groups Increasing Retention Identifying the Need for The way groups are developed varies by the type of group. A wide range Wraparound Services of therapeutic groups may be used with people who have substance use Group Agreements problems. For the purpose of this discussion, however, groups have been classified into two broad categories, each with the same two Phase­Specific subcategories: Group Tasks Beginning Phase— 1. Fixed membership groups Preparing the Group To A. Time­limited Begin Middle Phase—Working B. Ongoing Toward Productive 2. Revolving membership groups Change End Phase—Reaching A. Time­limited Closure B. Ongoing

59 Fixed Membership Groups training in group dynamics (such as individu­ als’ boundaries and the roles different mem­ Fixed membership groups are relatively small bers assume) and leadership along with excel­ (not more than 15 members); membership is lent supervisory skills. Examples in this catego­ relatively stable. Typically, the therapist ry include interpersonal process groups and screens prospective members, who then receive some psychoeducational therapy groups. formal preparation for participation. Any departure from the group occurs through a Fixed groups are rare because they demand a well­defined process. Two variations of this long­term commitment of resources. Most out­ category are patient programs provide only 8–20 sessions, and most inpatient programs are limited to •A time­limited group, in which the same 2–4 weeks. group of people attend a specified number of sessions, generally starting and finishing together Revolving Membership • An ongoing group, in which new members fill Groups vacancies in a group that continues over a New members enter a revolving membership long period of time group when they become ready for the service In time­limited groups with fixed membership, it provides. Revolving membership groups fre­ learning builds on what has taken place in quently are found in inpatient treatment pro­ prior meetings. Thus, members need to be in grams. As clients are admitted and discharged, the group from its start. New members are people come and go in the group. Conse­ admitted only in the earliest stages of group quently, revolving groups must adjust to fre­ development (for example, only during the first quent, unpredictable membership changes. week for a daily group or during the first The two variations of revolving membership month for a group that meets weekly). Ongoing groups are fixed membership groups may be used for •A time­limited group that members generally short­term therapy, skill building, psychoedu­ join for a set number of sessions cation, and relapse prevention. •An ongoing group that clients join until they In ongoing groups accomplish their goals with fixed member­ ship, the size of the Revolving membership groups can be larger group is set; new than fixed membership groups. The temptation members enter only to have many members often is strong due to New members when there is a insufficiently trained staff and shortages of vacancy. The leader funding. While revolving membership groups enter a revolving generally is less have no absolute limit on the number of mem­ active than is the bers, it is prudent to keep the group small membership group leader of a time­lim­ enough (about 15 or fewer) for participants to ited group, since the feel heard and understood, for the leader to know each of them, and for members to feel a when they become interaction among group members is sense of connection and belonging to the group. If a group becomes too large (more than 20), ready for the ser­ more important than leader­to­member group interaction breaks down and the clients interactions. To con­ become a class made up of individuals, rather vice it provides. duct this type of than a single, cohesive, therapeutic body. group, the leader Revolving membership groups generally are needs substantial more structured and require more active lead­

60 Group Development and Phase­Specific Tasks ership than fixed mem­ Several possible varieties of ongoing groups bership groups. have revolving membership. Such groups may Participation and be (1) open­ended, with clients staying for as learning are not highly many sessions as they wish; (2) repeating sets of One advantage to dependent on atten­ topics, with clients staying only until they have dance at previous ses­ completed all of the topics; or (3) a duration­ revolving member­ sions. In some settings, specific format, with clients attending for a set new members may be number of weeks (either consecutively or non­ ship groups is the brought in at fixed consecutively). An interpersonal process group intervals. In a daily as part of an intensive outpatient program is an stimulation that group, for instance, example of an ongoing group with revolving new members might membership. Clients enter this treatment group enter once a week. and attend until the work specified in the treat­ new members Members who have ment plan has been completed. been in the group for a provide. substantial number of Other examples of revolving membership meetings often help to groups include inpatient unit groups, continu­ orient newer members. ing care drop­in groups, transition groups for inpatients leaving and moving to outpatient One advantage to care, psychoeducational groups, expressive revolving membership therapy groups, and long­term support groups, groups is the stimulation that new members such as ongoing continuing care groups and provide. A potential problem is that new group maintenance groups. Figure 4­1 (see p. 62) pro­ members may dread joining a group, feeling vides the characteristics of fixed and revolving themselves to be at a disadvantage because membership groups. existing members already know each other, how the group operates, and what has been dis­ cussed in previous sessions. For its part, the Preparing for Client group itself may be apprehensive about the new Participation in Groups member (Rasmussen 1999). A related possible problem is the adverse effect Pregroup Interviews that membership changes can have on group Research shows a strong tendency toward cohesion. For these reasons, preparation for relapse early in the substance abuse treatment revolving groups is of paramount importance: process. A person early in recovery is at Group leaders need to pay special attention to greater risk for returning to use than someone helping new members become acclimated to the with 3, 6, or even 18 months of abstinence group, and clients chosen to fill a group vacan­ (Johnson 1973; Project MATCH 1997). The cy should have the capacity to observe and better clients are prepared for treatment, how­ adjust to the dynamics of the group ever, the longer they stay in treatment. If clini­ (Rasmussen 1999). cians ensure that clients come to the group with In time­limited groups, each member generally appropriate expectations, both clinicians and is expected to attend a certain number of ses­ clients can expect a greater degree of success. sions for a certain number of weeks or months. Group leaders should conduct initial individual A psychodrama group (one kind of expressive sessions with the candidate for group to form a therapy group), for example, might be offered therapeutic alliance, to reach consensus on every spring. Other common examples include what is to be accomplished in therapy, to edu­ psychoeducational groups and some skills­ cate the client about group therapy, to allay building groups. anxiety related to joining a group, and to

Group Development and Phase­Specific Tasks 61 Figure 4­1

Characteristics of Fixed and Revolving Membership Groups Entry Group Development Examples Fixed Membership Groups Time- •New members admitted •Learning built on what •Short­term therapy groups limited only in earliest stages of has happened in prior •Skills­building and group development meetings psychoeducational groups •Groups begin and end with •Relapse prevention groups same membership

Ongoing • Group size fixed •Dynamics of group process •Ongoing interpersonal •New members enter (such as individuals’ process groups only after vacancy or boundaries and the roles •Long­term supportive graduation different members assume) therapy groups are the primary source •Members expected to stay of learning, healing for for a substantial period of participants time Revolving Membership Groups Time- •Number of sessions •Learning at each session •Expressive therapy limited usually fixed relatively independent of groups (dance therapy, previous group sessions psychodrama) •Psychoeducational groups •Some skills­building groups Ongoing •Clients may (1) stay as •More structured •Client hall groups long as they wish, (2) be •Active leadership •Day hospital check­in required to attend sessions groups with set topics, or (3) be •Continuing care drop­in required to attend set groups number of weeks •Transition groups for •Usually a set maximum clients leaving inpatient number of participants and moving to outpatient care •Psychoeducational groups •Expressive therapy groups •Long­term supportive groups, such as ongoing continuing care groups and maintenance groups

62 Group Development and Phase­Specific Tasks explain the group agreement. These activities Explain how group interactions compare to may take as little as one meeting or as long as those in self­help groups, such as Alcoholics several weeks (Rutan and Stone 2001). Anonymous (AA). Clients should be informed Normally, the longer the expected duration of that group therapy differs from 12­Step or the group, the longer the preparation phase. other similar recovery groups. In particular, Clients should have an opportunity to air any the member­to­member “cross­talk” discour­ concerns, especially if they are apprehensive aged in 12­Step groups is an essential part of about their cultural status within the group. interactive therapy (Margolis and Zweben During this time, the group facilitator should 1998). Although clients sometimes perceive a learn how the client handles interpersonal conflict between their AA or Al­Anon experi­ functions on a day­to­day basis, how the ence and group therapy due to these different client’s family functions, and how the client’s formats, the therapist should know with cer­ culture perceives the substance abuse problem. tainty that the two are not mutually exclusive, but that they serve different functions and pro­ The process of preparing the client for partici­ vide support in distinct, complementary ways pation in group therapy begins as early as the (Vannicelli 1992). Therapists also should be initial contact between the client and the pro­ careful to distinguish treatment groups from gram. Clients’ preconceptions about the group, AA’s self­help approach, which, having no for­ their expectation of how the group will benefit mal leadership, cannot provide meaningful them, their understanding of how they are accountability (Vannicelli 1992; Zweben 1995). expected to participate, and whether they have experienced a motivational session prior to the Emphasize that treatment is a long­term pro­ group will all influence members’ participation. cess. Participants should know in advance that in group therapy, each person’s attendance at Preparation meetings serve a dual purpose. each session is vital. They should also recognize First, they ensure that clients understand that while the first 3 months of treatment after expectations and are willing and able to meet detoxification are critical, fully effective treat­ them. Second, these meetings help clients ment takes much longer. become familiar with group therapy processes. Where in­depth, one­on­one meetings are Let new members know they may be tempted to impractical because of group size or other con­ leave the group at times. It should be empha­ siderations, at least some form of orientation sized that although the work is difficult and should be provided, perhaps in the form of even upsetting at times, clients gain a great deal readings, videotape, group preparation meet­ from persistent commitment to the process and ing, or discussion with the primary counselor should resist any temptation to leave the group. prior to attending a group. Clients also should be encouraged to discuss thoughts about leaving the group when they Pregroup interviews are widely used to gather arise so that the antecedents of these thoughts useful information about clients and prepare can be examined and resolved. them for what they can expect from a group. The pregroup interview should cover clients’ Give prospective and novice members an goals for treatment, the group contract, client opportunity to express anxiety about group behaviors that might present an obstacle to work, and help allay their fears with informa­ group work, and any other information that tion. For some prospective members, group clients feel may be pertinent (Vannicelli 1992). process work may need to be demythologized. Clients should be thoroughly informed about Misperceptions should be countered to keep what group therapy will be like. In addition, them from interfering with group participation. client preparation should address the follow­ Some providers conduct a short­term group to ing: prepare clients for upcoming participation in other kinds of groups. This approach enables

Group Development and Phase­Specific Tasks 63 leaders to assess clients’ suitability for various It is important to explore issues of difference in types of group work. advance of group placement. It similarly is important to acknowledge cultural or ethnic Recognize and address clients’ therapeutic backgrounds and to emphasize that differences hopes. With help, clients can explain how they can be strengths that can contribute to the think group work can help them, identify their group. If a client believes that a particular preferences, and articulate realistic goals. group situation would be uncomfortable, how­ Leaders can use this information to be sure ever, the counselor may offer the client other that clients are placed in groups most likely to treatment options. fulfill their aspirations. The counselor also is responsible for raising the For a sample dialog that takes place in a prepa­ level of group members’ sensitivity and empa­ ration interview, see “Preparing the Patient for thy. It is important at times, for instance, to Group Psychotherapy” (Hoffman 1999). prepare group members for situations in which others have symptoms that could offend or In preparing prospective members for a group repel them. The therapist can initiate discus­ experience, it is important to be sensitive to sion by asking questions such as, “What would people who are different from the majority of it be like for you to be with people who some­ the other participants in some way. Such a per­ times cut themselves?” son may be much older or younger than the rest of the group, the lone woman, the only While group leaders have many responsibilities member with a particular disorder, or the per­ to prepare clients for participation in groups, son from a distinctive ethnic or cultural minori­ the clients have obligations, too. Their respon­ ty. The leader should consult privately with sibilities are specified in group agreements, dis­ people who stand out in the group to determine cussed later in this chapter. from their unique perspective how they are experiencing the group. They should always be allowed to be the experts on their own situa­ Increasing Retention tion. Further, clients should be encouraged to Throughout the initial sessions of therapy, define the extent of their identification with the clients are particularly vulnerable to return to groups to which they belong and to determine substance use and to discontinue treatment. what that identification implies. The first month appears to be especially critical (Margolis and Zweben 1998). Yalom (1995) The fixed membership format provides more writes that premature termination usually time to discuss issues of difference prior to “stems from problems caused by deviancy, sub­ joining a group. A person unlike the rest of grouping, conflicts in intimacy and disclosure, the group may be asked by the other group the role of the early provocateur, external members: stress, complications of concurrent individual •How do you think you would feel in a and group therapy, inability to share the lead­ group in which you differ from other group er, inadequate preparation, and emotional con­ members? tagion” (p. 315) (a concept discussed later in •What would it be like to be in a group where chapter 6). everyone else is a strong believer in some­ Retention rates are affected positively by client thing, such as AA, and you are not? preparation, maximum client involvement dur­ Such questions might be coupled with positive ing the early stages of treatment, the use of comments that stress the benefits that a unique feedback, prompts to encourage attendance, perspective may bring to the group. and the provision of wraparound services (such as child care and transportation) to make it possible or easier for clients to attend regularly.

64 Group Development and Phase­Specific Tasks Consideration needs to be given to the timing sobriety and the use of a continuing care and length of groups, too, because these factors participation contract. affect retention. •An appointment card and an automated telephone message reminder of each upcom­ To achieve maximum involvement in group ing group session. therapy during this period, motivational techniques, such as psychoeducation and •A note from the therapist following the first attendance prompts, may be used to engage the session saying that he was glad the client client. Evidence suggests that if people are self­ chose to attend the group and was looking motivated, they will persist longer in behaviors forward to seeing the client at upcoming consistent with recovery, and will attach more sessions. value to their quest than they would in •At least two follow­up phone calls after response to external pressure. Incorporating missed sessions (Lash and Blosser 1999). motivational elements in pregroup preparation or offering groups that focus on motivation is Yalom (1995) notes that it is common practice likely to increase compliance with continuing for therapists to try to forestall premature ter­ care requirements (Foote et al. 1999). mination by persuading clients who plan to leave group to attend just one more session. Some pretreatment techniques that appear to The hope is that other group members will reduce the incidence of dropping out include persuade the restless member not to drop out. the following: This tactic rarely works, however. Instead, during the preparation of clients for group, •Role induction uses formats such as inter­ Yalom suggests emphasizing that periods of dis­ views, lectures, and films to educate clients couragement are likely to occur during therapy. about the reasons for therapy, setting realistic goals for therapy, expected client behaviors, Another effective way to retain clients can be and so on. used in groups that have a few veteran mem­ •Vicarious pretraining using interviews, lec­ bers. When new members join, the old mem­ tures, films, or other settings demonstrates bers are asked to predict which new member what takes place during therapy so the client will be the first to drop out. This prediction can experience the process vicariously. paradoxically increases the probability that it will not be fulfilled (Yalom 1995). •Experiential pretraining uses group exercises to teach client behaviors like self­disclosure Researchers note that and examination of emotions. these simple initia­ •Motivational interviews use specific listening tives, which make so To achieve maxi­ and questioning strategies to help the client much difference in overcome doubt about making changes continuing care (Walitzer et al. 1999). engagement, and the mum involvement outcomes of treat­ Prompts to remind clients of upcoming group ment, “required mini­ in group therapy sessions are another important way to engage mal clinical and cleri­ group members during the first 3 months of cal time to conduct” during this period, treatment (Lash and Blosser 1999). One suc­ (Lash and Blosser cessful strategy increased the number of clients 1999, p. 58). motivational who began continuing care group therapy and However, while auto­ nearly doubled the attendance at group sessions mated phone techniques may (Lash and Blosser 1999). The plan included: reminders might be useful for highly •An explanation to each client of the impor­ be used. structured skills­ tance of continuing care in maintaining building groups early

Group Development and Phase­Specific Tasks 65 in recovery or for groups of low­functioning they provide wraparound services to meet these clients, in interpersonal process groups with and other practical needs, they retain clients in higher functioning clients, the prompts might therapy longer. As a result, clients are more set up norms that place too much responsibility likely to develop new behaviors and thought on the leader and too little on group members. processes that enable them to remain abstinent. Two examples of programs that provide such services are described in Figures 4­2 and 4­3. Identifying the Need for Wraparound Services The first step toward wraparound services is to document the need for them. The next step is Practical problems, such as a lack of suitable to recognize that wraparound services seldom childcare or transportation, deter many clients flourish in isolation. A thorough search of from participation in substance abuse counsel­ existing community resources may identify ser­ ing services. Many programs find that when vices already in place that could meet some

Figure 4­2

The Family Care Program of the Duke Addictions Program

The Family Care Program (FCP) at Duke University in Durham, North Carolina, is a substance abuse program for women who abuse substances and are pregnant and/or mothers of young children. Transportation is a major diffi­ culty for many of the women and should be provided if their group experience is to be consistent. Using vans supplied by the county and the State, FCP uses Medicaid funding to provide transportation to and from approved medical inter­ ventions. The program schedules appropriate transportation for the mother and her children on days that therapy is provided at the Duke Addictions Program.

Viewing the mother and child dyad as the client, FCP provides wraparound ser­ vices to support the involvement of the woman and her children in treatment. FCP works closely with the Department of Social Services, the Child Protection Team at Duke University Medical Center, Head Start, and Vocational Rehab­ ilitation, thus providing a wide range of services, all coordinated through FCP.

Because women are encouraged to bring their infants to group, changing tables and diapers are available within the group space. For the physical comfort of pregnant women, particularly those in the later stages of pregnancy, rooms are furnished with chairs that move into a variety of positions. Older children who are not yet in school are also included in the treatment pro­ gram. Because these children could be upset by the subject matter that can arise in the group, they are not present when women are discussing sensitive issues. Instead, they have their own treatment programs, supported by a specially trained child treatment and intervention specialist, who works with the children on issues of self­esteem, life skills, overall adjustment, and academic performance. Source: Jeffrey M. Georgi, Senior Clinician, Duke Addictions Program.

66 Group Development and Phase­Specific Tasks Figure 4­3

SageWind

SageWind in Reno, Nevada, provides a variety of wraparound services to sup­ port clients in recovery. First, it has a working agreement with the local school district’s alternative high school education program, under which two teachers help clients acquire high school credits that can be transferred to other schools in the district. SageWind pays the salary of one teacher and the district pays the other. SageWind also hires two summer school teachers in order to offer clients year­round schooling. Throughout the year, college students and other adult volunteers provide tutoring.

SageWind has a full­time wellness coordinator who is a licensed substance abuse counselor. The wellness program includes a wide range of recreational activities designed to teach clients to enjoy alcohol­ and drug­free experiences. Clients participate in such activities as woodshop projects, along with basketball, pool, bowling, baseball, and volleyball games.

Through a Qualified Service Organization Agreement with the county health department, SageWind offers onsite mandatory tuberculosis testing and counsel­ ing and voluntary HIV and pregnancy testing and counseling. A registered nurse teaches a weekly health class on issues ranging from communicable diseases to nutrition. Treatment technicians can provide transportation, picking up clients for treatment and returning them to work or home. When necessary, SageWind also offers bus passes.

An onsite mental health and family clinic at SageWind addresses co­occurring disorders and strengthens the family unit. Multifamily group counseling, family support groups, couples counseling, and family therapy help develop skills need­ ed for the survival and growth of the family.

All of SageWind’s primary counselors also function as case managers. If a client or the client’s family needs housing, food, clothing, or medical care, counselors will provide referral information and assistance. SageWind receives donated returned items from two of the area’s largest retailers. The agency maintains a clothes closet and can also help clients obtain household furnishings and similar necessities. Any remaining items are donated to other nonprofit organizations in nearby areas.

Finally, a full­time career counselor at SageWind facilitates a career track. The counselor provides individual and group services, as well as onsite monitoring of clients’ job performance. The goal is to assist clients not only to gain employ­ ment, but to perform well consistently in their jobs. Source: A Consensus Panel member.

Group Development and Phase­Specific Tasks 67 needs. Services still needed can be provided by agreement as the basis for group activities, initiating cooperative ventures with organiza­ group members can be asked to recall specific tions that have similar interests and comple­ agreements during the first session. To an mentary capabilities. Note all the cooperation appropriate response, the leader can reply, between and among organizations described in “Yes, that’s an important one.” Responses that Figures 4­2 and 4­3. are distorted may be referred to the group to determine how others recall the agreement (Vannicelli 1992). Group Agreements The agreement provides for “a mutual under­ A group agreement establishes the expectations standing of the common task and the conditions that group members have of each other, the under which it will be pursued. It is through leader, and the group itself. For example, the contract that the leader derives his authori­ many leaders require that group members ty to work: to propose activities, to confront a entering long­term fixed membership groups member, to make interpretations. And it is by commit to remain in the group for a set period. virtue of the contract that certain other activi­ Another common provision of group contracts ties can be declared ‘out of bounds’ by either stipulates that sessions will start and end at leader or member” (Singer et al. 1975, p. 147). specific times. The leader should make sure that these time boundaries are observed, both Sometimes, obtaining compliance to the group by clients and the leader. Group members can­ agreement requires flexibility and ingenuity. In not be expected to abide by the group agree­ some cultures, for example, time is a process, ment if the leader does not. not a concept represented by a number. Of course, it remains important to maintain time A group member’s acceptance of the contract boundaries. However, when many group mem­ before entering a group has been described as bers share a culture or ethnicity with a marked­ the single most important factor contributing to ly relaxed attitude toward time, it may be the success of outpatient therapy groups appropriate to design and adhere to a structure (Flores 1997). Consequently, it is important to appropriate for that group. For example, present the contract SageWind accommodates its Hispanic/Latino in a way that causes clients’ flexible view of time and traditions of clients to view it as a sociability. One model moves clients from a true commitment shared lunch to group. By the time group starts, It is important to and not a mere for­ all its members have arrived and are ready to mality. Particularly begin group work. Another tactic is to schedule present the con­ with people referred longer group times that enable members to move to treatment through into group work from a socializing phase, usual­ the criminal justice tract in a way that ly including rituals of food or music. system, it is impor­ tant to make thera­ causes clients to The group agreement is intended to inspire peutic contracts that clients to accept the basic rules and premises of are explicit and view it as a true the group and to increase their determination clear, and that carry and ability to succeed. These agreements are a firm expectation not meant to provide a basis for excluding or commitment and that the agreement is punishing anyone. On the contrary, the leader to be honored by all should understand that few group members are not a mere members of the able to meet all stipulations in the agreement group. throughout their recovery. When provisions of formality. the group agreement are violated, the leader To reinforce the should avoid assuming an authoritarian role importance of the

68 Group Development and Phase­Specific Tasks Figure 4­4

Examples of Agreements About Time and Attendance

Regular and timely attendance at all Attendance. Regular attendance and sessions is expected. As a member, it is punctuality increase the value of the your responsibility to notify the group group for each member. Such cohe­ in advance when you know that you siveness creates a climate of work, will be away or late for group. support, and success. In the event of a member’s inability or decision not to To emphasize the importance of each attend a session, a telephone call to person to the group, members are also this effect is expected. Group will required to notify the leader when begin and end promptly at the desig­ they are unable to attend. nated times. Group members will agree to be in group at the time it Members joining long­term groups starts and stay until it finishes. remain as long as they find the group useful in working on important issues Commitment. Members are allowed to in their lives. We recommend at least 1 join the group only if they are willing year’s participation. to make a 6­month commitment.

Members are required to make an ini­ This agreement ensures that the group tial 3­month commitment in order to process will not be disrupted by mem­ determine the usefulness of this partic­ bers “dropping in” for one or two ses­ ular group for them. sions and then dropping out of the group. The agreement also ensures In the event of an unexpected absence, that any person who joins the group group members are expected to notify will be making enough of a commit­ the group at least 24 hours in advance ment to benefit from the group. to avoid being charged for the missed session.

Source: Vannicelli 1992, p. 295. Source: Philip J. Flores.

and instead ask questions that refer infractions Communicating grounds for to the group. The violation becomes important exclusion and useful material for group members to dis­ cuss as part of the group process. The errant The terms under which clients will be excluded behavior should be understood as a meaningful from the group should be made explicit in the deviation and approached with interest and group agreement, so exclusion does not come as curiosity, not with an air of reproach. See a surprise. Some stipulations in the group Figures 4­4 and 4­5 (see p. 71) for examples of agreement might have to incorporate legal group agreement stipulations. requirements since court­mandated treatment groups may have attendance criteria set by the State. If so, the State will set forth the conse­ quences for failure to attend the requisite num­ ber of sessions.

Group Development and Phase­Specific Tasks 69 Confidentiality betrayed when someone outside the group knows about something said within the group. Group members should be asked not to discuss anything outside the group that could reveal Except in situations specified in Federal law, the identity of other members. The leader programs may not disclose information about should emphasize that confidentiality is critical the services a client receives without the client’s and should strongly encourage group members written consent. The law is explained in detail to honor their pledge of confidentiality. The in Confidentiality of Patient Records for principle that “what is said in the group stays Alcohol and Other Drug Treatment (Lopez in the group” is a way of delineating group 1994). boundaries and increasing trust in the group. This atmosphere of trust is essential for group The leader should emphasize how to structure members to feel safe enough to disclose their consent and disclosure, especially through dis­ feelings and problems. cussion of the minimum necessary principle. Only specific information can be disclosed. Though group members are precluded from Legal requirements commonly require, for identifying other members of the group or dis­ example, that the therapist report instances of cussing anything they say, members can discuss elder or child abuse and take action when the themes of the group and what they person­ clients threaten to harm themselves or others. ally have said. In fact, talking about the group Actions might include the hospitalization of the with a significant other or therapist in a way prospective perpetrator and/or a warning to that does not violate the confidentiality of oth­ the intended victim. Group leaders need to be ers can be important to a client’s growth. familiar with confidentiality requirements in their programs and their States. See chapter 6 Under some circumstances, as defined by the for a discussion of confidentiality. Federal confidentiality regulation or by more stringent State regulation, certain information may be shared. Physical contact However, the infor­ Touch in a group is never neutral. People have mation shared with­ different personal histories and cultural back­ out consent is grounds that lead to different interpretations of restricted by the what touch means. Consequently, the leader minimum necessary should evaluate carefully any circumstance in clause. Refer to 42 which physical contact occurs, even when it is Group leaders C.F.R., Part 2, intended to be positive. In most groups, touch Confidentiality of (handholding or hugs) as part of group rituals need to be familiar Alcohol and Drug is not recommended, though in others (such as Abuse Patient an expressive therapy or dance group), touch with confidenti­ Records to identify may be acceptable and normative. Naturally, the specific circum­ group agreements always should include a ality requirements stances under which clause prohibiting physical violence. these exceptions apply. Group mem­ in their programs Use of mood­altering bers should know what information substances and their States. about them might be Some programs, especially ones connected to shared and why, the judicial system, have policies that require how, and when this expulsion of group members who are using sharing occurs, so drugs of abuse. Counselors are required to they do not feel report these violations. Part of client prepara­

70 Group Development and Phase­Specific Tasks tion and orientation is to explain all legally viding that group rules permit and encourage mandated provisions and consequences for such disclosures). failure to comply with group and treatment guidelines. Contact outside the group Many in the substance abuse treatment field Generally speaking, the group agreement believe that such rules lead to withholding of should discourage personal contact outside the information (Vannicelli 1992). They reason that group. The reality is, however, that clients who clients cannot be open and honest about sub­ have bonded in group are likely to communi­ stance use if their candor is punished. A rea­ cate outside the group and may encounter each sonable requirement, many believe, is that other on occasions like AA meetings. Under clients “must be in an appropriate condition to some circumstances, it may even be desirable participate in order to be at the group. This to encourage individuals who support each allows the therapist to make a clinical judgment other’s efforts to abstain from substance abuse. on a case­by­case basis, as to whether or not a The group members need to be told and client who has slipped may benefit from being reminded that new intimate relationships are in the group that night” (Vannicelli 1992, pp. hazardous to early recovery and are therefore 59–60). Members also should pledge to discuss discouraged. Further, any contacts outside the a return to use promptly after it occurs (pro­ group should be discussed openly in the group.

Figure 4­5

Examples of Agreements About Group Participation

Members will have a commitment to To help you benefit most from your talk about important issues in their group experience, you will agree to: lives that cause difficulty in relating to others or in living life fully. Talk about the issues and problems that prompted you to join the group. Members will have a commitment to talk about what is going on in the Tell the emotionally meaningful stories group itself as a way of better under­ of your life. standing their own interpersonal Verbally communicate your immediate dynamics. thoughts and feelings about yourself, the group leaders, and the group members.

Take an equal share of the total talk­ ing time.

Not leave the group before you com­ plete or resolve what you came to the group to address.

Source: Vannicelli 1992, p. 295. Source: Philip J. Flores.

Group Development and Phase­Specific Tasks 71 Participation in the life of should emphasize the need to involve the group the group in termination decisions. Ultimately, however, the group members should make their own The group agreement should specify what choice about discontinuing treatment. group members are expected to divulge. For example, group members should be willing to Premature termination (dropping out) may discuss, in an honest way, the issues that have serious consequences for some clients. brought them to the group. Instructions to par­ Court­referred clients (those on parole, proba­ ticipants should emphasize that they are tion, and so on) must be reported if they drop responsible for maintaining their personal out of treatment. The group agreement should boundaries, and they should participate at the clearly state all requirements for reporting and pace and level they find comfortable. They all consequences established by the referring should not be required to share personal infor­ agency. Members of the group should all clear­ mation until they feel safe enough to do so. ly understand what behaviors might lead to a premature termination. Financial responsibility In the group agreement, members agree to pay Phase­Specific Group their bills at a specified time. The agreement also may specify (1) a commitment to discuss Tasks any problems that occur in making payments Every group has a beginning, middle, and end. (Vannicelli 1992) and (2) the circumstances These phases occur at different times for differ­ under which a group member will be held ent types of groups. One or two sessions of a responsible for payments. For example, group particular revolving membership group may members should know ahead of time that they cover all three stages of group therapy for a will be financially responsible for missed ses­ particular client, while for a long­term fixed sions if that is the agency policy. membership group, several sessions may be only part of the beginning phase. Whatever the Termination type or length of a group, the group leader is responsible for attending to certain key ele­ Group agreements should specify how group ments at each of these points. (Note that this members should handle termination or occa­ discussion focuses on phases of group develop­ sions when they are ment, not phases of treatment.) considering termina­ tion. Sometimes, a group member close Beginning Phase––Preparing Premature to an emotionally the Group To Begin charged issue may During the beginning phase of group therapy, decide to terminate termination issues arise around topics such as orientation, rather than to con­ beginners’ anxiety, and the role of the leader. front the uncomfort­ (dropping out) The purpose of the group is articulated, work­ able feelings. ing conditions of the group are established, Because group mem­ members are introduced, a positive tone is set may have serious bers often are tempt­ for the group, and group work begins. This ed to leave the group phase may last from 10 minutes to a number consequences for prematurely instead of months. In a revolving group, this orienta­ of working toward tion will happen each time a new member joins some clients. the necessary the group. changes in their lives, the agreement

72 Group Development and Phase­Specific Tasks Introductions members will need to enter to ensure survival of the group. In contrast, revolving member­ Even in short­term revolving membership ship groups may have frequent changes groups, it is important for the leader to connect because of the demands of treatment payment with each member. This joining can be as sim­ guidelines or admission and discharge proce­ ple as a friendly smile and a one­word wel­ dures. Careful thought should be given to the come. At this time, all members, at the very pace and timing of membership changes for least, should have an opportunity to give their particular group types. names and say something about themselves. Some leaders ask members to introduce them­ selves. Others let the group figure out how to Group agreement review get acquainted. One cautionary note, however, The group agreement should be reviewed in an is that many clients treated for substance abuse interactive way, involving the group members in also have histories of emotional and physical discussion of the abuse. Merely directing attention toward them terms. The can trigger feelings of shame. Thus, while it is group leader extremely important to make connections should ask between and among group members and to members if they Ideally, member­ involve them in the process, the sensitive leader are aware of will not insist on recitations. Emotional safety concerns that ship changes always should be foremost in the group might require leader’s mind. additional group should be held to agreement pro­ At the first meeting of a fixed membership visions to make group, group members also may be asked if the group a safe a minimum, they know anyone else in the group. If there place to share are connections that might cause difficulties, and grow. especially in fixed they will be discovered at the start. Group members Each new member who joins the group is enter­ should have an membership ing the beginning phase of the group—for that opportunity to individual. It is not easy to find one’s place in suggest and dis­ groups. an already established group. The leader can cuss further help build bridges between old and new mem­ stipulations. In bers by pointing out that it is difficult to be the addition, the new member and by encouraging old members group agree­ to help the new one join the group. In long­ ment should be reviewed periodically. term fixed membership groups, the group will require careful preparation to receive a new Providing a safe, cohesive member graciously. Even in revolving member­ environment ship groups, which provide less opportunity for preparation, the leader should let members During the beginning phase of the group, all know when to expect membership changes, members should feel that they have a part to introduce new members, and help build play in the group and have something in com­ bridges—for example, by inviting existing mon with other members. This cohesion, both members to say something about the group and among clients and between the clients and the how it works. group leader, will affect the productivity of work throughout the therapeutic process. Ideally, membership changes should be held to Among the many components of group cohesion a minimum, especially in fixed membership are “connectedness of the group demonstrated groups, though as members graduate, new by working toward a common therapeutic goal;

Group Development and Phase­Specific Tasks 73 acceptance, support, and identification with begin to withdraw. Care always should be the group; affiliation, acceptance, and attrac­ taken not to shame group members or to allow tiveness of the group; and engagement” others in the group to engage in shaming (Marziali et al. 1997, p. 476). behaviors.

In the beginning phase, the leader ordinarily The leader also should bear in mind that in the needs to be more supportive and active than beginning phase, the group is unable to with­ will be necessary once the group gets under­ stand much conflict. Before the group develops way. If particular members have spoken very trust and cohesion, conflict is likely to disrupt little, it helps to let them know that their con­ proceedings or even to threaten a group’s exis­ tributions are welcome. The leader might say tence, so it is unwise to permit confrontation. something like, “We haven’t heard much from Instead the group leader should encourage you tonight, Jane, but perhaps next week the interaction that minimizes aggression and hos­ group will have a chance to get to know you a tility. Later, when the group is more stable, little bit more” (Vannicelli 1992, p. 48). group members may be urged to risk more provocative positions (Flores 1997). To help group members bond with each other, the leader should encourage the connections members begin to make on their own and Establishing norms should point out similarities. The leader might It is up to the leader to make sure that healthy say, for instance, “It seems that Sue and Bob, group norms are established and that counter­ and perhaps others in here as well, are strug­ productive norms are precluded, ignored, or gling with very similar problems with their extinguished. The leader shapes norms not only anger” (Vannicelli 1992, pp. 48–49). through responses to events in the group, but also by modeling the behavior expected of oth­ The leader also is responsible for ensuring that ers. For example, norms to be encouraged in a early in the group, emotional expression stays process group include honesty, spontaneity, a at a manageable level. Otherwise, members high level of attentive involvement, appropriate quickly may feel emotionally overloaded and

Figure 4­6

Reminders for Each Group Session

Open.

Announcements: Who will be late? Absent? Does the leader plan any absences?

If there are new members, welcome them. Then explain the goals of the group. Encourage new members to express their goals.

Track process.

To refocus the direction of the group, ask:

•How are things going (or feeling) in the group? •What is happening right now? •Does it feel as if we are on track?

74 Group Development and Phase­Specific Tasks Figure 4­6

Reminders for Each Group Session (continued)

Don’t fight what is hard––use it!

Capitalize on the energy of resistance (the client’s defense against the pain of self­examination) by

•Noticing it •Validating it by welcoming honesty •tLinking i to group goals Connect before tackling. Ally before confronting or stopping behavior.

Note the speaker’s positive intentions or efforts. Then ask the speaker to exam­ ine his behavior or change course.

Encourage mutual connections among members.

Underscore resonating responses, either verbal or nonverbal. Ask how others are reacting to what is being shared.

Share the work.

Use the group to help you when the going gets rough:

•Share your conflict and ask the group to help with it. •When a problem occurs, ask the group members to share their thoughts about how to proceed. For example, “Max clearly has a lot on his mind. Do we go with that issue or stick to where we were headed a few minutes ago?” Close.

Note that the time is up, or soon will be.

As you state the end boundary, ask if it is a hard time to end.

Source: Vannicelli, unpublished manuscript.

self­disclosure, the desire for insight into one’s hostile to new members (Flores 1997). The own behavior, nonjudgmental acceptance of leader should respond quickly and clearly to others, and the determination to change habits that impede group work and that threat­ unhealthy practices (Flores 1997). Unhealthy en to become normative. norms that could hamper a process group include a tendency to become leader­centered, one­dimensional (that is, all­loving or all­ attacking), or so tightly knit that the group is

Group Development and Phase­Specific Tasks 75 Initiating actively, but even in more content­oriented the work groups, nonverbal cues are indicative and should not be ignored. Termination is of the group The group, then, is a forum where clients inter­ a particularly act with others. In this give and take of thera­ The leader py, clients receive feedback that helps them facilitates the important rethink their behaviors and move toward pro­ work of the ductive changes. The leader helps group mem­ group, bers by allocating time to address the issues opportunity for whether by that arise, by paying attention to relations providing among group members, and by modeling a members to honor information in healthy interactional style that combines hon­ a psychoedu­ esty with compassion. Figure 4­6 (p. 74) sug­ the work they cational group gests some ways in which a group leader can or by encour­ help the group accomplish its middle­phase have done. aging honest tasks. exchanges among mem­ bers in other End Phase––Reaching Closure types of Termination is a particularly important oppor­ groups. Most leaders strive to keep the focus on tunity for members to honor the work they the here and now as much as possible. The have done, to grieve the loss of associations and leader also may need to prompt a new group friendships, and to look forward to a positive with questions such as, “You seem to be future. Group members should learn and prac­ responding to what Jane was sharing. Can you tice saying “good­bye,” understanding that it is tell us something about what was going on for necessary to make room in their lives for the you as she was talking?” (Vannicelli 1992, p. 50). next “hello.”

“Termination,” Yalom (1995, pp. 361–362) Middle Phase––Working observes, “is more than the end of therapy; it is Toward Productive Change … an important force in the process of change … a stage in the individual’s career of growth.” The group in its middle phase encounters and The group begins this work of termination accomplishes most of the actual work of thera­ when the group as a whole reaches its agreed­ py. During this phase, the leader balances con­ upon termination point or a member deter­ tent, which is the information and feelings mines that it is time to leave the group. In overtly expressed in the group, and process, either case, termination is a time for which is how members interact in the group. The therapy is in both the content and process. •Putting closure on the experience Both contribute to the connections between and •Examining the impact of the group on each among group members, and it is those connec­ person tions that are therapeutic. •Acknowledging the feelings triggered by Many new leaders focus strongly on content, departure but thoughtful attention to group process is •Giving and receiving feedback about the extremely important. Even in an educational group experience and each member’s role group, tension in the room, rolling eyes, or side in it conversations can interfere with messages that need attention. In a process group, these cues •Completing any unfinished business are part of the work and need to be explored

76 Group Development and Phase­Specific Tasks •Exploring ways to carry on the learning the ample advance notice (perhaps 4 weeks) to give group has offered the group time to process the feelings associated with the leave­taking (Flores 1997). Group Departing clients have been classified into three members should be given permission to exam­ groups. Completers have finished the work ine existential issues like loss, growth, death, they came into group to do. Plateauers are not the shortness of time, the unfairness of life, and really finished, but their progress has slowed or other thoughts that can prey on the mind stopped for the time being. Fleers feel an irre­ (Yalom 1995). So often, clients who used drugs sistible need to escape as rapidly as possible, or alcohol to anesthetize their grief over losses often because they have encountered an upset­ come to confront their grief in early sobriety. ting reality in the group or in their lives outside Every group facilitator working with substance the group (Vannicelli 1992). abuse therefore should understand the grief process and should be prepared to deal with The group may be invited to explore the pro­ grieving clients. posal that a member leave the group. In addi­ tion, the leader might ask clients about to ter­ It is natural for individuals and groups to try minate to classify themselves as completers, to hold onto each other. “Some isolated plateauers, or fleers. If the client is a fleer, that patients may postpone termination because person might be asked a hypothetical question: they have been using the therapy group for If you remained in group, what do you think social reasons rather than as a means for devel­ you might work on? Such a query might bring oping the skills to create a social life for them­ to light the issue the fleer wants very much to selves in their home environment. The thera­ avoid. To dissuade a person departing prema­ pist should help these members focus on trans­ turely, it may also help to comment, “One of fer of learning and encourage risk taking out­ the characteristics of a good decision is that it side the group” (Yalom 1995, p. 363). remains a good decision even after considera­ Alternatively, groups tion a few weeks later” (Vannicelli 1992, p. (and therapists) may 179). Then ask the client if, by that standard, subtly pressure a par­ his decision to leave will be a good one. ticular group member to remain because Whatever attempts are made to dissuade pre­ they value the depart­ In general, the mature termination, some people with sub­ ing member’s contri­ stance abuse problems inevitably will leave butions and will miss longer members groups abruptly, for a variety of reasons. him or her. When a Groups should be forewarned that sudden senior member leaves, have been with the changes may take place, and leaders should be however, another prepared to help group members cope with ordinarily will assume these changes. group, the longer the role just vacated Completing a group successfully can be an (Yalom 1995). they may need important event for group members, when they Some client feelings see the conclusion of a difficult but successful may concern parting to spend on termi­ endeavor (Flores 1997). The termination of a from the therapist. group also is an opportunity for clients to prac­ Some clients who are nation. tice parting, with the understanding that a exquisitely sensitive to departure leads to the next opportunity for abandonment, for connection. example, may deny Even positive, celebrated departures, however, the gains they have can raise strong feelings, so soon­to­depart made. They need reassurance that, once they members of an ongoing group should give improve, they no longer will need the therapist.

Group Development and Phase­Specific Tasks 77 In other reluctant clients, symptoms may In general, the longer members have been with recur. These people need help seeing the the group, the longer they may need to spend apparent setback for what it really is: fear of on termination. The group leader plays an termination (Yalom 1995). important role in termination, either facilitat­ ing an individual’s good­bye to the group or the Under no circumstances should the therapist group’s good­bye to itself (if the group is end­ “collude in the denial of termination” (Yalom ing). Although group leaders cannot say good­ 1995, p. 365). The client has to come to grips bye for the group, they can encourage the with the reality of leaving and not routinely group to fashion its own farewell. returning. The departing client and the balance of the group should face the fact that “the group will be irreversibly altered; replacements will enter the group; the present cannot be frozen; time flows on cruelly and inexorably” (Yalom 1995, p. 365).

78 Group Development and Phase­Specific Tasks 5 Stages of Treatment

Overview This chapter describes the characteristics of the early, middle, and In This late stages of treatment. Each stage differs in the condition of clients, Chapter… effective therapeutic strategies, and optimal leadership characteristics.

Adjustments To For example, in early treatment, clients can be emotionally fragile, Make Treatment ambivalent about relinquishing chemicals, and resistant to treatment. Appropriate Thus, treatment strategies focus on immediate concerns: achieving absti­ nence, preventing relapse, and managing cravings. Also, to establish a The Early Stage of stable working group, a relatively active leader emphasizes therapeutic Treatment factors like hope, group cohesion, and universality. Emotionally charged Condition of Clients in factors, such as catharsis and reenactment of family of origin issues, are Early Treatment deferred until later in treatment. Therapeutic Strategies in Early Treatment In the middle, or action, stage of treatment, clients need the group’s Leadership in Early assistance in recognizing that their substance abuse causes many of their Treatment problems and blocks them from getting things they want. As clients reluctantly sever their ties with substances, they need help managing The Middle Stage of their loss and finding healthy substitutes. Often, they need guidance in Treatment understanding and managing their emotional lives. Condition of Clients in Middle­Stage Treatment Late­stage treatment spends less time on substance abuse per se and Therapeutic Strategies in turns toward identifying the treatment gains to be maintained and risks Middle­Stage Treatment that remain. During this stage, members may focus on the issues of liv­ Leadership in Middle­ Stage Treatment ing, resolving guilt, reducing shame, and adopting a more introspective, relational view of themselves. The Late Stage of Treatment Condition of Clients in Adjustments To Make Treatment Late­Stage Treatment Appropriate Therapeutic Strategies in Late­Stage Treatment As clients move through different stages of recovery, treatment must Leadership in Late­Stage move with them, changing therapeutic strategies and leadership roles Treatment with the condition of the clients. These changes are vital since interven­ tions that work well early in treatment may be ineffective, and even harmful, if applied in the same way later in treatment (Flores 2001).

79 Any discussion of resolve the issues that arise at any stage of intervention adjust­ recovery. The result is that different group ments to make treat­ members may achieve and be at different stages With guidance, ment appropriate at of recovery at the same time in the lifecycle of each stage, however, the group. The group leader, therefore, should necessarily must be use interventions that take the group as a clients can learn oversimplified for whole into account. three reasons. First, to recognize the stages of recov­ Third, therapeutic interventions, meaning the ery and stages of acts of a clinician intended to promote healing, the events and treatment will not may not account for all (or any) of the change correspond perfectly in a particular individual. Some people give up situations that for all people. drugs or alcohol without undergoing treatment. Clients move in and Thus, it is an error to assume that an individu­ al is moving through stages of treatment trigger renewed out of recovery stages in a nonlinear because of assistance at every point from insti­ tutions and self­help groups. To stand the best substance use. process. A client may fall back, but chance for meaningful intervention, a leader not necessarily back should determine where the individual best fits to the beginning. in his level of function, stance toward absti­ “After a return to nence, and motivation to change. In short, substance use, generalizations about stages of treatment may clients usually revert to an earlier change not apply to every client in every group. stage—not always to maintenance or action, but more often to some level of contemplation. They may even become precontemplators The Early Stage of again, temporarily unwilling or unable to try to Treatment change . . . [but] a recurrence of symptoms does not necessarily mean that a client has Condition of Clients in Early abandoned a commitment to change” (Center for Substance Abuse Treatment 1999b, p. 19). Treatment See chapters 2 and 3 for a discussion of the In the early stage of treatment, clients may be stages of change. in the precontemplation, contemplation, prepa­ ration, or early action stage of change, depend­ A return to drug use, properly handled, can ing on the nature of the group. Regardless of even be instructive. With guidance, clients can their stage in early recovery, clients tend to be learn to recognize the events and situations that ambivalent about ending substance use. Even trigger renewed substance use and regression to those who sincerely intend to remain abstinent earlier stages of recovery. This knowledge may have a tenuous commitment to recovery. becomes helpful in subsequent attempts leading Further, cognitive impairment from substances to eventual recovery. Client progress­regress­ is at its most severe in these early stages of progress waves, however, require the counselor recovery, so clients tend to be rigid in their to constantly reevaluate where the client is in thinking and limited in their ability to solve the recovery process, irrespective of the stage problems. To some scientists, it appears that of treatment. the “addicted brain is abnormally conditioned, Second, adjustments in treatment are needed so that environmental cues surrounding drug because progress through the stages of recovery use have become part of the addiction” is not timebound. There is no way to calculate (Leshner 1996, p. 47). how long any individual should require to

80 Stages of Treatment Typically, people who abuse substances do not connected to a dysfunctional subculture enter treatment on their own. Some enter treat­ but socially isolated from healthy con­ ment due to health problems, others because tacts (Milgram and Rubin 1992, p. 96). they are referred or mandated by the legal sys­ tem, employers, or family members (Milgram Emphasis therefore is placed on acculturating and Rubin 1992). Group members commonly clients into a new culture, the culture of recov­ are in extreme emotional turmoil, grappling ery (Kemker et al. 1993). with intense emotions such as guilt, shame, depression, and anger about entering treatment. Therapeutic Strategies in Early Even if clients have entered treatment volun­ Treatment tarily, they often harbor a desire for substances In 1975, Irvin Yalom elaborated on earlier and a belief that they can return to recreation­ work and distinguished 11 therapeutic factors al use once the present crisis subsides. At first, that contribute to healing as group therapy most clients comply with treatment expecta­ unfolds: tions more from fear of consequences than from a sincere desire to stop drinking or using •Instilling hope—some group members exem­ illicit drugs (Flores 1997; Johnson 1973). plify progress toward recovery and support others in their efforts, thereby helping to Consequently, the group leader faces the chal­ retain clients in therapy. lenge of treating resistant clients. In general, •Universality—groups enable clients to resistance presents in one of two ways. Some see that they are not alone, that others have clients actively resist treatment. Others passive­ similar problems. ly resist. They are outwardly cooperative and go to great lengths to give the impression of •Imparting information—leaders shed light on willing engagement in the treatment process, the nature of addiction via direct instruction. but their primary motivation is a desire to be •Altruism—group members gain greater self­ free from external pressure. The group leader esteem by helping each other. has the delicate task of exposing the motives •Corrective recapitulation of the primary behind the outward compliance. family group—groups provide a family­like The art of treating addiction in early treatment context in which long­standing unresolved is in the defeat of denial and resistance, which conflicts can be revisited and constructively almost all clients with addictions carry into resolved. treatment. Group therapy is considered an •Developing socializing techniques—groups effective modality for give feedback; others’ impressions reveal how a client’s ineffective social habits might …overcoming the resistance that char­ undermine relationships. acterizes addicts. A skilled group leader •Imitative behavior—groups permit clients to can facilitate members’ confronting try out new behavior of others. each other about their resistance. Such confrontation is useful because it is dif­ •Interpersonal learning—groups correct the ficult for one addict to deceive another. distorted perceptions of others. Because addicts usually have a history •Group cohesiveness—groups provide a safe of adversarial relationships with author­ holding environment within which people feel ity figures, they are more likely to free to be honest and open with each other. accept information from their peers •Catharsis—groups liberate clients as they than a group leader. A group can also learn how to express feelings and reveal what provide addicts with the opportunity for is bothering them. mutual aid and support; addicts who present for treatment are usually well

Stages of Treatment 81 •Existential factors—groups aid clients in are ready for such highly charged work. coming to terms with hard truths, such as Attention to group cohesiveness is important (1) life can be unfair; (2) life can be painful early in treatment because only when group and death is inevitable; (3) no matter how members feel safety and belonging within the close one is to others, life is faced alone; (4) it group will they be able to form an attachment to is important to live honestly and not get the group and fully experience the effects of new caught up in trivial matters; (5) each of us is knowledge, universality, and hope. responsible for the ways in which we live. Therapeutic factors such as catharsis, existen­ In different stages of treatment, some of these tial factors, or recapitulation of family groups therapeutic factors receive more attention than generally receive little attention in early treat­ others. For example, in the beginning of the ment. These factors often are highly charged recovery process, it is extremely important for with emotional energy and are better left until group members to experience the therapeutic the group is well established. factor of universality. Group members should come to recognize that although they differ in During the initial stage of treatment, the thera­ some ways, they also share profound connec­ pist helps clients acknowledge and understand tions and similarities, and they are not alone in how substance abuse has dominated and dam­ their struggles. aged their lives. Drugs or alcohol, in various ways, can provide a substitute for the give­and­ The therapeutic factor of hope also is particu­ take of relationships and a means of surviving larly important in this stage. For instance, a without a healthy adjustment to life. As sub­ new member facing the first day without drugs stances are withdrawn or abandoned, clients may come into a revolving membership group give up a major source of support without hav­ that includes people who have been abstinent ing anything to put in its place (Brown 1985; for 2 or 3 weeks. The mere presence of people Straussner 1997). able to sustain abstinence for days––even weeks––provides the new member with hope In this frightening time, counselors need to that life can be lived without alcohol or illicit ensure that the client has a sense of safety. The drugs. It becomes possible to believe that absti­ group leader’s task is to help group members nence is feasible because others are obviously recognize that while alcohol or illicit drugs may succeeding. have provided a temporary way to cope with problems in the past, the consequences were Imparting informa­ not worth the price, and new, healthier ways tion often is needed can be found to handle life’s problems. to help clients learn what needs to be In early­stage treatment, strong challenges to a done to get through client’s fragile mental and emotional condition a day without chemi­ can be very harmful. Out of touch with unmed­ Attention to group cals. Psychoedu­ icated feelings, clients already are susceptible cation also allows to wild emotional fluctuations and are prone to cohesiveness is group members to unpredictable responses. Interpersonal rela­ learn about addic­ tionships are disturbed, and the effects of sub­ important early in tion, to judge their stances leave the client prone to use “primitive practices against this defensive operations such as denial, splitting, treatment. factual information, projective identification, and grandiosity” and to postpone (Straussner 1997, p. 68). intense interaction This vulnerable time, however, is also one of with other group opportunity. In times of crisis, “an individual’s members until they attachment system opens up” and the therapist

82 Stages of Treatment A Note on Attachment Theory and Substance Abuse Treatment Attachment theory provides a comprehensive meta­theory of addiction that not only integrates diverse mental health models with the disease­concept, but also furnishes guidelines for clinical practice that are compatible with existing addiction treatment strategies including an abstinence basis and alignment with 12­Step treatment philosophy.

Attachment theory (Bowlby 1979) and self psychology (Kohut 1977b) provided the first compelling theories that offered a practical alternative rationale for the addiction cycle that is not only compatible with the disease concept, but expands it by providing a more complete and intellectually satisfying theoretical explana­ tion why Alcoholic Anonymous (AA) works as it does.

According to the theory, attachment is recognized as a primary motivational force with its own dynamics, and these dynamics have far­reaching and complex consequences (Bowlby 1979). In clients with substance use disorders there is an inverse relation between their substance abuse and healthy interpersonal attach­ ments. A person who is actively abusing substances can rarely negotiate the demands of healthy interpersonal relationships successfully.

Using this theoretical model, substance abuse can be viewed as an attachment disorder. Individuals who have difficulty establishing intimate attachments will be more inclined to substitute substances for their deficiency in intimacy. Because of their difficulty maintaining emotional closeness with others, they are more likely to substitute various behaviors (including substance abuse) to distract them from their lack of intimate interpersonal relations.

The use of substances may initially serve a compensatory function, helping those who feel uncomfortable in social situations because of inadequate interpersonal skills. However, substances of abuse will gradually compromise neurophysiologi­ cal functioning and erode existing interpersonal skills. Managing relationships tends to become increasingly difficult, leading to a heightened reliance on sub­ stances, which accelerates deterioration and increases abuse and dependence. Eventually, the individual’s relationship with substances of abuse becomes both an obstacle to and a substitute for interpersonal attachments. If problems in attachment are a primary cause of substance abuse, then a therapeutic process that addresses the client’s interpersonal relations will be effective for long­term recovery (Flores 2001; Straussner 1993). Treatment concentrates on removing stress­inducing stimuli, teaching ways to recognize and quell environmental cues that trigger inappropriate behaviors, providing positive reinforcement and sup­ port, cultivating positive habits that endure, and developing secure and positive attachments.

Stages of Treatment 83 has a chance to change the client’s internal gests changes that might enable the client to dynamics (Flores 2001, p. 72). Support net­ manage cravings better or avoid exposure to works that can provide feedback and structure strong cues. are especially helpful at this stage. Clients also need reliable information to strengthen their For some clients, chiefly those mandated into motivation. treatment by courts or employers, grave conse­ quences inevitably ensue as a result of relapse. At this time, clients are solidifying their “new As Vannicelli (1992) points out, however, clini­ identity as an alcoholic with the corresponding cians should view relapse not as failure, but as belief in loss of control.” They develop “a new a clinical opportunity for both group leader logical structure” with which to assail their and clients to learn from the event, integrate “former logic and behavior.” They also can the new knowledge, and strengthen levels of develop a “new story . . . the Alcoholics motivation. Discussion of the relapse in group Anonymous drunkalogue,” which recalls their not only helps the individual who relapsed experiences and compares previous events with learn how to avoid future use, but it also gives what life is like now (Brown 1985). other group members a chance to learn from the mistakes of others and to avoid making the Whether information is offered through skills same mistakes themselves. groups, psychoeducational groups, supportive therapy groups, spiritually oriented support groups, or process groups, clients are most Leadership in Early Treatment likely to use the information and tools provided Clients usually come to the first session of in an environment alive with supportive human group in an anxious, apprehensive state of connections. All possible sources of positive mind, which is intensified by the knowledge forces in a client’s life should be marshaled to that they will soon be revealing personal infor­ help the client manage life’s challenges instead mation and secrets about themselves. The ther­ of turning to substances or other addictive apist begins by making it clear that clients have behaviors. some things in common. All have met with the therapist, have acceded to identical agree­ Painful feelings, ments, and have set out to resolve important which clients are not personal issues. Usually, the therapist then sug­ yet prepared to face, gests that members get to know each other. One can sometimes trig­ technique is to allow the members to decide ger relapse. If exactly how they will introduce themselves. The During early treat­ relapses occur in an therapist observes silently—but not impassive­ outpatient ly—watching how interaction develops (Rutan ment, a relatively setting––as they and Stone 2001). often do, because relapses occur in all active leader seeks During early treatment, a relatively active lead­ chronic illnesses, er seeks to engage clients in the treatment pro­ including addic­ to engage clients in cess. Clients early on “usually respond more tion––the group favorably to the group leader who is sponta­ member should be the treatment neous, ‘alive,’ and engaging than they do to the guided through the group leader who adopts the more reserved regression. The lead­ process. stance of technical neutrality associated with er encourages the the more classic approaches to group therapy” client to attend self­ (Flores 2001, p. 72). The leader should not be help groups, overly charismatic, but should be a strong explores the enough presence to meet clients’ dependency sequence of events needs during the early stage of treatment. leading to relapse, determines what cues led to relapse, and sug­

84 Stages of Treatment During early treatment, the effective leader will subjects who abused focus on immediate, primary concerns: achiev­ stimulants (cocaine ing abstinence, preventing relapse, and learning and methaphetamine). ways to manage cravings. The leader should The studies also found create an environment that enables clients to that deficits persisted Cognitive capacity acknowledge that (1) their use of addictive sub­ for at least 3 to 6 stances was harmful and (2) some things they months after cessation usually begins to want cannot be obtained while their pattern of of drug use. Whether substance use continues. As clients take their these deficits predated return to normal first steps toward a life centered on healthy substance abuse or sources of satisfaction, they need strong sup­ not, treatment per­ in the middle stage port, a high degree of structure, positive sonnel should expect human connections, and active leadership. to see clients with of treatment. impaired decision­ In process groups, the leader pays particular making and impulse attention to feelings in the early stage of treat­ control manifested by ment. Many people with addiction histories are difficulties in attend­ not sure what they feel and have great difficul­ ing, concentrating, ty communicating their feelings to others. learning new material, remembering things Leaders begin to help group members move heard or seen, producing words, and integrat­ toward affect regulation by labeling and mir­ ing visual and motor cues. For the clinician, roring feelings as they arise in group work. this finding means that clients may not have the The leader’s subtle instruction and empathy mental structures in place to enable them to enables clients to begin to recognize and own make the difficult decisions faced during the their feelings. This essential step toward man­ action stage of treatment. If clients draw and aging feelings also leads clients toward empathy use support from the group, however, the with the feelings of others. client’s affect will re­emerge, combine with new behaviors and beliefs, and produce an increas­ ingly stable and internalized structure (Brown The Middle Stage of 1985). Treatment Cognitive capacity usually begins to return to normal in the middle stage of treatment. The Condition of Clients in frontal lobe activity in a person addicted to Middle­Stage Treatment cocaine, for example, is dramatically different after approximately 4–6 months of nonuse. Often, in as little as a few months, institutional Still, the mind can play tricks. Clients distinctly and reimbursement constraints limit access to may remember the comfort of their substance ongoing care. People with addiction histories, past, yet forget just how bad the rest of their however, remain vulnerable for much longer lives were and the seriousness of the conse­ and continue to struggle with dependency. quences that loomed before they came into They need vigorous assistance maintaining treatment. As a result, the temptation to behavioral changes throughout the middle, or relapse remains a concern. action, stage of treatment.

Several studies (Committee on Opportunities in Therapeutic Strategies in Drug Abuse Research 1996; London et al. 1999; Majewska 1996; Paulus et al. 2002; Middle­Stage Treatment Strickland et al. 1993; Volkow et al. 1988, In middle­stage recovery, as the client experi­ 1992) have observed decreased blood flow ences some stability, the therapeutic factors and metabolic changes rates in the brains of

Stages of Treatment 85 of self­knowledge and altruism can be As the recovering client’s mental, physical, and emphasized. Universality, identification, emotional capacities grow stronger, anger, sad­ cohesion, and hope remain important as well. ness, terror, and grief may be expressed more appropriately. Clients need to use the group as Practitioners have stressed the need to work in a means of exploring their emotional and inter­ alliance with the client’s motivation for change. personal world. They learn to differentiate, The therapist uses whatever leverage identify, name, tolerate, and communicate feel­ exists––such as current job or marriage con­ ings. Cognitive–behavioral interventions can cerns––to power movement toward change. provide clients with specific tools to help modu­ The goal is to help clients perceive the causal late feelings and to become more confident in relationship between substance abuse and expressing and exploring them. Interpersonal current problems process groups are particularly helpful in the in their lives. middle stage of treatment, because the authentic Counselors should relationships within the group enable clients to recognize and The goal is to help experience and integrate a wide range of emo­ respect the client’s tions in a safe environment. position and the clients perceive the difficulty of change. When strong emotions are expressed and dis­ The leader who cussed in group, the leader needs to modulate causal relationship leaves group mem­ the expression of emerging feelings, delicately bers feeling that they balancing a tolerable degree of expression and between substance are understood is a level so overwhelming that it inhibits positive more likely to be in a change or leads to a desire to return to sub­ abuse and current position to influence stance use to manage the intensity. It also is change, while sharp very important for the group leader to “sew the problems in confrontations that client up” by the end of the session. Clients arouse strong emo­ should not leave feeling as if they are “bleed­ their lives. tions and appear ing” emotions that they cannot cope with or judgmental may dispel. A plan for the rest of the day should be trigger relapse developed, and the increased likelihood of (Flores 1997). relapse should be acknowledged so group mem­ bers see the importance of following the plan. Therapeutic strategies also should take into account the important role substance abuse has played in the lives of people with addictions. Leadership in Middle­Stage Often, from the client’s perspective, drugs of Treatment abuse have become their best friends. They fill Historically, denial has been the target of most hours of boredom and help them cope with dif­ treatment concepts. The role of the leader was ficulties and disappointments. As clients move primarily to confront the client in denial, away from their relationship with their best thereby presumably provoking change. More friend, they may feel vulnerable or emotionally recently, clinicians have stressed the fact that naked, because they have not yet developed “confrontation, if done too punitively or if moti­ coping mechanisms to negotiate life’s inevitable vated by a group leader’s countertransference problems. It is crucial that clients recognize issues, can severely damage the therapeutic these feelings as transient and understand that alliance” (Flores 1997, p. 340). Inappropriate the feeling that something vital is missing can confrontation may even strengthen the client’s have a positive effect. It may be the impetus resistance to change, thereby increasing the that clients need to adopt new behaviors that rigidity of defenses. are adaptive, safe, legal, and rewarding.

86 Stages of Treatment When it is necessary to point out contradictions immediate gratification over long­range goals, in clients’ statements and interpretations of so benefits achieved and sought after should be reality, such confrontations should be well­ real, tangible, and quickly attainable. timed, specific, and indisputably true. For example, author Wojciech Falkowski had a The benefits of recovery yield little satisfaction client whose medical records distinctly showed to some clients, and for them, the task of stay­ abnormal liver functions. When the client ing on course can be difficult. Their lives in maintained that he had no drinking problem, recovery seem worse, not better. Many experi­ Falkowski gently suggested that he “convince ence depression, lassitude, agitation, or anhe­ his liver of this fact.” The reply created a rip­ donia (that is, a condition in which formerly ple of amusement in the group, and “the client satisfying activities are no longer pleasurable). immediately changed his attitude in the desired Eventually, their lives seem devoid of any direction” (Falkowski 1996, p. 212). Such car­ meaningful purpose, and they stop caring ing confrontations made at the right time and about recovery. in the right way are helpful, whether they come These clients may move quickly from “I don’t from group members or the leader. care” to relapse, so the group leader should be Another way of understanding confrontation is vigilant and prepared to intervene when a to see it as an outcome rather than as a style. client is doing all that should be done in the From this point of view, the leader helps group recovery process, yet continues to feel bleak. members see how their continued use of drugs Such clients need attention and accurate or alcohol interferes with what they want to get diagnosis. Do they have an undiagnosed co­ out of life. This recognition, supported by the occurring disorder? Do they need antidepres­ group, motivates individuals to change. It sants? Do they need more intensive, frequent, seems that people who abuse substances need adjuncts to therapy, such as more Alcoholics someone to tell it like it is “in a realistic fashion Anonymous or Narcotics Anonymous meetings without adopting a punitive, moralistic, or and additional contacts with a sponsor? superior attitude” (Flores 1997, p. 340). Leaders need to help group members under­ In the middle stage of treatment, the leader stand and accept that many forms of therapy helps clients join a culture of recovery in which outside the group can promote recovery. Group they grow and learn. The leader’s task is to members should be engage members actively in the treatment and encouraged to sup­ recovery process. To prevent relapse, clients port each other’s efforts to recover, need to learn to monitor their thoughts and In the middle stage feelings, paying special attention to internal however much their needs and treatment cues. Both negative and positive dimensions of treatment, the may be motivational. New or relapsed group options may differ. members can remind others of how bad their The leader helps leader helps clients former lives really were, while the group’s individuals assess the vision of improvements in the quality of life is a degree of structure distinct and immediate beam of hope. join a culture of and connection they The leader can support the process of change need as recovery recovery in which by drawing attention to new and positive devel­ progresses. Some group members find opments, pointing out how far clients have they grow traveled, and affirming the possibility of that participation in religious or faith increased connection and new sources of satis­ and learn. faction. Leaders should bear in mind, however, groups meets their that people with addictions typically choose needs for affiliation and support. For

Stages of Treatment 87 long­term, chronically impaired people with ing issues often emerge, such as poor self­ addictive histories, highly intensive participa­ image, relationship problems, the experience of tion in 12­Step groups is usually essential for shame, or past trauma. For example, an an extended period of time. unusually high percentage of substance and alcohol abuse occurs among men and women who have survived sexual or emotional abuse. The Late Stage of Many such cases warrant an exploration of dis­ Treatment sociative defenses and evaluation by a knowl­ edgeable mental health professional. Condition of Clients in When the internalized pain of the past is Late­Stage Treatment resolved, the client will begin to understand and experience healthy mutuality, resolving During the late (also referred to as ongoing or conflicts without the maladaptive influence of maintenance) stage of treatment, clients work alcohol or drugs. If the underlying conflicts are to sustain the attainments of the action stage, left unresolved, however, clients are at but also learn to anticipate and avoid tempting increased risk of other compulsive behavior, situations and triggers that set off renewed sub­ such as excessive exercise, overeating, gam­ stance use. To deter relapse, the systems that bling, or excessive sexual activity. once promoted drinking and drug use are sought out and severed. Therapeutic Strategies in Late­ Despite efforts to forestall relapse, many Stage Treatment clients, even those who have reached the late stage of treatment, do return to substance use In the early and middle stages of treatment, and an earlier stage of change. In these cases, clients necessarily are so focused on maintain­ the efforts to guard against relapse were not all ing abstinence that they have little or no capac­ in vain. Clients who return to substance abuse ity to notice or solve other kinds of problems. do so with new information. With it, they may In late­stage treatment, however, the focus of be able to discover and acknowledge that some group interaction broadens. It attends less to of the goals they set are unrealistic, certain the symptoms of drug and alcohol abuse and strategies attempted more to the psychology of relational interaction. are ineffective, and In late­stage treatment, clients begin to learn to environments engage in life. As they begin to manage their deemed safe are not emotional states and cognitive processes more at all conducive to During the late effectively, they can face situations that involve successful recovery. conflict or cause emotion. A process­oriented With greater insight group may become appropriate for some clients stage of treatment, into the dynamics of who are finally able to confront painful reali­ their substance ties, such as being an abused child or abusive clients work to abuse, clients are parent. Other clients may need groups to help better equipped to them build a healthier marriage, communicate sustain the attain­ make another more effectively, or become a better parent. attempt at recovery, Some may want to develop new job skills to ments of the and ultimately, to increase employability. succeed. action stage. Some clients may need to explore existential As the substance concerns or issues stemming from their family abuse problem fades of origin. These emphases do not deny the con­ into the background, tinued importance of universality, hope, group significant underly­

88 Stages of Treatment cohesion and other therapeutic factors. Instead premature termina­ it implies that as group members become more tion. While early­ and and more stable, they can begin to probe deep­ middle­stage interven­ er into the relational past. The group can be tions strive to reduce used in the here and now to settle difficult and or modulate affect, As group members painful old business. late­stage interven­ tions permit more become more and intense exchanges. Leadership in Late­Stage Thus, in late treat­ more stable, they Treatment ment, clients no longer are cautioned The leader plays a very different role in late­ against feeling too can begin to probe stage treatment, which refocuses on helping much. The leader no group members expose and eliminate personal longer urges them to deeper into the deficits that endanger recovery. Gradually, the apply slogans like leader shifts toward interventions that call “Turn it over” and upon people who are chemically dependent to relational past. “One day at a time.” take a cold, hard look at their inner world and Clients finally should system of defenses, which have prevented them manage the conflicts from accurately perceiving their self­defeating that dominate their behavioral patterns. To become adequately lives, predispose them resistant to substance abuse, clients should to maladaptive behaviors, and endanger their learn to cope with conflict without using chemi­ hard­won abstinence. The leader allows clients cals to escape reality, self­soothe, or regulate to experience enough anxiety and frustration to emotions (Flores 1997). bring out destructive and maladaptive charac­ As in the early and middle stages, the leader terological patterns and coping styles. These helps group members sustain abstinence and characteristics provide abundant grist for the makes sure the group provides enough support group mill. and gratification to prevent acting out and

Stages of Treatment 89

6 Group Leadership, Concepts, and Techniques

Overview This chapter describes desirable leader traits and behaviors, along with In This the concepts and techniques vital to process groups––though many of the Chapter… ideas can apply in other types of groups. Most of the ideas seem perfect­ ly logical, too, once they are brought to mind. The Group Leader For instance, consistency in manner and procedure helps to provide a Personal Qualities safe and stable environment for the newly recovering person with a sub­ Leading Groups stance use disorder. When the upheaval in the lives of people recovering Concepts, from addictions is considered, it becomes clear how important it is to Techniques, and keep as many factors as possible both constant and predictable. Considerations The pages that follow discuss issues such as Interventions Transference and •How to convert conflict and resistance into positive energy that powers Countertransference the group Resistance in Group •How to deal with disruptive group members, such as clients who talk Confidentiality incessantly or bolt from a session Biopsychosocial and Spiritual Framework— •How to cool down runaway affect or turn a crisis into an opportunity Treating the Whole Person Integrating Care People who abuse substances are a broad and diverse population, one Management of the Group that spans all ages and ethnic groups and encompasses people with a Managing Other Common wide variety of co­occurring conditions and personal histories. In work­ Problems ing with people who have substance use disorders, an effective leader uses the same skills, qualities, styles, and approaches needed in any kind of therapeutic group. The adjustments needed to treat substance abuse are simply that—adjustments within the bounds of good practice. The particular personal and cultural characteristics of the clients in group also will influence the therapist’s tailoring of therapeutic strategies to fit the particular needs of the group.

91 The Group Leader to exercise, how to structure the group, when to intervene, how to effect a successful interven­ tion, how to manage the group’s collective anxi­ Personal Qualities ety, and the means of resolving numerous other Although the attributes of an effective interper­ issues. It is essential for any group leader to be sonal process group leader treating substance aware of the choices made and to remember abuse are not strikingly different from traits that all choices concerning the group’s struc­ needed to work successfully with other client ture and her leadership will have consequences populations, some of the variations in (Pollack and Slan 1995). approach make a big difference. Clients, for example, will respond to a warm, empathic, Constancy and life­affirming manner. Flores (1997) states An environment with small, infrequent changes that “many therapists do not fully appreciate is helpful to clients living in the emotionally the impact of their personalities or values on turbulent world of recovery. Group facilitators addicts or alcoholics who are struggling to iden­ can emphasize the reality of constancy and tify some viable alternative lifestyle that will security through a variety of specific behaviors. allow them to fill up the emptiness or deadness For example, group leaders always should sit in within them” (p. 456). For this reason, it is the same place in the group. Leaders also need important for group leaders to communicate to respond consistently to particular behaviors. and share the joy of being alive. This life­ They should maintain clear and consistent affirming attitude carries the unspoken mes­ boundaries, such as specific start and end sage that a full and vibrant life is possible with­ times, standards for comportment, and ground out alcohol or drugs. rules for speaking. Even dress matters. The In addition, because many clients with sub­ setting and type of group will help determine stance abuse histories have grown up in homes appropriate dress, but whatever the group that provided little protection, safety, and leader chooses to wear, some predictability is support, the leader should be responsive and desirable throughout the group experience. affirming, rather than distant or judgmental. The group leader should not come dressed in a The leader should recognize that group mem­ suit and tie one day and in blue jeans the next. bers have a high level of vulnerability Active listening and are in need of Excellent listening skills are the keystone of any support, particularly effective therapy. Therapeutic interventions in the early stage of require the clinician to perceive and to under­ treatment. A discus­ stand both verbal and nonverbal cues to mean­ sion of other essen­ Excellent listening ing and metaphorical levels of meaning. In tial characteristics addition, leaders need to pay attention to the for a group leader skills are the context from which meanings come. Does it follows. Above all, it pertain to the here­and­now of what is occur­ is important for the ring in the group or the then­and­there history keystone of any leader of any group of the specific client? to understand that effective therapy. he or she is responsi­ ble for making a Firm identity series of choices as A firm sense of their own identities, together the group progresses. with clear reflection on experiences in group, The leader chooses enables leaders to understand and manage how much leadership their own emotional lives. For example,

92 Group Leadership, Concepts, and Techniques therapists who are aware of their own capaci­ Integrity ties and tendencies can recognize their own Largely due to the defenses as they come into play in the group. nature of the material They might need to ask questions such as: “Am group members are I cutting off discussions that could lead to ver­ sharing in process bal expression of anger because I am uncom­ Good leaders are groups, it is all but fortable with anger? Have I blamed clients for inevitable that ethical the group’s failure to make progress?” creative and issues will arise. Group work can be extremely intense emotion­ Leaders should be flexible. ally. Leaders who are not in control of their familiar with their own emotional reactions can do significant institution’s policies harm—particularly if they are unable to admit and with pertinent a mistake and apologize for it. The leader also laws and regulations. should monitor the process and avoid being Leaders also need to seduced by content issues that arouse anger be anchored by clear and could result in a loss of the required pro­ internalized standards fessional stance or distance. A group leader of conduct and able to also should be emotionally healthy and keenly maintain the ethical aware of personal emotional problems, lest parameters of their profession. they become confused with the urgent issues faced by the group as a whole. The leader Trust should be aware of the boundary between per­ Group leaders should be able to trust others. sonal and group issues (Pollack and Slan 1995). Without this capacity, it is difficult to accom­ plish a key aim of the group: restoration of Confidence group members’ faith and trust in themselves Effective group leaders operate between the and their fellow human beings (Flores 1997). certain and the uncertain. In that zone, they cannot rely on formulas or supply easy answers Humor to clients’ complex problems. Instead, leaders The therapist needs to be able to use humor have to model the consistency that comes from appropriately, which means that it is used only self­knowledge and clarity of intent, while in support of therapeutic goals and never is remaining attentive to each client’s experience used to disguise hostility or wound anyone. and the unpredictable unfolding of each ses­ sion’s work. This secure grounding enables the leader to model stability for the group. Empathy Empathy, one of the cornerstones of successful Spontaneity group treatment for substance abuse, is the ability to identify someone else’s feelings while Good leaders are creative and flexible. For remaining aware that the feelings of others are instance, they know when and how to admit a distinct from one’s own. Through these “tran­ mistake, instead of trying to preserve an image sient identifications” we make with others, we of perfection. When a leader admits error feel less alone. “Identification is the antidote to appropriately, group members learn that no loneliness, to the feeling of estrangement that one has to be perfect, that they––and seems inherent in the human condition” others––can make and admit mistakes, yet (Ormont 1992, p. 147). retain positive relationships with others. For the counselor, the ability to project empa­ thy is an essential skill. Without it, little can be

Group Leadership, Concepts, and Techniques 93 accomplished. Empathic listening requires ing out cues that indicate what another person close attention to everything a client says and may be feeling. the formation of hypotheses about the underly­ ing meaning of statements (Miller and Rollnick One of the feelings that the group leader needs 1991). An empathic substance abuse counselor to be able to empathize with is shame, which is common among people with substance abuse •Communicates respect for and acceptance of histories. Shame is so powerful that it should clients and their feelings be addressed whenever it becomes an issue. •Encourages a nonjudgmental, collaborative When shame is felt, the group leader should relationship look for it and recognize it (Gans and Weber 2000). The leader also should be able to •Is supportive and knowledgeable empathize with it, avoid arousing more shame, •Sincerely compliments rather than denigrates and help group members identify and process or diminishes another person this painful feeling. Figure 6­1 discusses shame •Tells less and listens more and group therapy. •Gently persuades, while understanding that the decision to change is the client’s Leading Groups •Provides support throughout the recovery Group therapy with clients who have histories process (Center for Substance Abuse of substance abuse or dependence requires Treatment [CSAT] 1999b, p. 41) active, responsive leaders who keep the group One of the great benefits of group therapy is lively and on task, and ensure that members that as clients interact, they learn from one are engaged continuously and meaningfully another. For interpersonal interaction to be with each other. Leaders, however, should not beneficial, it should be guided, for the most make themselves the center of attention. The part, by empathy. The group leader should be leader should be aware of the differing person­ able to model empathic interaction for group alities of the group members, while always members, especially since people with sub­ searching for common themes in the group. stance use disorders Themes to focus on, for example, might include often cannot identify loss, abandonment, and self­value (Pollack and and communicate Slan 1995). their feelings, let alone appreciate the Leaders vary therapeutic emotive world of styles with the needs of others. The group The group leader leader teaches group clients members to under­ As explained in chapter 5, group leaders should be able to stand one another’s should modify their styles to meet clients’ needs subjective world, at different times. During the early and middle model empathic enabling clients to stages of treatment, the therapist is more develop empathy for active, becoming less so in the late stage. interaction for each other (Shapiro Moreover, during the late stage of treatment, 1991). The therapist the therapist should offer less support and promotes growth in gratification. This keeps the group at an “opti­ group members. this area simply by mal level of anxiety,” one that would be intoler­ asking group mem­ able and counterproductive in the early or bers to say what they middle stages of treatment (Flores 1997). think someone else is feeling and by point­ To determine the type of leadership required to support a client in treatment, the clinician

94 Group Leadership, Concepts, and Techniques Figure 6­1

Shame

Often failed attachments in childhood and failed relationships thereafter result in shame, an internalized sense of being inferior, not good enough, or worthless. Shame flares whenever clients encounter the discrepancy between their drug­ affected behavior and personal or social values. In group therapy, feelings of shame may be intensified because feelings of self­consciousness are elevated and other group members are present. The presence of other group members “often stimulates regressive longings” (Gans and Weber 2000, p. 385). Furthermore, group members have a marked tendency to compare themselves with one anoth­ er (Gans and Weber 2000). In the past, when group facilitators used highly con­ frontational efforts to break through denial and resistance, an undesirable side effect was intensified shame, which increased the likelihood that group members would relapse or leave treatment. Shame interferes dramatically with attempts to heighten a client’s self­esteem, which in turn is important to recovery (Alonso and Rutan 1988).

Clients with addictions often are exquisitely sensitive and prone to project their shame onto relationships within the group. Often, at an unconscious level, they anticipate disapproval or hostility when none was intended. In this way, clients may demote themselves to the role of secondary player in the group.

One way to neutralize unintentionally shame­provoking comments is to reframe member­to­member communications. For example, if a group member asks, “Sally, where were you last week? You didn’t come to group.” Sally may inter­ pret the question as a criticism or even an implication that she has returned to active use. The group facilitator may choose to reframe this member­to­member communication by speaking to the concern that the questioner really has for Sally’s well­being.

This reframing would begin with the group leader asking why the group member wanted to know where Sally had been, adding something like, “I suspect your question reflects the feeling that you missed Sally last week and find group more enjoyable when she is here.”

By focusing on positive interactions that reveal competency, the group facilitator helps move clients from shame to an affirmative image of themselves. The group leader should pay attention to member­to­member interaction, looking for instances of relational competence and support. The leader’s supportive interac­ tions eventually develop into group norms that combat the shame attached to addictive illness. Source: Consensus Panel.

Group Leadership, Concepts, and Techniques 95 should consider the client’s capacity to manage including disclosure of a therapist’s past expe­ affect, level of functioning, social supports, and riences with substance abuse or addiction. Too stability, since these factors have some bearing often, self­disclosure occurs to meet the thera­ upon alcohol or illicit drug use. These consider­ pist’s own needs (for example, for affiliation ations are essential to determine the type of and approval) or to gratify clients. When per­ group best suited to meet the client’s needs. For sonal questions are asked, group leaders need example, a client at the beginning stage of to consider the motivation behind the question. treatment who is Often clients are simply seeking assurance that high functioning and the therapist is able to understand and assist used to working in them (Flores 1997). groups generally will require a less active Leaders can be cotherapists therapist and less structure. On the Cotherapy is an effective way to blend the Cotherapy is other hand, a lower­ diverse skills, resources, and therapeutic functioning client perspectives that two therapists can bring to a group. In addition, cotherapy is beneficial extremely power­ who has little or no group experience because, if properly carried out, it can provide and is just beginning ful when carried •The opportunity to watch “functional, treatment would best adaptive behavior in the co­leader pair” be placed in a struc­ out skillfully. tured, task­oriented •Additional opportunities for family group. Such a per­ transferences when the leaders are of son also would bene­ different genders fit from a clinician •An opportunity for “two sets of eyes to view who more actively the situation” (Vannicelli 1992, p. 238) expresses warmth Cotherapy, also called coleadership, is extremely and acceptance, thus powerful when carried out skillfully. A male– helping to engage the client. female cotherapy team may be especially helpful, for a number of reasons. It allows Leaders model behavior clients to explore their conscious and subcon­ It is more useful for the therapist to model scious reactions to the presence of a parental group­appropriate behaviors than to assume dyad, or pair. It shows people of opposite sexes the role of mentor, showing how to “do recov­ engaging in a healthy, nonexploitative relation­ ery.” For example, the therapist can model the ship. It presents two different gender role way to listen actively, give accurate feedback, models. It demonstrates role flexibility, as and display curiosity about apparent discrep­ clients observe the variety of roles possible for ancies in behavior and intent. a male or a female in a relationship. It provides an opportunity for clients to discover and work Therapists should be aware that self­disclosure through their gender distortions (Kahn 1996). is always going on, whether consciously or unconsciously. They intentionally should use Frequently, however, cotherapy is not done self­disclosure only to meet the task­related well, and the result is destructive. At times, a needs of the group, and then only after supervisor and a subordinate act as cothera­ thoughtful consideration, perhaps including a pists, and power differentials result. Alter­ discussion with a supervisor. natively, cotherapists are put together out of convenience, rather than their potential to Both therapists and their institutions should work well together and improve and facilitate have a thoughtful policy about self­disclosure, group process. True cotherapy takes place

96 Group Leadership, Concepts, and Techniques between clinicians of equal authority and Beck 1997, p. 2). The development of a healthy mutual regard. (Naturally, the foregoing does relationship between cotherapists will have a not apply to training opportunities in which a positive effect on their relationship to the trainee sits in with a seasoned group therapist. group, relationships among members of the In such a setting, the trainee functions as an group, and on individuals within the group as observer, not a cotherapist.) they experience the continuous changes and growth of the group (Dugo and Beck 1997). Problems also may arise because institutions and leaders fail to allow enough time for cotherapists to prepare for group together and Leaders are sensitive to to process what has happened after the group ethical issues has met. Some suggest that cotherapists confer Group therapy by nature is a powerful type of for as much time outside the group as the intervention. As the group process unfolds, the length of the group itself, that is, 45 minutes of group leader needs to be alert, always ready to consultation for each 45­minute group session. perceive and resolve issues with ethical dimen­ While this amount of time may be ideal, the sions. Some typical situations with ethical con­ realities of most organizations do not make this cerns follow. level of commitment feasible. At the least, how­ ever, cotherapists should have a minimum of 15 Overriding group agreements minutes before and after each group meets. Group agreements give the group definition and clarity, and are essential for group safety. Personal conflict or professional disagreements In rare situations, however, it would be unethi­ can be a third source of negative effects on the cal not to bend the rules to meet the needs of group. Thus, cotherapists should carefully an individual. For example, group rules may work out their own conflicts and develop a say that failure to call in before an absence leadership style suitable for the group before from group is cause for reporting the infraction engaging in the therapeutic process. Cothera­ to a referring agency. If the client can demon­ pists also should work out important theoreti­ strate that an unavoidable emergency prevent­ cal differences before taking on a group, reach­ ed calling in, the group leader may agree that ing full agreement on their view of the group the offense does not merit a report. Further­ and appropriate ways to facilitate the group’s more, the needs of the development (Wheelan 1997). Achieving a group may sometimes healthy, collaborative, and productive cothera­ override courtesies py team will require a “(1) commitment of time shown to an individu­ and sharing, (2) the development of [mutual] al. For example, a respect…and (3) use of supervision to work out group may have made differences and identify…problems” (Kahn an agreement not to Group agreements 1996, p. 443). discuss any group Inevitably, cotherapist relationships will grow member when that give the group def­ and evolve over time. The relationship between member is not pre­ the cotherapists and the group, too, will evolve. sent. If, however, a inition and clarity, Both the cotherapists and the group should member should recognize this process and be ready to adapt to relapse, become seri­ and are essential constant change and growth (Dugo and Beck ously ill, or experi­ 1997). The most successful cotherapy is carried ence some other dire for group safety. out “by partners who make a commitment to problem, the no­dis­ an ongoing relationship, who reason with each cussion rule has to be other, and who accept responsibility to work on set aside if the group the evolution of their relationship” (Dugo and leader is to allow the

Group Leadership, Concepts, and Techniques 97 members to express their concerns for the miss­ Acting in each client’s best interest ing member and to consider how that person’s It is possible that the group collectively may problem affects the group as a whole. validate a particular course of action that may Informing clients of options not be in a client’s best interest. For example, if there is stress in one group member’s mar­ Even when group participation is mandated, riage, other group members might support a clients should be informed clearly of the course of action that could have dangerous or options open to them. For example, the client harmful consequences. Similarly, the group deserves the option to discuss with program might engage in problem solving in some area administrators any forms of treatment or of a member’s life and recommend a course of leadership style that the client believes to be action that would clearly be undesirable. inappropriate. In such an instance, issues of cultural competence should be kept in mind, It is the responsibility of the group facilitator to because what is appropriate for an individual challenge the group’s conclusions or recommen­ or a group is by no means universal. dations when they deny individual autonomy or could lead to serious negative consequences. Preventing enmeshment Any such challenge, however, should come in a Leaders should be aware that the power of nonshaming fashion, primarily through the groups can have a dark side. Although cohe­ review of other options. sion is a positive outcome to be sought and supported, the strong desire for affiliation also Handling emotional can place undue pressure on group members who already are in contagion the throes of a major Another’s sharing, such as an agonized account transition from sub­ of sexual abuse, can stir frightening memories stance abuse to and intense emotions in listeners. In this pow­ The leader is obli­ abstinent lives. The erful and emotional atmosphere, the spreading need to belong is so excitement of the moment, or emotional conta­ gated to foster strong that it can gion, requires the leader to sometimes cause a cohesion while client to act in a way •Protect individuals. The group leader should that is not genuine guard the right of each member to refrain from involvement. The leader makes it clear respecting the or consistent with personal ethics. that each group member has a right to pri­ Regardless of the vate emotions and feelings. When the group rights and best kind of group, the pressures a member to disclose information, leader needs to be the leader should remind the group that interests of indi­ aware of this possi­ members need only reveal information about bility and to monitor themselves at levels with which they are com­ viduals. group sharing to fortable. ensure that clients •Protect boundaries. Group pressure or the are not drawn into group leader’s interest should not obligate situations that vio­ anyone to disclose intimate details that the late their privacy or integrity. The leader is client prefers not to share. At the same time, obligated to foster cohesion while respecting the clients are responsible for managing their rights and best interests of individuals. feelings in the face of the group’s power and deciding what they will and won’t share. •Regulate affect. At all times, the therapist should be mindful of the need to modulate

98 Group Leadership, Concepts, and Techniques affect (emotionality), always keeping it at a thereby avoiding pow­ level that enables the work of the group to erfully charged issues. continue. Yalom (1995) suggests an interven­ It is easier, for exam­ tion that group leaders could use to limit con­ ple, to deal with the flict or almost any unacceptable escalation of problems of being a In all therapeutic affect: “We’ve been expressing some intense scapegoat than it is to feelings here today….To prevent us from work on recovery settings, the overload, it might be valuable to stop what from addiction. we’re doing and try together to understand clinician should what’s been happening and where all these While it is natural for powerful feelings come from” (p. 350). group members to assume certain be sensitive to roles––there are, after Working within professional all, natural leaders–– issues of dual limitations individual members Group leaders never should attempt to use benefit from the relationships. group techniques or modalities for which they opportunity to experi­ are not trained. When new techniques are used ence different aspects with any group, leaders should be certain to of themselves. Role have appropriate training and the supervision variation also keeps of experts familiar with the techniques to be the group lively and employed. Therapists likewise should decline to dynamic. These benefits will be lost if the same work with any population or in any situation group members consistently assume the same for which they are unprepared. For example, roles in group. It is important for the group an addiction counselor who has never run a facilitator to support role sharing within the long­term therapy group and has not learned membership. how to do so should not accept an assignment to lead such a group. Further, a counselor can­ Avoiding role conflict not read about psychodrama and, using a In all therapeutic settings, the clinician should workbook, successfully apply this highly be sensitive to issues of dual relationships. A charged technique with clients in an early stage group leader’s responsibilities outside the of treatment. Such a misguided effort could group that place him in a different relationship have serious psychological consequences. to group participants should not be allowed to compromise the leader’s in­group role. For Ensuring role flexibility example, a client’s group leader should not also Different group members may assume particular be that client’s Alcoholics Anonymous (AA) roles within the group. Natural leaders may sponsor. Both roles and functions are impor­ emerge, as may a member who expresses anger tant, but should not be performed by the same for the group and someone who provides sup­ person. If the leader happens to be in recovery port. One client may take on a scapegoat role and is attending self­help meetings at which and then blame the group. group members are present, this possible role conflict should be discussed with supervisors. Playing different roles and examining their dynamics can provide a corrective emotional Ethical behavior is absolutely essential to group and interpersonal experience for the group. On leadership. As the best practice guidelines the other hand, rigid roles can restrict group (1998) from the Association for Specialists in work. If, for example, a group consistently Group Work (ASGW) declare, “ASGW views places individuals in particular roles, they may ethical process as being integral to group work use their placements as defense mechanisms, and views Group Workers as ethical agents.”

Group Leadership, Concepts, and Techniques 99 The ASGW statement is regarded as so and 3 for more detailed discussions of the important that the entire text is reproduced in stages of change). Techniques to enhance appendix E. motivation that are appropriate at one stage of change may not be useful at another stage and Leaders improve motivation may even trigger treatment resistance or non­ compliance (CSAT 1999b). For example, clients Client motivation is a vital factor in the success in the contemplation stage are weighing the of treatment for substance use disorders. pros and cons of continued substance abuse. Motivation­boosting techniques have been An intervention for the action stage is appro­ shown to increase both treatment participation priate for a client who has already made a and outcomes (Chappel 1994; Easton et al. commitment to change. If such an intervention 2000; Foote et al. 1999). Motivation generally is used too early, the client understandably improves when may fail to cooperate. •Clients are engaged at the appropriate stage of change. Leaders overcome resistance •Clients receive support for change efforts. Resistance is especially strong among clients •The therapist explores choices and their referred by the courts. It generally arises as a consequences with the client. defense against the pain that therapy and examining one’s own behavior usually brings. •The therapist honestly and openly communi­ In group therapy, resistance appears at both cates care and concern for group members. the individual and the group level. The group •The therapist points out the client’s compe­ leader should have a repertoire of means to tencies. overcome the resistance that prevents success­ •Steps toward positive change are noted ful substance abuse treatment in groups within the group and further encouragement (Milgram and Rubin 1992). is provided. The group therapist should be prepared to The therapist helps clients enjoy their triumphs work effectively against intense resistance to with questions such as, “What’s it like, Bill, to “experiencing, expressing, and understanding communicate your thoughts so clearly to Claire emotions” (Cohen 1997, p. 443). In order to and to have her understand you so well?” or overcome resistance to the experience of emo­ “What was it like to be able to communicate tion, “the group members should experience your frustration so directly?” feelings at a level of arousal wherein feelings are undeniable, but not to the extent that the group One effective motivational tool is the FRAMES member is overcome” (Cohen 1997, p. 445). approach, which uses the six key elements of Feedback, Responsibility, Advice, Menus (of Leaders defend limits change options), Empathic therapy, and Self­ efficacy (Miller and Sanchez 1994). This Providing a safe, therapeutic frame for clients approach engages clients in their own treat­ and maintaining firm boundaries are among ment and motivates them to change in ways the most important functions of the group lead­ that are the least likely to trigger resistance. er. For many group members, a properly con­ The FRAMES approach is discussed in detail ducted group will be the first opportunity to in chapter 2 of TIP 35, Enhancing Motivation interact with others in a safe, supportive, and for Change in Substance Abuse Treatment substance­free environment. (CSAT 1999b). The boundaries established should be mutually When this kind of supportive technique is agreed upon in a specific contract. When employed, however, a client’s stage of change leaders point out boundaries and boundary should be taken into account (see chapters 2 violations, they should do so in a nonshaming,

100 Group Leadership, Concepts, and Techniques nonjudgmental, matter­of­fact way. Some possi­ connection” at one ble ways of dealing with this situation might be end of the continuum (Gans and Weber •“This is a hard place to end, but . . .” 2000, p. 382). At the •“I know how angry you’re feeling, but we other end is “unme­ The boundaries have agreed . . .” tabolized shame,” or shame that “in a nar­ established should When boundary violations occur, group mem­ cissistically vulnerable bers should be reminded of agreements and person produces its be mutually given an opportunity to discuss the meaning pathological vari­ and implication of the limit­breaking behavior ants…Whereas guilt agreed upon in a as they see it. For example, if three group is a response to a members are coming in late, the leader might thought or deed, say, “It’s interesting that although everyone specific contract. shame connotes a who joined the group agreed to arrive on time, more pervasive (self) many members are having a difficult time meet­ condemnation” (Gans ing this agreement.” Or the leader might ask, and Weber 2000, p. “How would this group be different if everyone 382). It is thus poten­ came on time?” tially harmful to group members who are struggling to be honest with themselves and The group members may respond, for example, with the other group members. that they would not be obliged to repeat what already has been said to help latecomers catch The group needs to feel safe without blaming or up and, thus, get more out of each session. scapegoating an individual member. If a mem­ This group involvement in limit setting is cru­ ber makes an openly hostile comment, the lead­ cial. It transmits power and responsibility to er’s response should state clearly what has hap­ the group, and the leader avoids the isolated pened and set a firm boundary for the group role of enforcer. While leaders inevitably will that makes clear that group members are not to be regarded as authority figures, they certainly be attacked. Sometimes, the leader simply may want to avoid creating the image of an insensi­ need to state what has occurred in a factual tive, punitive authority. manner: “Debby, you may not have intended this effect, but that last remark came across as Leaders maintain a safe really hurtful.”

therapeutic setting When group members’ responses lack empathy Emotional aspects of safety or treat one group member as a scapegoat, this Group members should learn to interact in pos­ targeted individual represents “a disowned itive ways. In the process, leaders should part of other members of the group.” Members expect that people with substance abuse histo­ may fault Sally repeatedly for her critical ries will have learned an extensive repertoire of nature and lack of openness. The leader may intimidating, shaming, and other harmful intervene with a comment such as, “We’ve behaviors. Because such conduct can make taken up time dealing with Sally’s problems. group members feel unsafe, the leader should My guess is that part of the reason the group is use interventions that deflect the offensive so focused on this is that it’s something every­ behavior without shaming the shamer. body in here knows a little about and that this issue has a lot of meaning for the group. Shame is not a point, but a range, some Perhaps the group is trying to kick this charac­ researchers argue. “Healthy” shame “helps to teristic down and beat it out because it’s too regulate a person’s behavior in the service of close to home and simply cannot be ignored” preserving self­esteem, values, and personal (Vannicelli 1992, p. 125).

Group Leadership, Concepts, and Techniques 101 When individual guage” (Rosenthal 1999a, p. 159). The therapist group members are can achieve this control by warning potential It is the therapist’s verbally abusive and group members of the emotional hazards of other group mem­ revealing their feelings to a group of strangers responsibility to bers are too intimi­ and by helping new members regulate the dated to name the amount of their self­disclosure. maintain the problem, the leader should find a way to Substance use In a group of people trying to maintain appropriate level provide “a safe envi­ ronment in which abstinence, the presence of someone in the such interactions can group who is intoxicated or actively using illicit of emotion and be productively pro­ drugs is a powerful reality that will upset many cessed and under­ members. In this situation, the leader should stimulation in the stood—not only by intervene decisively. The leader will make it as the attacking group easy as possible for the person who has group. member but also by relapsed to seek treatment, but a disruptive the other members member should leave the group for the present. (who need to under­ The leader also will help group members stand what is moti­ explore their feelings about the relapse and vating their reluctance to respond)” (Vannicelli reaffirm the primary importance of members’ 1992, p. 165). To accomplish this goal, the agreement to remain abstinent. Some sugges­ leader may intervene with statements such as: tions follow for situations involving relapse: •To the group as a whole: “John has been •If clients come to sessions under the influence pretty forthright with some of his feelings of alcohol or drugs, the leader should ensure this evening. It seems as if others in here are that the individual does not drive home. having more difficulty sharing their feelings. Even a person walking home sometimes Perhaps we can understand what it is about should be escorted to prevent falls, pedestri­ what John has shared or the way in which he an accidents, and so on. shared it that makes it hard to respond” •If a client obviously is intoxicated at the (Vannicelli 1992, p. 165). beginning of the group, that person should be •To John: “John, how do you suppose Mary asked to leave and return for the next session might be feeling just now about your in a condition appropriate for participation response to her?” or “If you had just (Vannicelli 1992). received the kind of feedback that you gave to Mary, how do you suppose you’d be feeling Vannicelli (1992) addresses several other right now?” (Vannicelli 1992, pp. 165–166). situations that commonly occur: Whatever intervention is used should show the Signs indicate that the client is not abstinent, group “that it is appropriate to let people know but the client will not admit using alcohol or how you feel, and that people can learn in the drugs. When signs (such as bloodshot eyes) group how to do this in a way that doesn’t push indicate that the client is using substances others away” (Vannicelli 1992, p. 166). repeatedly before coming to the group, but the client does not admit the infraction, the A client can be severely damaged by emotional leader might: overstimulation. It is the therapist’s responsibil­ ity to maintain the appropriate level of emotion •Use empathy to join with the client, letting and stimulation in the group. This will “prevent the member know that the leader under­ a too sudden or too intense mobilization of feel­ stands why it’s hard to acknowledge ing that cannot be adequately expressed in lan­ substance use to the group.

102 Group Leadership, Concepts, and Techniques •Describe the impasse, namely, that it is Boundaries and physical contact important that both client and therapist feel When physical boundaries are breached in the that they are in a credible relationship, but group, and no one in the group raises the issue, the way things are shaping up, it must be the leader should call the behavior to the increasingly difficult for the client to come in group’s attention. The leader should remind week after week knowing that the therapist members of the terms of agreement, call atten­ doubts him. tion to the questionable behavior in a straight­ •Brainstorm, permitting the group to solve the forward, factual way, and invite group input problem and get past the impasse (Vannicelli with a comment such as, “Joe, you appear to 1992). be communicating something nonverbally by putting your hand on Mary’s shoulder. Could A client has been using alcohol or drugs, but you please put your actions into words?” will not acknowledge it. If other group mem­ bers do not confront clients who are using sub­ Most agencies have policies related to violent stances, the leader should raise the issue in an behavior; all group leaders should know what empathic manner designed to encourage hon­ they are. In groups, threatening behavior esty, such as, “It must be hard for you, Sandy, should be intercepted decisively. If necessary, to find yourself in a group in which you don’t the leader may have to stand in front of a feel safe enough to talk about your drinking” group member being physically threatened. (Vannicelli 1992, p. 65). Some situations require help, so a lone leader should never conduct a group session without A client defiantly acknowledges using sub­ other staff nearby. On occasion, police inter­ stances. A client who uses substances and vention may be necessary, which could be clearly has no intention of stopping should be expected to disrupt the group experience asked to leave the group. In contrast, a client completely. who slips repeatedly needs an intervention that invites the group’s help in setting conditions for The leader should not suggest touching, holding continued participation: “It is clear, Maria, hands, or group hugs without first discussing that you feel it is appropriate for you to stop this topic in group. This tactic will convey the using and yet, so far, the ways that you have message that strong feelings should be talked been dealing with the problem have not been about, not avoided. In general, though, group adequate. Since it is important that your members should be behavior, as well as your words, support the encouraged to put group norm, we need to find ways that will be their thoughts and more effective in supporting abstinence.” The feelings into words, group may then help set up specific require­ not actions. A group may need ments for Maria that will help her maintain Whenever the thera­ abstinence. Suggestions might include increased to set up specific AA participation, the development of a relapse pist invites the group prevention plan, increased supportive social to participate in any requirements contact, or the use of medications (like form of physical con­ Antabuse for alcoholism) (Vannicelli 1992, tact (for example, in p. 68). psychodrama or to help a member dance therapy), indi­ Many outpatient groups have mandated clients viduals should be maintain who are required to submit to urine tests. The allowed to opt out counselor is required to report infractions or without any negative abstinence. test failures. These stipulations should appear perceptions within the in the group agreement, so they do not come as group. All members a surprise to anyone. uncomfortable with

Group Leadership, Concepts, and Techniques 103 physical contact should be assured of permis­ leader should not express discomfort with the sion to refrain from touching or having anyone level of emotion or indicate a wish to avoid touch them. hearing what was being said. Leaders can say something such as Leaders also should make sure that sug­ •“As I ask you to stop, there’s a danger that gestions to touch are what you hear is, ‘I don’t want to hear you.’ Group leaders intended to serve the It’s not that. It’s just that for now, I’m con­ clients’ best interests cerned that you may come to feel as if you carefully monitor and not the needs of have shared more than you might wish.” the therapist. Under •“I’m wondering how useful it would be for the level of emo­ no circumstances you to continue with what you’re doing right should a counselor now.” This intervention teaches individuals tional intensity in ask for or initiate how to regulate their expression of emotions physical contact. and provides an opportunity for the group to the group. Like their clients, comment. counselors need to •“Let’s pause for a moment and every few learn that such minutes from now. How are you feeling right impulses affect them now? Let me know when you’re ready to as well. Nothing is move on.” wrong with feeling attracted to a client. It is wrong, however, for group leaders to allow A distinction needs to be made whether the these feelings to dictate or influence their strong feelings are related to there­and­then behavior. material or to here­and­now conduct. It is far less unsettling for someone to express anger— Leaders help cool down even rage—at a father who abused her 20 years affect ago than it is to have a client raging at and threatening to kill another group member. Group leaders carefully monitor the level of Also, the amount of appropriate affect will emotional intensity in the group, recognizing differ according to the group’s purpose. Much that too much too fast can bring on extremely stronger emotions are appropriate in psy­ uncomfortable feelings that will interfere with chodrama or gestalt groups than in psycho­ progress––especially for those in the earlier educational or support groups. stages of recovery. When emotionally loaded topics (such as sexual abuse or trauma) come For people who have had violence in their up and members begin to share the details of lives, strong negative emotions like anger can their experiences, the level of emotion may be terrifying. When a group member’s rage rapidly rise to a degree some group members adversely affects the group process, the leader are unable to tolerate. may use an intervention such as

At this point, the leader should give the group •“Bill, stop for a moment and hear how what the opportunity to pause and determine you’re doing is affecting other people.” whether or not to proceed. The leader might •“Bill, maybe it would be helpful for you to ask, “Something very powerful is going on right hear what other people have been thinking now. What is happening? How does it feel? Do while you’ve been speaking.” we want to go further at this time?” •“Bill, as you’ve been talking, have you At times, when a client floods the room with noticed what’s been happening in the emotional information, the therapist should group?” mute the disturbing line of discussion. The

104 Group Leadership, Concepts, and Techniques The thrust of such interventions is to modulate •Helping members the expression of intense rage and encourage with difficulty ver­ the angry person and others affected by the balizing know that anger to pay attention to what has happened. their contributions In support and Vannicelli (1992) suggests two other ways to are valuable and modulate a highly charged situation: putting them in interpersonal charge of requesting •Switch from emotion to cognition. The leader assistance. The process groups, can introduce a cognitive element by asking leader might ask, “I clients about their thoughts or observations can see that you are the leader’s prima­ or about what has been taking place. struggling, Bert. My •Move in time, from a present to a past focus guess is that you are ry task is stimulat­ or from past to present. carrying a truth that’s important for When intervening to control runaway affect, ing communication the group. Do you the leader always should be careful to support have any sense of the genuine expressions of emotion that are how they can help among group appropriate for the group and the individual’s you say it?” stage of change. members. In general, group Leaders encourage communi­ leaders should speak often, but briefly, cation within the group especially in time­lim­ In support and interpersonal process groups, ited groups. In group, the best interventions the leader’s primary task is stimulating commu­ usually are the ones that are short and simple. nication among group members, rather than Effective leadership demands the ability to between individual members and the leader. make short, simple, cogent remarks. This function also may be important on some occasions in psychoeducational and skills­ building groups. Some of the many appropriate Concepts, Techniques, interventions used to help members engage in and Considerations meaningful dialog with each other are •Praising good communication when it hap­ Interventions pens. Interventions may be directed to an individual •Noticing a member’s body language, and or the group as a whole. They can be used to without shaming, asking that person to clarify what is going on or to make it more express the feeling out loud. explicit, redirect energy, stop a process that is •Building bridges between members with not helpful, or help the group make a choice remarks such as, “It sounds as if both you about what should be done. A well­timed, and Maria have something in common . . .” appropriate intervention has the power to •Helping the group complete unfinished busi­ •Help a client recognize blocks to connection ness with questions such as, “At the end of with other people our session last time, Sally and Joan were •Discover connections between the use of sharing some very important observations. substances and inner thoughts and feelings Do you want to go back and explore those further?” •Understand attempts to regulate feeling states and relationships •When someone has difficulty expressing a thought, putting the idea in words and ask­ •Build coping skills ing, “Have I got it right?”

Group Leadership, Concepts, and Techniques 105 •Perceive the effect of substance abuse on •In addition to using one’s own skills, build one’s life skills in participants. Avoid doing for the •Notice meaningful inconsistencies among group what it can do for itself. thoughts, feelings, and behavior • Encourage the group to learn the skills neces­ •Perceive discrepancies between stated goals sary to support and encourage one another and what is actually being done because too much or too frequent support from the clinician can lead to approval seek­ Any verbal interven­ ing, which blocks growth and independence. tion may carry Supporting each other, of course, is a skill A process group important nonverbal that should develop through group phases. elements. For exam­ Thus, in earlier phases of treatment, the ple, different people that remains leader may need to model ways of communi­ would ascribe a cating support. Later, if a client is experienc­ variety of meanings ing loss and grief, for example, the leader leader focused lim­ to the words, “I am does not rush in to assure the client that all afraid that you have will soon be well. Instead, the leader would its the potential for used again,” and the invite group members to empathize with each interpretation will other’s struggles, saying something like, learning and vary further with the “Joanne, my guess is at least six other people speaker’s tone of here are experts on this type of feeling. What growth. voice and body lan­ does this bring up for others here?” guage. Leaders •Refrain from taking on the responsibility to should therefore repair anything in the life of the clients. To a be careful to avoid certain extent, they should be allowed to conveying an observation in a tone of voice that struggle with what is facing them. It would be could create a barrier to understanding or appropriate, however, for the leader to response in the mind of the listener. access resources that will help clients resolve problems. Avoiding a leader­centered group Confrontation Generally a counselor leads several kinds of Confrontation is one form of intervention. In groups. Leadership duties may include a psy­ the past, therapists have used confrontation choeducational group, in which a leader usual­ aggressively to challenge clients’ defenses of ly takes charge and teaches content, and then a their substance abuse and related untoward process group, in which the leader’s role and behaviors. In recent years, however, clinicians responsibilities should shift dramatically. A have come to recognize that when “confronta­ process group that remains leader­focused lim­ tion” is equivalent to “attack,” it can have an its the potential for learning and growth, yet all adverse effect on the therapeutic alliance and too often, interventions place the leader at the process, ultimately leading to failure. Trying to center of the group. For example, a common force the client to share the clinician’s view of a sight in a leader­centered group is a series of situation accomplishes no therapeutic purpose one­on­one interactions between the leader and and can get in the way of the work. individual group members. These sequential interventions do not use the full power of the A more useful way to think about confrontation group to support experiential change, and is “pointing out inconsistencies,” such as dis­ especially to build authentic, supportive inter­ connects between behaviors and stated goals. personal relationships. Some ways for a leader William R. Miller explains: to move away from center stage:

106 Group Leadership, Concepts, and Techniques The linguistic roots of the verb “to con­ response to a group member’s transference is front” mean to come face to face. When referred to as countertransference. Vannicelli you think about it that way, confronta­ (2001) describes three forms of countertrans­ tion is precisely what we are trying to ference: accomplish: to allow our clients to come face to face with a difficult and often •Feelings of having been there. Leaders with threatening reality, to “let it in” rather family or personal histories with substance than “block it out,” and to allow this abuse have a treasure in their extraordinary reality to change them. That makes con­ ability to empathize with clients who abuse frontation a goal of counseling rather substances. If that empathy is not adequately than a particular style or technique. . . understood and controlled, however, it can [T]hen the question becomes, What is become a problem, particularly if the thera­ the best way to achieve that goal? pist tries to act as a role model or sponsor, or Evidence is strong that direct, forceful, discloses too much personal information. aggressive approaches are perhaps the •Feelings of helplessness when the therapist is least effective way to help people consid­ more invested in the treatment than the client er new information and change their is. Treating highly resistant populations, such perceptions (CSAT 1999b, p. 10). as clients referred to treatment by the courts, can cause leaders to feel powerless, demoral­ Confrontation in this light is a part of the ized, or even angry. The best way to deal change process, and therefore part of the help­ with this type of countertransference may be ing process. Its purpose is to help clients see to use the energy of the resistance to fuel the and accept reality so they can change accord­ session. (See “Resistance in Group,” next ingly (Miller and Rollnick 1991). With this section.) broader understanding of what interventions •Feelings of incompetence due to unfamiliarity that “confront” the client really mean, it is not with culture and jargon. It is helpful for lead­ useful to divide therapy into “supportive” and ers to be familiar with 12­Step programs, cul­ “confrontative” categories. tures, and languages. If a group member uses unfamiliar terms, however, the leader should Transference and ask the client to Countertransference explain what the term means to that Transference means that people project parts person, using a The therapist’s of important relationships from the past into question like, relationships in the present. For example, “‘Letting go’ means emotional Heather may find that Juan reminds her of her something a bit dif­ judgmental father. When Juan voices his suspi­ ferent to each per­ response to a cion that she has been drinking, Heather feels son. Can you say a the same feelings she felt when her father criti­ little more about group member’s cized all her supposed failings. Within the how this relates to microcosm of the group, this type of incident your situation?” transference is not only relates the here­and­now to the past, (Vannicelli 2001, but also offers Heather an opportunity to learn p. 58). a different, more self­respecting way of referred to responding to a remark that she perceives as When countertrans­ criticism. ference occurs, the as counter­ clinician needs to The emotion inherent in groups is not limited bring all feelings asso­ transference. to clients. The groups inevitably stir up strong ciated with it to feelings in leaders. The therapist’s emotional

Group Leadership, Concepts, and Techniques 107 awareness and manage them appropriately. have been in sharing their feelings this evening Good supervision can be really helpful. and in being so forthcoming about really speak­ Countertransference is not bad. It is inevitable, ing up. My hope is that people will continue to and with the help of supervision, the group be able to talk in this open way to make our leader can use countertransference to support time together as useful as possible” (Vannicelli the group process (Vannicelli 2001). 2001, p. 55).

Leaders should recognize that clients are not Resistance in Group always aware that their reasons for nonatten­ dance or lateness may be resistance. The most Resistance arises as an often unconscious helpful attitude on the clinician’s part is curios­ defense to protect the client from the pain of ity and an interest in exploring what is happen­ self­examination. These processes within the ing and what can be learned from it. Leaders client or group impede the open expression of need not battle resistance. It is not the enemy. thoughts and feelings, or block the progress of Indeed, it is usually the necessary precursor to an individual or group. The effective leader change. will neither ignore resistance nor attempt to override it. Instead, the leader helps the indi­ It would be a serious mistake, however, to vidual and group understand what is getting in imagine that resistance always melts away once the way, welcoming the resistance as an oppor­ someone calls attention to it. “Resistance is tunity to understand something important always there for a reason, and the group mem­ going on for the client or the group. Further, bers should not be expected to give it up until resistance may be viewed as energy that can be the emotional forces held in check by it are suf­ harnessed and used in a variety of ways, once ficiently discharged or converted, so that they the therapist has helped the client and group are no longer a danger to the safety of the understand what is happening and what the group or its members” (Flores 1997, p. 538). resistant person or persons actually want (Vannicelli 2001). When a group (rather than an individual) is resistant, the leader may have contributed to In groups that are mandated to enter treat­ the creation of this phenomenon and efforts ment, members often have little interest in need to be made to understand the leader’s role being present, so in the problem. Sometimes, “resistance can be strong resistance is induced by leaders who are passive, hostile, to be expected. Even ineffective, guarded, weak, or in need of con­ this resistance, how­ stant admiration and excessive friendliness” ever, can be incorpo­ (Flores 1997, p. 538). rated into treatment. For the group For example, the leader may invite the Confidentiality group members to leader, strict For the group leader, strict adherence to talk about the diffi­ confidentiality regulations builds trust. If the culties experienced adherence to con­ bounds of confidentiality are broken, grave in coming to the legal and personal consequences may result. All session or to express group leaders should be thoroughly familiar fidentiality regula­ their outrage at hav­ with Federal laws on confidentiality (42 C.F.R. ing been required to Part 2, Confidentiality of Alcohol and Drug tions builds trust. come. The leader Abuse Patient Records; see Figure 6­2) and rel­ can respond to this evant agency policies. Confidentiality is recog­ anger by saying, “I nized as “a central tenet of the practice of psy­ am impressed by chotherapy” (Parker et al. 1997, p. 157), yet a how open people

108 Group Leadership, Concepts, and Techniques vast majority of States either have vague decide what to say statutes dealing with confidentiality in group and what they want therapy or have no statutes at all. Even where from the group. The a privilege of confidentiality does exist in law, therapist can prompt Clinicians should enforcement of the law that protects it is often clients to share infor­ difficult (Parker et al. 1997). Clinicians should mation in the group warn clients that be aware of this legal problem and should warn with a comment like, clients that what they say in group may not be “I wonder if the group what they say in kept strictly confidential. Some studies indicate understands what a that a significant number of therapists do not hard time you’ve been group may not advise group members that confidentiality has having over the last 2 limits (Parker et al. 1997). weeks?” On the other hand, therapists be kept strictly One set of confidentiality issues has to do with should reserve the the use of personal information in a group ses­ right to determine confidential. sion. Group leaders have many sources of what information will information on a client, including the names of be discussed in group. the client’s employer and spouse, as well as any A leader may say ties to the court system. A group leader should firmly, “Understand be clear about how information from these that whatever you tell me may or may not be sources may and may not be used in group. introduced in group. I will not keep important information from the group, if I feel that with­ Clinicians consider the bounds of confidentiali­ holding the information will impede your ty as existing around the treatment enterprise, progress or interfere with your recovery.” not around a particular treatment group. Clients should know that everyone on the treat­ Still other confidentiality issues arise when ment team has access to relevant information. clients discuss information from the group In addition, clinicians should make it clear to beyond its bounds. Violations of confidentiality clients that confidentiality cannot be used to among members should be managed in the conceal continued substance abuse, and the same way as other boundary violations; that is, therapist will not be drawn into colluding with empathic joining with those involved followed the client to hide substance use infractions. by a factual reiteration of the agreement that Clinicians also should advise clients of the exact has been broken and an invitation to group circumstances under which therapists are legal­ members to discuss their perceptions and feel­ ly required to break confidentiality (see Figure ings. In some cases, when this boundary is vio­ 6­2). lated, the group may feel a need for additional clarification or addenda to the group agree­ A second set of confidentiality issues has to do ment. The leader may ask, both at the begin­ with the group leader’s relationships with ning of the group or when issues arise, whether clients and clients with one another. When the group feels it needs additional agreements counseling a client in both individual therapy in order to work safely. Such amendments, and a group context, for example, the leader however, should not seek to renegotiate the should know exactly how information learned terms of the original group agreement. See in individual therapy may be used in the group Figure 6­2 (see p. 110) for helpful information context. In almost every case, it is more benefi­ on confidentiality and the law. cial for the client to divulge such information than for the clinician to reveal it. In an individ­ Because a group facilitator generally is part of ual session, the therapist and the client can the larger substance abuse treatment program, plan how the issue will be brought up in group. it is recommended that the group facilitator This preparation gives clients ample time to take a practical approach to exceptions. This

Group Leadership, Concepts, and Techniques 109 Figure 6­2

Confidentiality and 42 C.F.R., Part 2

Confidentiality is both an ethical and a legal issue. Federal law (Title 42, Part 2 or 42 C.F.R., Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records) guarantees strict confidentiality of information about all people receiv­ ing substance abuse prevention and/or treatment services. Clients should be fully informed regarding issues of confidentiality, and group leaders should do all they can to build respect for confidentiality and anonymity within groups.

There are six conditions under which limited disclosure is permitted under the regulations. These exceptions are

•The group member has signed a Release of Information document that allows the group facilitator to communicate with another professional and/or agency. •A group member threatens imminent harm to him­ or herself, and the group facilitator believes that the client may act on this threat. •A client threatens imminent harm to another named person, and the group facilitator believes that there is a reasonable likelihood that the client will act on the threat. •A medical emergency requires that a client’s drug and alcohol status be revealed in order to ensure that the client gets appropriate medical attention. •A client is suspected of child neglect and/or abuse, as defined by the laws of the State in which the substance abuse treatment services are being provided. •A direct court order mandates the release of specific information related to a client’s history and/or treatment. However, an authorizing court order alone does not compel disclosure—for example, if the person authorized to disclose confidential information does not elect to make the disclosure, he or she can­ not be forced to do so unless there is a valid subpoena (i.e., the subpoena has not expired) or other compulsory process introduced that would then compel disclosure. An appropriate judge issues a court order. It specifies the exact information to be provided about a particular client and is properly signed and dated. More detailed discussions of confidentiality can be found in TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b); TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT 1994a); TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment (Lopez 1994); and TAP 18, Checklist for Monitoring Alcohol and Other Drug Confidentiality Compliance (CSAT 1996).

Source: Consensus Panel.

110 Group Leadership, Concepts, and Techniques practical approach is to have the group facilita­ the clinician and then tor discuss the potential application of the break into smaller exceptions with the program director or mem­ groups to discuss, ber of the program staff who is the lead on the practice, or role­play confidentiality regulation. the particular topic. Successful treat­ Each group has a ment for substance Biopsychosocial and Spiritual client leader, and the Framework—Treating the clinician circulates among the groups to use disorders Whole Person ensure that the topic Substance use disorders include a wide range is understood and should address the of symptoms with different levels of associated that discussion is pro­ disability. Clients always bring into treatment ceeding. The clinician whole person. vulnerabilities other than their alcohol or illicit does not participate in drug dependencies. Group interventions may the groups. Research­ be needed to resolve psychological problems, ers describing this physical ailments, social stresses, and perhaps, model note that spiritual emptiness or bankruptcy. In short, because the clinicians successful treatment for substance use disor­ step back from assuming leadership roles in the ders should address the whole person, includ­ groups, the clients become empowered to take ing that person’s spiritual growth. group sessions in the necessary direction and demonstrate feelings and insights that might While the group experience is a powerful tool not occur in a group formally led by a clinician in the treatment of substance use disorders, it (Goldberg and Simpson 1995). is not the only tool. Other interventions, such as individual therapy, psychological interven­ It is well known that 12­Step programs are an tions, pharmacological supports, and intensive important part of many therapeutic programs case management, may all be necessary to (Page and Berkow 1998). While 12­Step pro­ achieve long­term remission from the symptoms grams have a proven record of success in help­ of addictive disorders. ing people overcome substance use disorders, there is a basic conflict inherent in them that For example, people who are homeless with a group therapists need to reconcile. In the 12­ co­occurring mental disorder have three com­ Step program, people are urged to cede control plicated sets of problems that require a contin­ to a higher power. Yet, in group, the clinician uous and comprehensive care system—one that is prompting clients to take control of their integrates or coordinates interventions in (1) emotions, behavior, and lives. the mental health system, (2) the addiction sys­ tem, and (3) the social service system for home­ As a result, some researchers have stated that less persons. In group therapy, each condition it is “impossible to integrate psychotherapy and should be regarded as a primary interactive AA approaches dealing with addictions without problem; that is, one in which each problem compromising one approach or the other” develops independently but contributes to both (Page and Berkow 1998, pp. 1–2). Another of the others (Minkoff and Drake 1992). researcher has argued that “the AA approach is consistent with existential philosophy” One model offered for treating homeless per­ because both stress that people should accept sons with substance use disorder is a modified their “human limitations and security­seeking training group designed to accommodate a behaviors” (Page and Berkow 1998, p. 2). large number of members whenever a tradi­ Although the literature currently has few tional small group is not possible. In this straightforward discussions of spirituality and model, participants meet in a large group with

Group Leadership, Concepts, and Techniques 111 its role in the familiar with the self­help group. Matano and dynamics of group Yalom (1991) strongly recommend that group therapy, most clini­ leaders become thoroughly familiar with AA’s cians would agree language, steps, and traditions because mis­ Recent research that the spiritual conceptions about the program, whether by well­being of the the client or therapist, can raise barriers to client is essential to recovery. has clearly demon­ breaking free of sub­ stance abuse. Recent research has clearly demonstrated the strated the ability ability of self­help groups to improve outcomes When clients join (Tonigan et al. 1996). Research also has shown of self­help groups self­help groups, that clients receiving mental health services as they sometimes hear well as participating in 12­Step meetings have to improve out­ from individuals an even better prognosis (Ouimette et al. 1998). who strongly oppose Marilyn Freimuth’s research on integrating the use of any medi­ group psychotherapy and 12­Step work has comes. cation. Some people shown that “if mere co­participation in psy­ in 12­Step programs chotherapy and 12­Step groups supports a erroneously believe, client’s recovery, it is reasonable to expect that for example, that the a more integrated approach will provide fur­ use of pharmacologi­ ther benefits” (Freimuth 2000, p. 298). Both cal adjuncts to ther­ activities “support abstinence and emotional apy is a violation of the program’s principles. growth” (Freimuth 2000, p. 301). Together, They consequently oppose methadone mainte­ the two modalities supply multiple relationship nance, the use of Antabuse, or the use of medi­ models, potentially of immense value to the cations needed to control co­occurring disor­ client. ders. Some suggestions for maximizing the therapeu­ Clinicians should be prepared to handle these tic potential of participation in both process misapprehensions. One way to help would be and 12­Step groups follow: to refer apprehensive clients to the pamphlet, The AA Member—Medications and Other Orientation should prepare new group mem­ Drugs: A Report from a Group of Physicians bers who are also members of 12­Step groups in AA (Alcoholics Anonymous World Services for differences in the two groups. A key differ­ 1984). It stresses the value of appropriate ence will be the fact that members interact with medication prescribed by a physician who each other. Such “cross talk” is discouraged at understands addictive disorders and reassures 12­Step meetings. “The new psychotherapy clients that such use of medication is wholly group member may need to be told that the consistent with AA and Narcotics Anonymous’ topic of conversation is much wider than the 12­Step programs. 12­Step meeting’s focus on addiction and recov­ ery, and that it includes feelings and reactions Many clients enrolled in a process group for toward other group members” (Freimuth persons with substance use disorders are likely 2000, p. 300; see also Vannicelli 1992). participating in a 12­Step program or other self­help groups as well. On occasion, appar­ During early recovery, it is particularly impor­ ently conflicting messages can be an issue. For tant to avoid making the 12­Step program’s instance, many people with addiction histories encouragement of “unquestioning acceptance” try to use AA and its jargon as material for a focus of analysis in group therapy. Too resistance. Such problems can readily be man­ critical an interpretation offered too early may aged, provided the therapist is thoroughly disrupt the 12­Step program’s status as an “ideal object,” belief in which “is critical to

112 Group Leadership, Concepts, and Techniques maintaining early abstinence” (Dodes 1988; The following vignette illustrates a typical Freimuth 2000, p. 305). intervention intended to clarify and harmonize appropriate participation in 12­Step and Sometimes clients experience “splitting”— process groups: seeing “the [12­Step] program as the all­good parent and all others, including the The group leader knew that Henry, who therapist/group as the all­bad/ambivalent was well along in recovery but new to object.” Later, the split may be just the oppo­ group, had not expressed his anger at site (Freimuth 2000). The group leader should Jenna for having cut him off for the be attuned to this potential and should be pre­ third time. When asked how he experi­ pared to work through these perceptions and enced Jenna, he simply replied that the feelings underlying them. Further, when according to the program you are not to the process group is perceived as the “less take another person’s inventory. The than” modality and the client enthusiastically leader took the opportunity to say that quotes insights from a 12­Step group, the ther­ in group therapy it is important to con­ apist should watch for possible countertrans­ sider one’s feelings about what others ference and bear in mind the benefits the client say and do even if [the feelings] are is receiving from both programs. negative. Expressing one’s own feelings is different from focusing on another’s Sponsors of 12­Step members may distrust character (taking his inventory) therapy and discourage group member from (Freimuth 2000, p. 308). continuing in treatment. The leader should be prepared to respond to a variety of potential No matter what the modality, however, group issues in ways that avoid appearing to compete therapy is sure to remain an integral part of with the self­help group. For example, if a substance abuse treatment. client says, “In my AA group, they say I don’t need to be here. As long as I’m not drinking, Addressing life issues my life is fine.” The therapist might acknowl­ edge the importance of continued sobriety, but Substance abuse affects every aspect of life: remind the client of depression experienced home, family, friends, job, health, emotional before the onset of heavy drinking. well­being, and beliefs. As clients move into recovery, the wide range of issues they should Group leaders should beware of their possible face may overwhelm them. Leaders need to biases against 12­Step groups that may be help clients rank the based on inaccurate information. For example, importance of the it is not true that the 12­Step philosophy oppos­ challenges, taking es therapy and medication, as AA World care to make the best Service pamphlets clarify. It also is a miscon­ possible use of the ception that 12­Step programs encourage peo­ resources the client Naturally, clients ple to abdicate responsibility for substance use. and the leader can AA, however, does urge people with addiction bring to bear. will vary in their problems to attend meetings in the early stages of recovery, even though they may still be using Naturally, clients will ability to address alcohol or illicit drugs. Finally, some clinicians vary in their ability to believe that 12­Step programs discourage address many con­ many concerns strong negative emotions. On the contrary, cerns simultaneously; capacity for change “there is no unilateral discouragement of nega­ simultaneously. tive affects within [12­Step] program philoso­ also is variable. For phy; only when anger threatens sobriety is it example, some indi­ considered necessary to circumvent negative viduals with cognitive feelings” (Freimuth 2000, p. 308). impairments will have a much harder time

Group Leadership, Concepts, and Techniques 113 than others engaging each client that continued substance abuse in a change process. might jeopardize. For some individuals, it is In the early stage of their job. For others, it is their spouse, health, treatment, such family, or self­respect. In some cases, it might clients need simple be the threat of incarceration. Such knowledge ideas, structures, can be used to encourage, and even coerce, The leader should and principles. individuals to utilize the tools of treatment, group, or AA (Flores 1997). explore the impor­ As the client moves forward, the clini­ Incorporating faith tance of spiritual cian can keep in mind the issues that While spirituality and faith may offer to some life with the group. a client is not ready the hope, nurturing, sense of purpose and or able to manage. meaning, and support needed to move toward As this process goes recovery, people obviously interpret spiritual on, the leader should matters in diverse ways. It is important not to remember that the confuse spirituality with religion. Even if client’s priorities clients are not religious, their spiritual life is matter more than important. Some clinicians mistakenly conclude what the leader that their own understanding of spirituality will thinks ought to come next. Unless both client help the client. Other clinicians err in the and leader operate in the same motivational opposite direction and are overly reluctant to framework the leader will not be able to help address spiritual beliefs. Actually, a middle the client make progress. ground is preferable. The leader should explore the importance of spiritual life with the No matter what is missing—even if it is a roof group, and if the search for spiritual meaning over the client’s head—it is possible to engage is important, the clinician can incorporate it the client in treatment. A client never should be into group discussions. told to come back after problems other than substance abuse have been resolved. On some For clients who lack meaningful connection to front, constructive work can always be done. anything beyond themselves, the group may be Of course, this assertion does not mean that the first step toward a search for meaning or a critical needs can be ignored until treatment feeling of belonging to something greater than for substance abuse is well underway. The the self. The clinician’s role in group therapy therapist should recognize that a client preoc­ simply is to create an environment within cupied with the need to find a place to sleep which such ego­transcending connections can will not be able to engage fully in treatment be experienced. until urgent, practical needs are met. Life issues facing the client provide two power­ Integrating Care ful points of therapeutic leverage that leaders can use to motivate the client to pursue recov­ Interaction with other health ery. First, group leaders should be aware that care professionals people with alcoholism and other addictions Professionals within the entire healthcare net­ will not give up their substance use until the work need to become more aware of the role of pain it brings outweighs the pleasure it pro­ group therapy for people abusing substances. duces. Consequently, they should be helped to To build the understanding needed to support see the way alcohol and drugs affect important people in recovery, group leaders should edu­ areas of their lives. Second, early in treatment, cate others serving this population as often as group leaders should learn what is important to opportunities arise, such as when clinicians

114 Group Leadership, Concepts, and Techniques from different sectors of the healthcare system cravings, the therapist work together on a case. Similar needs for might talk with the understanding exist with probation officers, physician to deter­ families, and primary care physicians. mine whether appro­ priate medication Integration of group therapy could help the client through the difficult and other forms of therapy period following Conflict in group It is common for a client to be in both individu­ substance abuse al and group therapy simultaneously. The dual cessation. Therapists therapy is normal, relationship creates both problems and oppor­ should be wary, how­ tunities. Skilled therapists can use what they ever. From former healthy, and discover in group about the client’s style of days of active sub­ relatedness to enhance individual therapy. stance abuse, clients unavoidable. Conversely, the individual alliance can help the may have ties to care­ client use the group effectively. So long as the less physicians who therapist does not collude consciously or enabled addiction by unconsciously with the client to keep what is providing cross­addic­ said as a secret between them, most obstacles tive medications. If an can be overcome. evaluation of pre­ scription medications In conjoint treatment, that is, a situation in is needed, counselors which one therapist sees a client individually should refer the client to a consulting physician while another therapist treats the same client in working with the agency or to a physician a group, the therapists should be in close com­ knowledgeable about chemical dependency. munication with each other. Clinicians should Attention needs to be paid to medications pre­ coordinate the treatment plan, keeping impor­ scribed for physical illnesses as well. For exam­ tant interpersonal issues alive in both settings. ple, it would be important for the group leader The client should know that this collaboration to know that a group member has diabetes and routinely occurs for the client’s benefit. requires medication. Medication knowledge base Management of the Group Clinicians need general knowledge of common medications used to assist in recovery, relapse Handling conflict in group prevention, and co­occurring disorders. Group Conflict in group therapy is normal, healthy, leaders should be aware of various medication and unavoidable. When it occurs, the thera­ needs of clients, the type of medications pre­ pist’s task is to make the most of it as a learn­ scribed, and potential side effects. Prescribing ing opportunity. Conflict can present opportu­ medication involves striking a balance between nities for group members to find meaningful therapeutic and detrimental pharmacological connections with each other and within their effects. For example, benzodiazepines can own lives. reduce anxiety, but they can be sedating and might lead to dependency. Handling anger, developing empathy for a dif­ ferent viewpoint, managing emotions, and The pregroup interview for long­term groups working through disagreements respectfully are should ask what medications group members all major and worthwhile tasks for recovering are taking and the names of prescribing physi­ clients. The leader’s judgment and manage­ cians so cooperative treatment is possible. For ment are crucial as these tasks are handled. It example, if a client is awake all night with drug is just as unhelpful to clients to let the conflict

Group Leadership, Concepts, and Techniques 115 go too far as it is to the therapist should consider the function the shut down a conflict conflict is serving for the group. It actually may before it gets worked be the most useful current opportunity for After a conflict, it through. The thera­ growth in the group. pist must gauge the is important for verbal and nonver­ On the other hand, as Vannicelli (1992) points bal reactions of out, conflicts can be repetitive and predictable. When two members are embroiled in an end­ the group leader to every group member to ensure that every­ less loop of conflict, Vannicelli suggests that the leader may handle the situation by asking, speak privately one can manage the emotional level of “John, did you know what Sally was likely to the conflict. say when you said X?” and “Sally, did you with group mem­ know what John was likely to say when you The clinician also said Y?” “Since both participants are likely to bers and see how facilitates interac­ answer, ‘Yes, of course,’ the therapist would tions between mem­ then inquire what use it might serve for them to each is feeling. bers in conflict and engage in this dialogue when the expected out­ calls attention to come is so apparent to both of them (as well as subtle, sometimes to other members of the group). This kind of unhealthy patterns. distraction activity or defensive maneuver For example, a should come to signal to group members that group may have a member, Mary, who fre­ something important is being avoided. It is the quently disagrees with others. Group peers leader’s task to help the group figure out what regard Mary as a source of conflict, and some that might be and then to move on” (Vannicelli of them have even asked Mary (the scapegoat) 1992, p. 121). to leave so that they can get on with group work. In such a situation, the therapist might Group leaders also should be aware that many ask, “Do you think this group would learn conflicts that appear to scapegoat a group more about handling this type of situation if member are actually displaced anger that a Mary left the group or stayed in the group?” member feels toward the therapist. When the An alternative tack would be, “I think the therapist suspects this kind of situation, the group members are avoiding a unique opportu­ possibility should be forthrightly presented to nity to learn something about yourselves. the group with a comment such as, “I notice, Giving in to the fantasy of getting rid of Mary Joe, that you have been upset with Jean quite a would rob each of you of the chance to under­ bit lately. I also know that you have been a lit­ stand yourself better. It would also prevent you tle annoyed with me a since couple weeks ago from learning how to deal with people who about the way I handled that phone call from upset you.” your boss. Do you think some of your anger belongs with me?” Conflicts within groups may be overt or covert. The therapist helps the group to label covert Individual responses to particular conflicts can conflicts and bring them into the open. The be complex, and may resonate powerfully observation that a conflict exists and that the according to a client’s personal values and group needs to pay attention to it actually beliefs, family, and culture. Therefore, after a makes group members feel safer. The therapist conflict, it is important for the group leader to is not responsible, however, for resolving con­ speak privately with group members and see flicts. Once the conflict is observed, the deci­ how each is feeling. Leaders also often use the sion to explore it further is made based on last 5 minutes of a session in which a conflict whether such inquiry would be productive for has occurred to give group members an oppor­ the group as a whole. In reaching this decision, tunity to express their concerns.

116 Group Leadership, Concepts, and Techniques Subgroup management Responding to disruptive In any group, subgroups inevitably will form. behavior Individuals always will feel more affinity and Clients who cannot stop talking more potential for alliance with some members When a client talks on and on, he or she may than with others. One key role for the therapist not know what is expected in a therapy group. in such cases is to make covert alliances overt. The group leader might ask the verbose client, The therapist can involve the group in identify­ “Bob, what are you hoping the group will learn ing subgroups by saying, “I notice Jill and from what you have been sharing?” If Bob’s Mike are finding they have a good deal in com­ answer is, “Huh, well nothing really,” it might mon. Who else is in Jill and Mike’s subgroup?” be time to ask more experienced group mem­ Subgroups can sometimes provoke anxiety, bers to give Bob a sense of how the group especially when a therapy group is made up of works. At other times, clients tend to talk more individuals acquainted before becoming group than their share because they are not sure what members. Group members may have used else to do. It may come as a relief to have their drugs together, slept together, worked together, monolog interrupted (Vannicelli 1992, p. 167). or experienced residential substance abuse If group members treatment together. Obviously, such connec­ exhibit no interest in tions are potentially disruptive, so when groups stopping a perpetually are formed, group leaders should consider filibustering client, it whether subgroups would exist. may be appropriate to In managing When subgroups somehow stymie full partici­ examine this silent pation in the group, the therapist may be able cooperation. The subgroups, one to reframe what the subgroup is doing. At group may be all too other times, a change in the room arrangement willing to allow the key role for the may be able to reconfigure undesirable combi­ talker to ramble on, to avoid examining nations. On occasion, however, subtle therapist is to approaches fail. For instance, adolescents talk­ their own past failed ing among themselves or making obscene ges­ patterns of substance make covert tures during the session should be told factually abuse and forge a and firmly that what they are doing is not per­ more productive missible. The group leader might say, “We future. When this alliances overt. can’t do our work with distractions going on. motive is suspected, Your behavior is disrespectful and it attempts the leader should to shame others in the group. I won’t tolerate explore what group any abuse of members in this group.” members have and have not done to sig­ Subgroups are not always negative. The leader nal the speaker that it is time to yield the floor. for example may intentionally foster a sub­ It also may be advisable to help the talker find group that helps marginally connected clients a more effective strategy for being heard and move into the life of the group. This gambit understood (Vannicelli 1992). might involve a question like, “Juanita, do you think it might help Joe if you talked some Clients who interrupt about your experience with this issue?” Interruptions disrupt the flow of discussion in Further, to build helpful connections between the group, with frustrating results. The client group members, a group member might be who interrupts is often someone new to the asked, “Bob, who else in this group do you group and not yet accustomed to its norms and think might know something about what you’ve rhythms. The leader may invite the group to just said?” comment by saying, “What just happened?” If

Group Leadership, Concepts, and Techniques 117 the group observes, the group is very serious and should never be “Jim seemed real done without careful thought and consultation, anxious to get in it is sometimes necessary. It may be required right now,” the lead­ because of a policy of the institution, because er might intervene the therapist lacks the skills needed to deal with, “You know, with a particular problem or condition, or Sometimes, clients Jim, my hunch is because an individual’s behavior threatens the that you don’t know group in some significant and insupportable are unable to us well enough yet to way. be certain that the participate in ways group will pay ade­ Though groups do debate many issues, the quate attention to decision to remove an individual is not one the consistent with your issues; thus, at group makes. On the contrary, the leader this point, you feel makes the decision and explains to the group in a clear and forthright manner why the action group agreements. quite a lot of pres­ sure to be heard and was taken. Members then are allotted time to understood. My work through their responses to what is bound guess is that when to be a highly charged event. Anger at the other people are group leader for acting without group input or speaking you are acting too slowly is common in expulsion situa­ often so distracted tions, and should be explored. by your worries that it may even be hard to completely follow what Managing Other Common is going on” (Vannicelli 1992, p. 170). Problems Clients who flee a session Clients who run out of a session often are act­ Coming late or missing ing on an impulse that others share. It would sessions be productive in such instances to discuss these Sometimes, addiction counselors view the client feelings with the group and to determine what who comes to group late as a person who, in members can do to talk about these feelings some sense, is behaving badly. It is more pro­ when they arise. The leader should stress the ductive to see this kind of boundary violation point that no matter what is going on in the as a message to be deciphered. Sometimes this group, the therapeutic work requires members attempt will fail, and the clinician may decide to remain in the room and talk about problems the behavior interferes with the group work too instead of attempting to escape them (Vannicelli much to be tolerated. 1992). If a member is unable to meet this requirement, reevaluation of that person’s placement in the group is indicated. Silence A group member who is silent is conveying a Contraindications for contin­ message as clearly as one who speaks. Silent ued participation in group messages should be heard and understood, since nonresponsiveness may provide clues to Sometimes, clients are unable to participate in clients’ difficulties in connecting with their own ways consistent with group agreements. They inner lives or with others (Vannicelli 1992). may attend irregularly, come to the group intoxicated, show little or no impulse control, Special consideration is sometimes necessary or fail to take medication to control a co­occur­ for clients who speak English as a second lan­ ring disorder. Though removing someone from guage (ESL). Such clients may be silent, or respond only after a delay, because they need

118 Group Leadership, Concepts, and Techniques time to translate what has just been said into Fear of losing control their first language. Experiences involving As Vannicelli (1992) notes, sometimes clients strong feelings can be especially hard to trans­ avoid opening up because they are afraid they late, so the delay can be longer. Further, when might break down in front of others––a fear feelings are running high, even fluent ESL particularly common in the initial phases of speakers may not be able to find the right groups. When this restraint becomes a barrier words to say what they mean or may be unable to clients feeling acute pain, the therapist to understand what another group member is should help them remember ways that they saying about an intense experience. have handled strong feelings in the past. Tuning out For example, if a female client says she When the group is in progress and clients seem might “cry forever” present in body but not in mind, it helps to once she begins, the tune into them just as they are tuning out. The leader might gently leader should explore what was happening as inquire, “Did that A group member an individual became inattentive. Perhaps the ever happen?” Clients person was escaping from specific difficult are often surprised to material or was having more general difficulties who is silent is realize that tears gen­ connecting with other people. It may be helpful erally do not last very to involve the group in giving feedback to conveying a mes­ long. The therapist clients whose attention falters. It also is possi­ can further assist this ble, however, that the group as a whole is sage as clearly as client by asking, sidestepping matters that have to do with con­ “How were you able nectedness. The member who tunes out might one who speaks. to stop?” (Vannicelli be carrying this message for the group 1992, p. 152). (Vannicelli 1992). When a client’s fears Participating only around the of breaking down or issues of others becoming unable to function may be Even when group members are disclosing little founded in reality (for example, when a client about themselves, they may be gaining a great has recently been hospitalized), the therapist deal from the group experience, remaining should validate the feelings of fear, and should engaged around issues that others bring up. To concentrate on the strength of the person’s encourage a member to share more, however, a adaptive abilities (Vannicelli 1992). leader might introduce the topic of how well members know each other and how well they Fragile clients with psycho­ want to be known. This topic could be explored in terms of percentages. For instance, a man logical emergencies might estimate that group members know about Since clients know that the group leader is 35 percent about him, and he would eventually contractually bound to end the group’s work like them to know 75 percent. Such a discus­ on time, they often wait intentionally until the sion would yield important information about last few minutes of group to share emotionally how much individuals wish to be known by oth­ charged information. They may reveal some­ ers (Vannicelli 1992). thing particularly sad or difficult for them to deal with. It is important for the leader to rec­ ognize they have deliberately chosen this time to share this information. The timing is the

Group Leadership, Concepts, and Techniques 119 client’s way of Lan individually right after the session. limiting the group’s Whatever the decision and subsequent action, responses and avoid­ the leader should not simply drift casually and ing an onslaught of quietly over the time boundary. The important Clients may feel interest. All the message is that boundaries should be honored same, the group and that Lan will get the help she needs. The great anxiety after members or leader group leader can say explicitly that Lan’s needs should point out will be addressed after group. disclosing some­ this self­defeating behavior and Figure 6­3 shows that group leaders should thing important. encourage the client be prepared to deal not only with substance to change it. abuse issues, but with co­occurring psychiatric concerns as well. Near the end of a session, for example, Anxiety and resistance after a group leader has an exchange with a group member named Lan, self­disclosure who has been silent throughout the session: Clients may feel great anxiety after disclosing something important, such as the fact that they Leader: Lan, you’ve been pretty quiet today. I are gay or incest victims. Often, they wonder hope we will hear more about what is happen­ about two possibilities: “Does this mean that I ing with you next week. have to keep talking about it? Does this mean that if new people come into the group, I have Lan: I don’t think you’ll see me next week. to tell them too?” (Vannicelli 1992, p. 160). Further exploration reveals that Lan intends to To the first question, the therapist can respond kill herself that night. In view of the approach­ with the assurance, “People disclose in here ing time boundary, what should the leader do? when they are ready.” To the second, the In such a situation, the group leader has dual member who has made the disclosure can be responsibilities. First, the leader should assured of not having to reiterate the disclosure respond to Lan’s crisis. Second, the incident when new clients enter. Further, the disclosing should be handled in a way that reassures member is now at a different stage of develop­ other group members and preserves the integri­ ment, so the group leader could say, “Perhaps ty of the group. Group members will have a the fact that you have opened up the secret a high level of anxiety about such a situation. little bit suggests that you are not feeling that it Because of their concern, some group leaders is so important to hide it any more. My guess is are willing to extend the time boundary for that that this, itself, will have some bearing on how session only, provided that all members are you conduct yourself with new members who willing and able to stay. Others feel strongly come into the group” (Vannicelli 1992, p. 160 that the time boundary should be maintained & p. 161). and that the leader should pledge to work with

120 Group Leadership, Concepts, and Techniques Figure 6­3

Jody’s Arm

A long­term outpatient interpersonal process group meets in 90­minute sessions to support sustained recovery. The group, which includes five women and four men, is relatively stable and successfully abstinent. Many of the clients, however, still struggle with profound psychological concerns that require ongoing attention.

In one group session, all members are present except Jody, a 43­year­old client who is opioid­dependent and has co­occurring psychiatric difficulties. Jody walks in approximately 35 minutes late, apologizing for her lateness. The group facilitator makes a mental note that Jody is wearing several sweatshirts, despite weather too mild to justify the need for layered clothing.

Approximately 15 minutes before the close of group, blood seeps through the top layer of clothing covering Jody’s left arm. The group leader asks Jody if her injured arm is making some statement to the group members. Is there something specific that she wants from the group at this particular moment? The leader is confident that Jody is saying something very important not only to, but for, the group as a whole.

Jody indicates that the previous week she felt diminished by comments from a number of members in the group. In an effort to deal with the anxiety and shame associated with returning to the group, she has cut herself before attending.

A number of group members quickly share their concern for her and hopes that their comments of the previous week could be revisited and revised to be more supportive. Jody shows the group the cut on her forearm, which has all but stopped bleeding. She explains how deep her pain is and her desire for the group not to judge her for that pain.

Because Jody appears to be in no imminent danger, the leader chooses to contin­ ue with the group process, ending it at the regularly scheduled time. The group meets at a major medical center, so the leader is able to walk with Jody to the emergency room. The leader assures the group that Jody will receive the medical attention she needs.

The next week, the entire group makes substantial gains. They carefully exam­ ine their judgment and willingness to allow Jody to be the primary spokeswoman for the profound emotional pain that each of them feels. The dramatic and unexpected situation the previous week has not interrupted the group process. It has instead been used adroitly to make the group even more productive.

Group Leadership, Concepts, and Techniques 121

7 Training and Supervision

Overview In This Substance abuse counselors come to the field from a variety of back­ Chapter… grounds, education, and experience. Many have not had specific train­ ing and supervision in the special skills needed to be an effective group Training therapist. Counselors may be promoted to positions of supervision with­ Training Opportunities out the additional training in the skills needed to perform supervisory tasks, which are Training Opportunities in Types of Group Therapy • Administrative Supervision • Evaluative The Supervisor’s Essential • Clinical Skills The Supervisory Alliance •Supportive Funding for Training and This chapter describes the skills group therapy clinicians need, the pur­ Supervision Programs pose and value of clinical supervision, and how to get the training neces­ sary to be a top­flight group clinician or supervisor of clinicians.

Training In a brief article, Geoffrey Greif lists “Ten Common Errors Beginning Substance Abuse Workers Make in Group Treatment.” He contends that these errors are common because people who abuse substances are supremely adept at helping group leaders make mistakes. Some of these are

• Impatience with the clients’ slow pace of dealing with change • Inability to drop the mask of professionalism • Failure to recognize countertransference issues • Not clarifying group rules • Conducting individual therapy rather than using the entire group effectively • Failure to integrate new members effectively into the group (Greif 1996)

123 Training and educa­ Therapists need to become well versed in the tion for group thera­ substance abuse treatment philosophy, its ter­ pists working in the minology, and techniques of recovery, including A group leader for substance abuse field the self­help approaches (Kemker et al. 1993). can alleviate or elim­ people in sub­ inate such errors. A group therapist with roots in the mental Simultaneously, health field planning to become more compe­ stance abuse treat­ additional training is tent in group work for the treatment of sub­ becoming even more stance abuse will need to make a number of ment requires critical because (1) adjustments. First, the therapist working with the traditionally sep­ clients with substance use disorders should be competencies in arate fields of mental able to screen and assess for substance abuse health and substance problems. On this subject, see TIP 11, Simple Screening Instruments for Outreach for both group work abuse counseling increasingly overlap, Alcohol and Other Drug Abuse and Infectious Diseases (Center for Substance Abuse and addiction. requiring more and more cross­knowl­ Treatment [CSAT] 1994b); TIP 24, A Guide to edge; and (2) an ever Substance Abuse Services for Primary Care younger pool of Clinicians (CSAT 1997a); and TIP 31, clients is presenting Screening and Assessing Adolescents for with more cognitive deficits, abuse issues, and Substance Use Disorders (CSAT 1999c). co­occurring disorders. Second, the therapist will need to recognize the importance of abstinence. Third, the therapist A group leader for people in substance abuse will need to be sensitive to a client’s anxiety treatment requires competencies in both areas: and shame, especially in early stages of treat­ group work and addiction. For example, facili­ ment for substance abuse. In a modified inter­ tators should understand group process, group personal process group, for example, the group dynamics, and the stages of group develop­ leader should create a safe, supportive envi­ ment; they need to understand that group ther­ ronment free from the stigma of addiction while apy is not individual therapy in a group setting. promoting a client’s attachment to other group Further, facilitators should be aware that members, self­help groups, therapy, and the although Alcoholics Anonymous (AA) or other entire healing community of which the group 12­Step programs are complementary to sub­ is a part. stance abuse treatment, these modalities are distinct from group therapy. Group therapists who move into the treatment of clients who are chemically dependent typi­ As trends move toward integrated mental and cally need staff development in: substance abuse treatment, counselors already adept at working with groups of clients with • Theories and techniques. Theories may substance abuse problems may need specific include traditional psychodynamic methods, training to manage mental disorders such as cognitive–behavioral modes, and systems the­ depression, which often co­occur with substance ory. From such theoretical bases are drawn abuse. Further, counselors in recovery may be applications that pertain to a wide variety of familiar with the stages of addiction treatment settings and particular client populations. but lack a background in group therapy. • Observation. The observer can sit in on group therapy sessions, study videotapes On the other hand, group counselors who have of senior therapists leading group sessions treated clients without addictions may not (ordinarily followed by a discussion), or always have sufficient skills to combat addic­ watch groups live through one­way mirrors tion and its effect on a group therapy situation. as experienced therapists lead groups.

124 Training and Supervision • Experiential learning. With this approach, a pists do not perceive substance abuse problems therapist may participate in a training group the same way, use different methods to treat offered by an agency, become a member of a substance abuse, and differ in personality and personal therapy group (these are often pro­ attitudinal traits. cess­oriented), or join in group experiences at conferences, such as those offered at the Some people dismiss the notion that all people Institute of the American Group Psycho­ with addictions prefer to work with a group therapy Association’s annual conference. leader who is in recovery. They insist that, on (For more on experiential training, see the the contrary, some people with addictions pre­ section on “Experiential Learning” later in fer not to work with recovering leaders, fearing this chapter.) that leaders in recovery will share the issues and problems of people with addictions and •Supervision. A large part of this type of thus will not be in a position to help them with training is ongoing work with groups under these issues. the supervision of an experienced therapist. Supervision may be dyadic, that is, supervi­ Others say that a staff of group leaders should sor and supervisee, but while simple and include people in recovery. Those holding this easy, this setting does not allow opportunities point of view reason that people with addic­ for actual group work. Supervision of group tions are highly skilled at manipulating people therapists ideally is conducted in a superviso­ and situations. With both recovering and non­ ry group format. Supervision in a group recovering group leaders, a clinical team will enables therapists to obtain first­hand expe­ be best positioned to see and treat the whole rience and helps them better understand client––and not be duped by agreeable, but what is happening in groups that they will false, façades. eventually lead. Several other important ben­ efits accrue as well. The supervisory group In group therapy with clients with substance creates a safe place for trainees to reveal use disorders, it can be challenging to establish themselves and the skills they need to devel­ and maintain credibility with all group clients. op. It provides support from peers and a Facilitators not in recovery will need to antici­ chance to learn from their experience. It pate and respond to group members’ questions stimulates dialog around theory and tech­ about their experience with substances and will nique and encourages a healthy kind of com­ need skills to handle group dynamics focused petition. It expands the capacity for empathy on this issue. On the other hand, leaders who (Alonso 1993). Finally, this kind of supervi­ are in recovery may sion provides an opportunity for trainees to tend to focus too explore sensitive issues, such as child abuse, much on themselves. sexual abuse, and prostitution. (For more on Group leaders emo­ supervisory groups, see the “Supervision” tionally invested in Supervision in a section later in this chapter.) acting as models of recovering perfection Before leaving the matter of what group leaders are easy marks for group enables treating substance abuse should know, it is clients. desirable to assess the importance of the group therapists to facilitator’s being a person who is in recovery. Of course, the main issue is not whether There is some tension around this issue. obtain first­hand Culbreth (2000) reviewed 16 relevant studies the leader is in recov­ and concluded that while clients do not per­ ery. What matters experience. ceive differences in treatment related to a ther­ most is whether the apist being in recovery or not, and no differ­ counselor knows the ences in treatment outcomes could be dis­ fields of group thera­ cerned, recovering and nonrecovering thera­ py and addiction treatment and has

Training and Supervision 125 good judgment and leadership skills (see Figure Professional associations 7­1). Helping the group explore why the recov­ ery status of the group leader is important can American Group Psychotherapy be discussed if and when the issue is raised. Association (AGPA) AGPA, founded in 1942, has more than 4,000 members and 33 local and regional affiliate Training Opportunities societies, which provide a broad range of pro­ National professional organizations are a rich fessional, educational, and social support for source of training. Through conferences or group therapists in the United States and regional chapters, national associations provide abroad. The organization publishes The training—both experiential and direct instruc­ International Journal of Group Psychotherapy tion—geared to the needs of a wide range of and The Group Circle. professionals, from the novice to the highly AGPA’s Special Interest Groups (SIGs) share experienced therapist. More training options ideas and knowledge through interaction with are usually available in large urban areas. It is colleagues. Some SIGs focus on substance likely, however, that online training will make abuse; children and adolescents; cotherapy; some types of professional development acces­ diversity; gay, lesbian, and bisexual clients; the sible to a greater number of counselors in medically ill; the severe and persistent mentally remote areas. A number of professional ill; and women in group therapy. SIGs are open organizations that provide a variety training to nonmembers of AGPA. settings are listed below. Inclusion in the list does not imply endorsement by the Substance At its annual conferences, AGPA offers train­ Abuse and Mental Health Services Adminis­ ing institutes for individuals. Three of these tration (SAMHSA). Note that not all of these institutes focus on substance abuse training. organizations approach substance abuse The association can also provide in­house treatment through group therapy. training to agency staff at a very low cost. Further, AGPA has developed basic and

Figure 7­1

How Important Is It for a Substance Abuse Group Leader To Be In Recovery?

A leader who is in recovery will probably elicit trust more quickly from group members, especially people with hard­core addictive backgrounds, because such clients often assume––correctly or not––that a person in recovery can empathize with the pain of addiction. Such group leaders, as success stories, have the added advantage of serving as role models for group members struggling against temptations and cravings in the early stages of recovery.

A leader having personally recovered, however, does not automatically make that person an effective therapist. Many counselors in recovery cannot make the switch from self­ to client­centered approaches and hold rigid views of how to manage the recovery process. Source: Consensus Panel.

126 Training and Supervision advanced core courses. They tend to be practi­ Psychology, and an Office of Ethnic Minority cal in nature, and they contribute to certifica­ Affairs that provides publications and informa­ tion. The certified group therapy program is tion. Recent APA books on this topic describe available through the regional affiliates. relationships among Asian­American women and health­promoting and health­compromis­ American Psychiatric Association ing behaviors among minority adolescents. (APA) The American Psychiatric Association is a med­ American Society of Addiction ical specialty society recognized world­wide. Its Medicine (ASAM) more than 35,000 U.S. and international mem­ One of ASAM’s goals is educating health pro­ ber physicians work together to ensure humane fessionals about addiction. The organization care and effective treatment for all persons develops credentialing guidelines and publishes with mental disorder, including mental retarda­ the comprehensive and influential volume, tion and substance­related disorders. To its Principles of Addiction Medicine (Graham et members, the APA offers board certification al. 2003), among other books and journals. and continuing medical education from online The society has also developed patient place­ sources as well as at annual meetings. ment criteria called PPC­2R (published in 2001), as well as screening and assessment American Psychological Association tools. Each year, ASAM hosts several confer­ (APA) ences and training meetings on various aspects The APA College of Professional Psychology of addiction medicine. ASAM offers audiotapes offers a Certificate of Proficiency in the of its conferences for continuing medical educa­ Treatment of Alcohol and Other Psychoactive tion credit. Physicians certified by the society Substance Use Disorders. This certificate is a in addiction medicine are listed in an ASAM uniform nationally recognized credential directory. offered exclusively to licensed psychologists who meet specific criteria related to experience Association for the Advancement in substance abuse treatment, including com­ of Social Work with Groups pletion of an APA examination. (AASWG) This international professional organization Two of APA’s 55 subgroups may be of special has developed standards that reflect the distin­ interest. Division 49, Group Psychology and guishing features of group work, as well as the Group Psychotherapy, serves psychologists’ unique perspective that social workers bring to interest in research, teaching, and the practice their practice with groups. These standards are of group psychology and group therapy. applicable to the types of groups that social Division 50, Addictions, centers on research, workers encounter in the various settings in professional training, and clinical practice which they practice and allow the practitioner dealing with a broad range of addictive behav­ to apply a variety of relevant group work mod­ iors. Both divisions publish a newsletter and els. AASWG has also collected a 29­page bibli­ journal, and both have annual meetings and ography of books, monographs, and videos award programs. available for practitioners, educators, and researchers. APA has extensive resources on cultural diver­ sity and ethnic/racial issues related to therapy, including online brochures, a quarterly jour­ nal, Cultural Diversity and Ethnic Minority

Training and Supervision 127 Association for Specialists in Group mentoring programs to support the work of Work (ASGW) African­American social workers. A division of the American Counseling National Association of Social Association, the ASGW was founded to Workers (NASW) promote high quality in group work training, NASW is the world’s largest organization of practice, and research, both nationally and professional social workers. The association internationally. The organization has devel­ has developed practice standards and clinical oped Best Practice Guidelines, Principles for indicators, a credentialing program, continuing Diversity­Competent Group Workers, and education courses on national and State levels, Professional Standards for the Training of and numerous publications for members and Group Workers. These criteria are available nonmembers. on the organization’s Web site: http://asgw.org. The Web site also provides resources, including Distance learning courses are listed on NASW’s products, institutes, and links to other Web Web site. Many topics are relevant to addiction pages, along with a calendar describing upcom­ counselors, such as Chemical Dependency and ing conferences and professional development the African American: Counseling Strategies activities of interest to a broad spectrum of and Community Issues, Dual Diagnosis, group leaders. HIV/AIDS and Substance Abuse, and National Association of Alcohol Multicultural Counseling—The New Paradigm for Substance Abuse Professionals. and Drug Abuse Counselors (NAADAC) National Registry of Certified NAADAC is the largest national organization Group Psychotherapists for alcoholism and drug abuse professionals In an effort to maintain the highest standards across the country. The association offers for group therapy practice, the National opportunities for professional development, Registry certifies group therapists according to such as workshops, seminars, and education nationally accepted criteria and promotes these programs for members. In addition to a criteria among mental health professionals, bimonthly magazine, The Counselor, NAADAC employers, insurers, education personnel, and provides an Educational Resources Guide that clients. The registry has developed guidelines lists colleges and universities offering degree that are clinically based, client­focused service and certification programs in addiction coun­ indicators to be used in discussions with seling and a listing of approved education accrediting organizations regarding appropri­ providers for trainers in each State. Through ate standards of quality. The guidelines also its national certification program, including the apply in discussions with employers regarding National Certified Addiction Counselor and the delivery of mental health services in groups, as Masters Addiction Counselor designation, well as managed care and health maintenance NAADAC recognizes counselors with advanced organizations. The registry’s newsletter, The skill levels. Group Solution, provides up­to­date informa­ National Association of Black Social tion on the use of group therapy in the current behavioral health care atmosphere. Workers (NABSW) NABSW offers national and international education conferences, as well as projects and

128 Training and Supervision Frequent continuing education seminars are Institute on Drug Abuse, which provides given by local affiliate societies and at the information on research and treatment. annual meeting of the parent group, AGPA. The National Mental Health Information Center (NMHIC) at SAMHSA provides a Other sources of training wealth of information for the public and Many agencies mandate a certain number of for treatment professionals. A search for trainings each year and provide in­house “training” on its Web site resulted in a list of training that draws on the resources of cre­ numerous opportunities for training and dentialed senior management. Each of the technical assistance on a variety of topics as States has a department of alcohol and drug well as bibliographies, publications, and abuse services, and some may provide sub­ links. stance abuse training for group therapy. Training in mental health issues is often available through the mental health division Training Opportunities in of government agencies, professional associ­ Types of Group Therapy ations, and psychological and psychiatric organizations. Most colleges, universities, Experiential learning and community colleges offer relevant For the therapist in training, the experience courses, many of them certified by profes­ of being in a group is particularly important sional organizations. for both the development of skills and the level of comfort with one’s developing lead­ Several Federal entities offer resources for ership style. Whether this experience is training. SAMHSA provides a number of acquired through a process group, a super­ resources, including publications for sub­ vision group, or experiences offered through stance abuse treatment professionals. These organizations like the AGPA, experiential include the Technical Assistance Publication opportunities afford learners not only (TAP) series. TAP 21 is relevant to training: insight into their personal growth, but a Addiction Counselor Competencies: The first­person appreciation for the healing Knowledge, Skills, and Attitudes of power of group therapy. Professional Practice (CSAT 1998a). Experienced group therapists are able to In addition, SAMHSA’s Treatment lead process groups Improvement Protocol (TIP) series includes because training in more than 40 publications to assist thera­ this area is part of pists and counselors in treating people with the preparation pro­ SAMHSA substance abuse problems. To view TAPs gram for mental and TIPs online, go to health professionals. provides a number http://www.kap.samhsa.gov and click on In these groups, “Publications.” members study their of resources, These publications also are available free own behavior to through the SAMHSA Store at 1­877­726­ learn about group including 4727. The SAMHSA Store can also provide dynamics, individual a catalog of other resources and publica­ dynamics, bound­ publications for tions on addiction counseling and treatment. aries, and interper­ sonal communica­ One of them, for example, is the National substance abuse tions. In addition, professionals.

Training and Supervision 129 leadership of process groups provides one of classes in techniques and learning how to apply the best continuing education tools available them with a population that has substance to senior clinicians (Swiller et al. 1993). One abuse problems. The National Expressive experienced supervisor of training groups for Therapy Association offers conferences, therapists in training has found that “one of professional education, and in affiliation with the most striking aspects of the supervision of the National Institute of Expressive Therapy, group therapists in the group setting is its effec­ continuing education units, credentialing, and tiveness in bringing about the identification, board certification. emotional recognition, and resolution of…untherapeutic behaviors, which we term Cross­training counterresistances” (Rosenthal 1999b, p. 201). Though group therapists work in the field of A great many institutions and individuals offer mental health, they generally have little train­ workshops and courses in conducting group ing in the specifics of substance abuse treat­ therapy. One of these is the A.K. Rice Institute ment. This situation will have to change if the and its affiliate societies, which provides group fields of substance abuse treatment and mental relations training based on the Tavistock health are to integrate their activities. model, which originated at the Tavistock Institute in England. The training, offered in To supplement courses that professional orga­ weekend or longer conferences, is a model of nizations offer individuals, agencies can use a experiential training that focuses exclusively on case study approach. Case studies that include group­level dynamics. educational materials on diagnosis, symptoms, and treatment serve as a good foundation for The A.K. Rice Institute cross­training. The cases that cause counselors Anne­Marie Kirkpatrick, R.N., Administrator to struggle the most could be analyzed. What P.O. Box 1776 strategies were used? What were the outcomes? Jupiter, Florida 33468­1776 What alternatives did other staff recommend? Phone: (561) 744­1350 Case conferences can be conducted at weekly Fax: (561) 744­5998 staff development sessions, as part of regular meetings, or (more quickly) at morning feed­ Expressive therapies back meetings on clinical topics. A case confer­ ence might involve counselors, social workers, A wide range of expressive therapies (therapy and psychologists. based on an artist’s working process) is often used in substance abuse treatment. Expressive therapy groups may use dance, music, art, Legal issues writing, psychodrama, drama, role playing, It is important for therapists to know Federal adventure, and gestalt. Training in these areas regulations and the laws of their States, espe­ is available through AGPA, ASGW, and APA. cially those concerning “duty to warn” stipula­ The Gestalt Institute has training centers in tions regarding the abuse of children or elders, most large cities and offers a certification in commitment procedures for psychiatric clients, psychodrama. and confidentiality laws pertaining to HIV/ AIDS, adolescents, and managed care. The National Institute of Expressive Psycho­ Practitioners should be familiar with the therapy offers a 2­year online program for Federal confidentiality regulation, 42 C.F.R. those who have participated annually in the Part 2, Confidentiality of Alcohol and Drug institute’s 2­day residency. Professionals are Abuse Patient Records. In addition, there are required to participate as a member of a role­ State laws that also guide the confidentiality of playing or drama group before attending

130 Training and Supervision alcohol and drug abuse information, and treatment professionals to a wide variety of whichever is more restrictive (i.e., State law or useful information. ATTCs Federal law) governs. Professional and legal organizations usually address these topics in • Provide State­by­State credentialing their coursework. It is best to find such courses information at the regional or State level, so that attendees • Post news in the field can grasp the laws governing residents in their • List new resources, including publications specific geographical areas. • Translate technical and academic journal articles into easy­to­read language Videos • List alcohol and other drug treatment pro­ While impersonal media cannot replace the grams in each State relationships between supervisors and trainees, •Provide a worldwide catalog of online courses videos can be used to explain theoretical princi­ ples, provide information on various types of To tap into ATTC’s lode of professional drugs, and support skills­building activities. development information, log onto http://www.nattc.org. Distance learning Distance learning systems, which often commu­ Supervision nicate via cable or satellite, can assist with Supervisory oversight is a significant training explaining concepts, theories, and case studies. requirement for group therapists. Powell Like videos, distance learning may lack the (1993) defines clinical supervision as “a disci­ close personal relationship with a supervisor, plined, tutorial process wherein principles but interactive forms of distance learning do are transformed into practical skills with permit questions, comments, and requests for four overlapping foci—administrative, evalu­ clarification. ative, clinical, and supportive.” Powell’s Group therapy for trainees using an online description points out that the clinical super­ chat room is an interesting possibility and visor has an administrative task, namely the could be especially helpful to people in remote development of an appropriate supervision settings. Licensing boards, however, would first plan for clinician trainees. This task includes need to resolve any potential legal issues planning, coordination, and delegation of regarding confidentiality. Also, some critics responsibilities; determining appropriate have worried that computerized communica­ staff assignments; and helping to define tion would interfere with attachment (one of administrative polcies and procedures. the most powerful therapeutic factors). This In addition, the clini­ problem does not seem to occur in educational cal supervisor has seminars conducted online (see Figure 7­2 on duties in the sphere p. 132). of evaluation. As the Every State has a Every State has a credentialing process for skills and knowledge substance abuse treatment professionals, and of new group facilita­ credentialing pro­ NAADAC lists all the particulars at tors begin to grow, http://www.NAADAC.org. At the same address, they need consistent, cess for substance NAADAC posts training calendars and a useful feedback that great deal of other information on training will direct their work abuse treatment opportunities. and will support pro­ fessional growth. In professionals. The 14 regional Addiction Technology Transfer the early stages of Centers (ATTCs), launched by SAMHSA’s CSAT in 1993, connect substance abuse

Training and Supervision 131 Figure 7­2

Does Online Communication Impede Attachment?

As a faculty member with the Fielding Graduate Institute, a distance learning program, I teach psychology in both on­ and offline formats. In many of the online seminars, students post their papers and comment on the contributions of others. The students are dispersed around the country, so few (if any) know each other prior to the seminar.

Even though the students’ interactions are asynchronous (that is, not in real time; a lag separates comment and response), a group of learners develops that is indistinguishable from learners sitting in the same room together. Alliances develop between students who share similar ideas, and disagreements take place between opposing positions. The attachments that develop through the written word outside of real time seem as genuine as any other relationships.

In the online seminars, some students find in cyberspace a safer format than traditional classes. Not having to confront all the verbal cues that may distract people in a face­to­face conversation, learners are freer to be genuine. Several of my students who were involved in a seminar with in­person and online compo­ nents were more interactive and spontaneous in the online segment.

I don’t see why these dynamics would be different in supervisory groups. I don’t know of any online therapy groups, but some AA meetings are conducted online.

Further, Haim Weinberg operates a discussion list that includes about 400 group therapists from more than 30 countries. This arena for exchanging ideas about group therapy behaves very much like any large group, with a few surprising departures. Among them:

• In this highly diverse group representing many schools of thought, conflicts do not arise over differing theoretical stances or the appropriateness of interven­ tions. Instead, “word wars,” (commonly called “flaming”) break out due to impatience or personal attitudes and exchanges. One member wrote, for exam­ ple, “I thought you either have to be very young and inexperienced or very rude and insulting.” Some of the flaming seems to stem from misunderstand­ ings that in turn result from having only words as cues. What is meant in jest, for example, may be taken seriously (Weinberg 2002). •Traditionally, the larger the group, the more impersonal it was, but Weinberg finds startling self­disclosure and intimacy over the Internet. For example, a man whose newborn son had died wrote, “My heart is broken. Words can’t convey the grief, and I realize only now that the depth of this pain is beyond comprehension. I feel waves of horrible sadness and utter bewilderment.” Messages of condolence flooded back to the distraught father (Weinberg 2002). Source: A Consensus Panel member.

132 Training and Supervision group facilitation, answers to the question, will not only keep this question in mind, but “How am I doing?” are extremely important, also provide clear, cogent responses to trainees. but unfortunately, the question often goes Figure 7­3 gives an example of group experien­ unanswered. Appropriate clinical supervision tial training.

Figure 7­3

Group Experiential Training

Through the Mountain Area Health Education Center in Asheville, North Carolina, I conducted an 18­month intensive group training and supervision experience, which is one of many ways to provide clinicians with an expanded knowledge base and the opportunity to sense the power of group therapy. The group met one Saturday a month from 9:00 a.m. to 6:00 p.m.

The model had three main components. The first, conducted in a direct instruc­ tion format, communicated basic, intermediate, and eventually advanced group skills. It also highlighted the role of failed attachment in the expression of addic­ tive disease and the theoretical means by which groups address these concerns.

The trainees’ experiential group process, the second component, took place three times throughout the day. In these 1­hour sessions, trainees participated in a training group. From the outset, it was made clear that this training group was not therapy. Although personal information inevitably was shared, the primary purpose of the experience was trainees’ encounter with the here­and­now aspects of interpersonal group process, while being exposed to the same anxi­ eties, excitement, and achievements that clients feel within the context of group. At the end of each experiential group process, trainees evaluated not only the group process, but also reflected on aspects of the supervisor’s leadership style, commenting on its facilitation of the process or difficulties it presented.

The third aspect of this training and supervision experience was an in­depth evaluation of the clinical experiences of the trainees. At each session, group members brought in clinical issues that occurred in their practice for comment, discussion, and review. They received information not only from the group supervisor, but also from peers. This opportunity enabled trainees to integrate a theory base with practice, thus satisfying one of Powell’s key components of clin­ ical supervision, that is, “a tutorial process wherein principles are transformed into practical skills” (Powell 1993).

After leading this intensive experience, as well as many less intensive 30­hour training courses in group therapy, the need for such continuing training oppor­ tunities is clear to us. We can say with some authority that the continued advancement of one’s personal skills is essential, from initiation into the field throughout the trajectory of a professional’s career. Source: A Consensus Panel member.

Training and Supervision 133 The clinical function lence. This reassurance is especially beneficial that the supervisor to novice counselors. Further, fulfills is the devel­ • Group disclosure increases the potential for The supervisory opment of a basic core of knowledge self­disclosure and confirmation, creating opportunities for growth. alliance is needed and skills, which includes an in­depth • Empathy and sharing of interests are avail­ understanding of able to a greater extent than in individual to teach the addictive disease, an supervision. integrated model of trainee the skills • Working together over time, a group can group process, reinforce its members’ personal growth. group dynamics, and • Alternative clinical approaches and methods and knowledge the stages of group of helping are available to a far greater development. extent than in dyadic supervision. As a required to lead The interaction result, group members acquire a broad perspective on counseling styles. groups effectively. between supervisory personnel and • Each counselor can do reality testing, trainees has a sup­ presenting perceptions for peer scrutiny, and portive function, possibly, validation. which is vital to the •The potential for critique is greatly expanded growth of trainees. (Powell 1993). When they begin to apply their newly acquired knowledge is the time that they need the most For treatment facilities, group supervision is support and the most discerning supervision. attractive in its efficiency and effectiveness:

Clinical supervision, as it pertains to group • It provides a cost­effective way of supervising therapy, often is best carried out within the more people in the same amount of time. context of group supervision. Group dynamics • The diversity of people in the group increases and group process facilitate learning by setting opportunities for learning. The number of up a microcosm of a larger social environment. group members (up to the desired limit of Each group member’s style of interaction will four to six members) exponentially expands inevitably show up in the group transactions. the range of learning opportunities. Given enough time, all the people in the super­ • Group supervision creates a working alliance visory group will interact with group members among counselors, engendering a sense just as they interact with others in wider social of psychological safety and reducing self­ and clinical spheres, and every person will defeating behavior (Powell 1993). create in the group the same interpersonal universe inhabited outside the group. As this process unfolds, group members, guided by the The Supervisor’s Essential supervisor, learn to model effective behavior in Skills an accepting group context. A supervisor should be competent in several For the beginning counselor, supervisory content areas, including substance abuse treat­ groups reduce, rather than escalate, the level ment, group training, cultural competence, and of threat that can accompany supervision. In diagnosis of co­occurring conditions. A supervi­ place of isolation and alienation, group partici­ sor may be an administrator, an in­house train­ pation gives counselors a sense of community. er, or a therapist from another agency. They find that others share their worries, A recent survey of members of NAADAC fears, frustrations, temptations, and ambiva­ indicates that many counselors receive and are

134 Training and Supervision satisfied with weekly clinical supervision. strategies to planning and managing However, a significant percentage of the termination) respondents (who were not differentiated as to • Comprehensive knowledge of substance abuse, whether they work with individuals or groups) which, depending upon the treatment setting, indicated they receive no clinical supervision could entail broad general knowledge of, or a (Culbreth 1999). This finding is disturbing con­ thorough facility with, a particular field sidering the benefits of clinical supervision for • Knowledge of the preferred theoretical the delivery of high­quality service to clients approach and the professional development of counselors. Other findings from the NAADAC survey have • Knowledge of psychodynamic theory clear implications for supervisory training. For • Knowledge of group dynamics theory example, respondents preferred a supervisor • Knowledge of the institution’s preferred who is a knowledgeable professional in the field theoretical approaches and supervision that is more proactive and • Diagnostic skills for determining co­occurring intentional than reactive (Culbreth 1999). disorders • Capacity for self­reflection, such as recogniz­ The Supervisory Alliance ing one’s own vulnerability and, when this Some training experts believe the key to effec­ problem arises, the ability to monitor and tive group therapy supervision is the develop­ govern behavioral and emotional reactions ment of the supervisory alliance. This positive • Consultation skills, such as the ability to working relationship between the supervisor consult with a referring therapist, provide and trainee is a unique and appropriate setting feedback, and coordinate treatment in both within which a new therapist can develop skills individual and group modes in group analysis and refine an ability to devel­ •Capacity to be supervised; for example, op appropriate treatment strategies. openness in supervision, setting goals for The supervisory alliance is needed to teach the training, and discussing with supervisor one’s trainee the skills and knowledge required to learning style and preferences (Kleinberg lead groups effectively and to make sure that 1999) the group accomplishes its purpose. The super­ visor helps by establishing an open and collab­ Planning ways to train new orative climate, identifying the unique learning counselors needs and styles of the supervisory group members, formulating a responsive supervisory In planning a training approach, a supervisor contract, and pinpointing any problems that needs to consider the characteristics of the emerge within the alliance (Kleinberg 1999). supervisory team, that is, the supervisor plus Supervision also includes encouraging and the trainees. Variables to be considered include mentoring students from specific cultural • The sophistication of trainees’ knowledge groups, since it is difficult to locate well­trained and skills therapists to treat certain populations. • The supervisory setting Assessment of trainee skills • The characteristics of the client population • The nature of the supervised treatment The supervisor should be able to assess the various domains that trainees are required • The personality fit of the members on the to master. supervisory team • The format of the supervision • Clinical skills (from selecting prospective group members and designing treatment •The theoretical compatibility of the supervi­ sory team (Kleinberg 1999)

Training and Supervision 135 After weighing all these variables, the supervi­ Other options can be found through the sor discusses the focus and goals of the work Foundation Center, a nonprofit library system with the team. The particulars will take shape that as the supervisory contract. The necessary mastery of specified clinical subjects, as well as • Collects and disseminates information on the skills associated with them, can be devel­ sources of funding oped through reading assignments, video pre­ • Conducts and promotes research on trends in sentations, written assessments, and both philanthropy direct and indirect supervision. • Provides education on grant seeking •Publishes The Foundation Directory, avail­ Funding for Training and able on CD­ROM through The Foundation Supervision Programs Center Given the time and financial resources needed The five foundation libraries (located in to create formal academic preparation pro­ Atlanta, Cleveland, New York, San Francisco, grams, it is a challenge to provide extended and Washington) provide many resources with training (beyond 1­ and 2­day seminars) that is information on grants for projects related to well grounded in theory and application and health and education. The center has recently that addresses the needs of substance abuse designed a virtual classroom to assist in counselors, especially those leading therapy • Researching philanthropy groups. The best way to fund such training is to incorporate it into an agency or organization • Writing proposals budget. These outlays should be viewed as • Identifying nearby corporations, government investments that pay handsome dividends. For agencies, and other sources of funds in spe­ instance, opportunities for training can help cific geographical areas attract new, highly motivated employees. • Training in fundraising One alternative source of funding is a Federal • Online fundraising or State grant. Such funds are often available, The Foundation Center can be reached at though frequently they require a great deal of http://www.fdncenter.org. The Frequently administrative work Asked Questions section on this Web site is a and strict adherence useful introduction to the center’s services. to specific guidelines It is a challenge to for project direction, As with training, an inherent cost is associated staffing, and evalua­ with high­quality clinical supervision, both in tion. Grants are also financial commitment and clinical time. Despite provide extended available to agencies the positive returns that stem from good, bet­ and individuals ter, or best clinical supervision, staff resources, training that is through certain pro­ agency or organizational requirements, and the fessional and train­ needs of the leader in training often dictate the well grounded in ing organizations. specific type of supervision available. For example, AGPA Every agency providing services to clients theory and gives scholarships to abusing substances should take clinical super­ students who wish to vision seriously and direct appropriate application. attend its annual resources toward constant improvement meetings and train­ through the clinical supervision process. ing conferences.

136 Training and Supervision Appendix A: Bibliography

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Bibliography 147

Appendix B: Adult Patient Placement Criteria

Adult Patient Placement Criteria For the Treatment of Psychoactive Substance Use Disorders

Levels of Care Dimensions Level I Level II Level III Criteria Outpatient Intensive Outpatient Medically g Treatment Treatment Monitored Intensive i Inpatient Treatment

1 Level IV Medically Managed No withdrawal risk. Minimal withdrawal Acute Intensive Inpatient risk. Intoxication Treatment and/or Withdrawal Potential 2 Severe withdrawal Severe None or very None or nondistract­ Biomedical risk but manageable withdrawal risk. stable. ing from addiction Conditions and in Level III. treatment and man­ Complications ageable in Level II.

3 Requires medical Requires 24­hour Mild severity with Moderate severity Emotional and monitoring but not medical, nursing potential to distract needing a 24­hour Behavioral intensive treatment. care. from recovery. structured setting. Conditions and Complications None or very stable.

4 Severe problems Willing to cooperate Resistance high Resistance high Treatment requiring 24­hour but needs motivat­ enough to require despite negative Acceptance psychiatric care ing and monitoring structured program, consequences and and Resistance with concomitant strategies. but not so high as to needs intensive addiction treatment. render outpatient motivating strategies treatment ineffective. in 24­hour structure.

(continued on next page)

149 Adult Patient Placement Criteria For the Treatment of Psychoactive Substance Use Disorders (continued)

Levels of Care Level I Level II Level III Level IV Criteria Outpatient Intensive Outpatient Medically Medically Managed g Treatment Treatment Monitored Intensive Intensive Inpatient Dimensions i Inpatient Treatment Treatment

5 Able to maintain Intensification of Unable to control Problems in this Relapse abstinence and addiction symp­ use despite active dimension do not Potential recovery goals toms and high participation in qualify patient with minimal likelihood of less intensive care for Level IV treat­ support. relapse without and needs 24­hour ment. close monitoring structure. and support.

6 Supportive recov­ Environment Environment dan­ Problems in this Recovery ery environment unsupportive but gerous for recovery dimension do not Environment and/or patient has with structure or necessitating qualify patient skills to cope. support, the removal from the for Level IV treat­ patient can cope. environment; ment. logistical impedi­ ments to outpatient treatment.

Source: American Society of Addiction Medicine 2001.

150 Adult Patient Placement Criteria Appendix C: Sample Group Agreement

Appleton Outpatient Psycho­ therapy Group Ground Rules The following is excerpted from Vannicelli 1992, pp. 295–296.

The behavior and feelings of members of the therapy group mirror in important ways behavior and feelings in other important relationships. Consequently, the group provides a setting in which to examine patterns of behavior in relationships. The group also provides a context in which members learn to identify, understand, and express their feelings. The therapist’s role is to facilitate this group process.

To foster these goals, we believe that several group ground rules are important. These are as follows:

1. Members joining long­term groups remain as long as they find the group useful in working on important issues in their lives. We recommend at least a year. Members are required to make an initial 3­month commitment in order to determine the usefulness of this particular group for them.

2. Regular and timely attendance at all sessions is expected. As a member, it is your responsibility to notify the group in advance when you know that you will be away or late for group. In the event of an unexpected absence, you should notify the group at least 24 hours in advance to avoid being charged for the missed session.

3. Members of Appleton substance abuse groups are committed to maintaining abstinence. If a relapse does occur, it must be discussed promptly in the group—as must thoughts or concerns about resuming drug/alcohol use. Members of ACOA (Adult Children of Alcoholics) and family groups are asked to be reflective about their own sub­ stance use and to bring up changes in patterns of use or concerns that may be associated with use.

151 4. Members will notify the group if they are 8. Outside­of­group contact often has consid­ considering leaving the group. Because leav­ erable impact on the group’s therapeutic ing the group is a process, just as joining is, effectiveness. Therefore, any relevant inter­ members are expected to see this process actions between members which occur out­ through for at least 3 weeks following notifi­ side the group should be brought back into cation of termination. the next meeting and shared with the entire group. 5. Members will have a commitment to talk about important issues in their lives that 9. What you share in the group will be shared cause difficulty in relating to others or in with other members of the treatment team living life fully. when we feel that it is important to your treatment to do so. 6. Members will also have a commitment to talk about what is going on in the group 10. Payments for group are due at the last itself as a way of better understanding their meeting of the month unless other arrange­ own interpersonal dynamics. ments are discussed and explicitly worked out in the group. If for any reason timely 7. Members will treat matters that occur in the payment becomes problematic, members group with utmost confidentiality. To that are expected to discuss this in the group. end, members are expected not to discuss what happens in the group with people who are not members of the group.

152 Sample Group Agreement Appendix D: Glossary

AA Alcoholics Anonymous, the best known of the 12­Step self­help organizations.

ASAM The American Society of Addiction Medicine is a national specialty society of the American Medical Association and is dedicated to edu­ cating physicians and improving the treatment of individuals with alcoholism and other addictions. ASAM publishes the Patient Placement Criteria for the Treatment of Substance­Related Disorders: ASAM PPC­2R (2001), a widely used system of criteria for placing clients in appropriate treatment settings.

Basic teaching skills Organizing the content to be taught, planning for participant involvement in the learning process, and delivering information in a culturally relevant and meaningful way.

Cognitive–behavioral groups Groups formed to change learned patterns of thinking and behavior that lead to substance abuse or other psychological and interperson­ al disorders.

Cognitive therapy Attempts to modify maladaptive behavior by influencing a client’s beliefs, schemas, self­statements, and problemsolving strategies. Assumes that emotional problems are largely caused by irrational or maladaptive thinking and that restructuring these cognitions will be therapeutic.

Cohesion A positive quality of groups denoting a sense of enthusiastic solidari­ ty within the group; Yalom (1995, p. 48) notes that cohesive groups “have a higher rate of attendance, participation, and mutual sup­ port,” and that members “will defend the group standards much more than groups with less esprit de corps.”

153 Communal and culturally effective for clients who have difficulty specific groups verbalizing thoughts and feelings. Groups formed to use the sense of belong­ Diversity ing to a culture to reduce or eliminate drug As used in this TIP, diversity refers to any abuse and other negative behaviors. difference that distinguishes one individual Conflict from another and that affects how clients A basic dynamic in groups in which mem­ identify themselves and are identified by bers have opposing views, beliefs, or emo­ others. tions; conflict can be constructive by (1) Emotional contagion assisting members to consider and respect Rapid and intense escalation of excitement other opinions, (2) generating energy and in a group, which if uncontrolled, can investment in the group, and (3) creating a threaten boundaries and an individual’s variety of options for change; conflict is sense of well­being, potentially leading to detrimental when (1) it distracts members’ premature termination of treatment. attention or allows them to avoid issues in the group, (2) any group member feels his Fixed membership groups or her beliefs or world views are not under­ Relatively small group with a set number of stood or viewed as valid, or (3) the conflict members who stay together over a long leads to destructive behaviors, such as period of time; people in time­limited fixed denigration or other verbal abuse. membership groups start and stay together, while ongoing fixed membership groups Confrontation bring in new members if a vacancy occurs. A form of intervention that literally means “coming face to face” or “pointing out Gestalt therapy inconsistencies” that keep clients from Developed by Friedrich S. and Laura facing unpleasant realities (CSAT 1999b, Perls, gestalt therapy aims to enhance p. 10). clients’ awareness, which frees them to grow in their own consciously guided ways. Content It seeks to reestablish stalled growth pro­ Information and feelings expressed in cesses by helping clients become aware of group; its complement is process. feelings they have disowned but that are a Culture genuine part of them, and recognize feelings Integrated patterns of human behavior that and values that they think are a genuine include the language, thoughts, communi­ part of them but are borrowed from other cations, actions, customs, beliefs, values, people. and institutions of a racial, ethnic, reli­ Group agreement gious, or social group (Giachello 1995; A contract between provider and client Office of Minority Health 2001). stipulating the responsibilities of clients and Eco­map, or sociogram their expectations of other group members, A graphic that clients construct to repre­ the leader, and the group; group agreements sent their important social relationships. typically specify grounds for exclusion from group, expectations of confidentiality, Expressive groups restrictions on physical contact, conse­ Groups formed to use some kind of creative quences for returns to substance use, activity (such as painting, dance, play ther­ boundaries on contact outside the group, apy, or psychodrama) to help clients expectations for participation in group, explore their substance abuse, its origins financial responsibilities, and procedures and effects, and new coping options; for termination (leaving the group). expressive groups may be especially

154 Glossary Group dynamics clients recreate past experiences in the Forces at work among small groups of here­and­now microcosm of the group; interacting people; collectively, group interpersonal process groups attend more dynamics are a complex amalgam of indi­ to process (how people act and talk) and vidual personalities and actions combined less to content (what people do and say). with the overarching properties of the Interpersonal relationship dynamics group as a whole; put another way, group How people relate to one another in group dynamics are the collective impact of indi­ settings and how one individual can influ­ vidual members on the group and the ence the behavior of others in group, such impact the group has on each individual. as by giving and receiving feedback from Group process each other. How events take place in group, in contrast Interventions to content, which is what takes place; if, for Words or actions with a therapeutic pur­ example, a question is raised, a process­ori­ pose; interventions may clarify what is ented group leader might silently note cir­ happening in group, redirect energy, stop cumstances such as voice quality, facial unhelpful processes, or present the group expression, what came before and after the with a choice. question, and how the question was direct­ ed (to the leader? the group? to an individu­ Intrapsychic al? away from someone?); overall, process Relating to events occurring within the psy­ concerns include (1) the impact and quality che, mind, or personality; that is, internally of interaction among group members, (2) without reference to any external factors. the impact of group on individuals, and (3) the life phases of the group. Leadership skills Include helping the group get started in a Heterogeneous groups session, managing (though not necessarily Groups made up of a mixture of clients eliminating) conflict between group mem­ whose only similarity is the need they share bers, helping withdrawn members of the for a particular kind of group. group become more active, and making sure that all group members have a roughly Homogeneous groups equal chance to participate. Groups made up of clients who are alike in some respect other than a common sub­ Problem­focused groups stance use problem; homogeneous groups Groups formed to address a particular may include, for example, only women, problem that contributes to substance only adolescents or elderly people, or only abuse or limits recovery options; problem­ people from a certain cultural heritage. focused groups also look at the process of problemsolving so members can generalize IPGP their experience in group to other life areas. Interpersonal process group psychothera­ py, shortened in this TIP to interpersonal Process process groups. How members interact in the group; its complement is content. Interpersonal process groups Formed to use group interactions to pro­ Process­oriented therapy mote change and healing; such groups are An approach to group therapy that empha­ used after abstinence is well established; sizes group interaction as the healing agent; they delve into major developmental issues the role of the leader is the promotion of that contribute to addiction and interfere interaction among group members. with recovery; the primary interest is how

Glossary 155 Projective identification Reality therapy Involves projecting one’s disowned Developed by William Glasser, the basic attributes onto another person (Yalom principle of reality therapy is that we are 1995). responsible for what we choose to do. Reality therapy focuses on solving prob­ Psychodynamic emphases lems and on coping with the demands of The dynamic interplay of psychological reality in society by making more effective forces conceptualized using psychodynamic choices. theories. Within an individual these forces influence behavior, interaction with others, Redecision therapy and emotions. Is aimed at helping people challenge them­ selves to discover ways in which they per­ Psychodynamic therapy, ceive themselves in victimlike roles and to psychodynamic approach take charge of their lives by deciding for An approach to psychological growth and themselves how they will change. change that emphasizes the evolution and adaptation of the psychological structure Relapse prevention groups within an individual. Psychodynamic ther­ Groups formed to help clients maintain apy often focuses on changing behavior in abstinence or minimize the impact and the present by re­examining and revising a duration of relapse. person’s understandings and reactions to events in the past. Resistance to therapy An often subconscious defense against the Psychotherapy (or therapy) groups pain of examining one’s own behavior, per­ Groups formed to reduce or eliminate sub­ ceptions, beliefs, and feelings; resistance stance abuse or other problematic behav­ can appear in many disguises: continual iors by changing long­standing relational claims to be too upset to work on issues in and intrapsychic difficulties. Psycho­ group, missing group or coming late, or therapy groups differ from other groups aversion to strong emotions, such as anger. traditionally used for substance abuse Resistance is a natural part of any change treatment, such as problem­solving or sup­ process, but if it is not dealt with, it port groups, in that the group (1) has a rel­ impedes growth and blocks the progress of atively long­term contract; (2) focuses more individuals and groups. on psychodynamic issues (rather than edu­ cation, support, or problem solving); (3) Revolving membership groups begins in later stages of treatment and Somewhat larger than fixed membership recovery; (4) tolerates the expression of groups, revolving membership groups more emotion; and (5) stresses process over acquire new members when they become content. ready for its services; time­limited revolv­ ing membership groups keep a member for Psychoeducational groups a specified period of time, while ongoing Groups formed to educate clients about revolving membership groups may have substance abuse, related behaviors, and clients who (1) stay as long as they wish, (2) the behavioral, medical, and psychological enter a group with a repeating cycle of top­ consequences of use, abuse, and dependen­ ics and stay until they have completed all cy; psychoeducational groups provide the topics, or (3) attend for a set time information important for achieving absti­ (either consecutively or nonconsecutively). nence and maintaining recovery.

156 Glossary Skills development groups front and modify deeply ingrained relation­ Groups formed to bring about or improve al problems and other psychological issues. the skills needed to achieve and maintain A client’s stage of recovery is one determi­ abstinence; such skills may relate directly nant of placement. to substance abuse (such as ways to refuse Stages of treatment drugs or cope with urges to use them), or In early treatment, clients are ambivalent they may be designed to reduce or elimi­ about relinquishing substance abuse, so nate general life problems that imperil heavy emphasis is placed on drawing clients recovery (such as inadequate anger man­ into a culture of recovery and helping them agement or an inability to relax). get through each day without substances. Splitting Strong challenges to the mental and emo­ A divide­and­conquer tactic used to come tional state are set aside until later in treat­ between cotherapists (Yalom 1995). ment. In the middle stage, clients’ mental and emotional condition improves, but they Stages of change have an acute need for satisfying new direc­ Prochaska and DiClemente’s (1984) contin­ tions that can fulfill the role that substance uum that describes the stages a client abuse once played in their lives. In late moves through to achieve lasting recovery: treatment, clients sustain earlier gains, but precontemplation, contemplation, prepara­ learn to anticipate temptations and triggers tion, action, maintenance, and recurrence for relapse. Also, the client may need to (for definitions, see chapter 2); the stage a address issues like poor self­image, relation­ client is in helps to determine what group ship problems, shame, or trauma. treatment models and methods are appro­ priate for that person. Support groups Groups formed to (1) develop and strength­ Stages (or phases) of group en clients’ abilities to manage their own development thinking and emotions (2) improve inter­ In the beginning phase, the group is pre­ personal skills, (3) manage day­to­day life pared to begin its work. Tasks in this period more effectively, and (4) boost self­esteem involve introductions, a review of the group and self­confidence. agreement, and the establishment of a safe environment and healthy norms. The mid­ Transactional analysis dle phase, or actual work of the group, is Is both a theory of personality and an the time for here­and­now interactions that organized system of interactional therapy. help clients rethink behaviors and under­ Its basic assumption is that people make take changes. The end phase is a mixture of current decisions based on past premises recognition and celebration of work done that were at one time appropriate to and goals achieved, mourning for the loss of survival but may no longer be valid. the attachments formed in group, and Transactional analysis emphasizes the reorientation toward the future. cognitive, rational, and behavioral aspects of the therapeutic process. Stages of recovery In early recovery, clients establish absti­ Transference and countertransference nence. During this period, they are fragile Transference is a perceptual distortion in and highly prone to relapse. In middle which the characteristics of one person are recovery, abstinence becomes stable attributed to another; in other words, enough so that the client can begin to work parts of past relationships are projected on life problems. In late recovery, clients onto relationships in the present; if, for continue working to maintain abstinence example, group member A reminds mem­ and make life changes, but may also con­ ber B of a dour, narrow­minded father,

Glossary 157 member B may transfer the attributes of 12­Step programs his father to member A and react to him in Self­help programs that are based on mas­ group with extraordinary and irrational tering a set of steps to achieve and maintain hostility. In a narrow sense, countertrans­ abstinence; they are often loosely organized ference occurs when clients’ transference around a drug of abuse: Alcoholics evokes (often unconscious) emotional Anonymous (alcohol), Narcotics responses in therapists. In recent years, the Anonymous (opioids and illicit drugs), concept has widened to include any emo­ Cocaine Anonymous. tional reaction in a therapist brought on by a client.

158 Glossary Appendix E: Association for Specialists in Group Work Best Practice Guidelines

Approved by the ASGW Executive Board, March 29, 1998 Prepared by: Lynn Rapin and Linda Keel, ASGW Ethics Committee Co­Chairs The Association for Specialists in Group Work (ASGW) is a division of the American Counseling Association whose members are interested in and specialize in group work. We value the creation of community; service to our members, clients, and the profession; and leadership as a process to facilitate the growth and development of individuals and groups.

The Association for Specialists in Group Work recognizes the commit­ ment of its members to the Code of Ethics and Standards of Practice (as revised in 1995) of its parent organization, the American Counseling Association (ACA), and nothing in this document shall be construed to supplant that code. These Best Practice Guidelines are intended to clari­ fy the application of the ACA Code of Ethics and Standards of Practice to the field of group work by defining Group Workers’ responsibility and scope of practice involving those activities, strategies, and interven­ tions that are consistent and current with effective and appropriate professional ethical and community standards. ASGW views ethical process as being integral to group work and views Group Workers as ethical agents. Group Workers, by their very nature in being responsible and responsive to their group members, necessarily embrace a certain potential for ethical vulnerability. It is incumbent upon Group Workers to give considerable attention to the intent and context of their actions because the attempts of Group Workers to influence human behavior through group work always have ethical implications. These Best Practice Guidelines address Group Workers’ responsibilities in planning, performing, and processing groups.

159 Section A: Best Practice in potential group leaders regarding group Planning work, client attitudes regarding group work, and multicultural and diversity considera­ tions. Group Workers use this information as A.1. Professional Context and the basis for making decisions related to their Regulatory Requirements group practice, or to the implementation of Group Workers actively know, understand, groups for which they have supervisory, eval­ and apply the ACA Code of Ethics and uation, or oversight responsibilities. Standards of Best Practice, the ASGW Professional Standards for the Training of Group Workers, these ASGW Best Practice A.4. Program Development and Guidelines, the ASGW diversity competencies, Evaluation the ACA Multicultural Guidelines, relevant a. Group Workers identify the type(s) of State laws, accreditation requirements, rele­ group(s) to be offered and how they relate to vant National Board for Certified Counselors community needs. Codes and Standards, their organizations’ b. Group Workers concisely state in writing the standards, and insurance requirements impact­ purpose and goals of the group. Group ing the practice of group work. Workers also identify the role of the group members in influencing or determining the A.2. Scope of Practice and group goals. Conceptual Framework Group Workers define the scope of practice c. Group Workers set fees consistent with the related to the core and specialization compe­ organization’s fee schedule, taking into con­ tencies defined in the ASGW Training sideration the financial status and locality of Standards. Group Workers are aware of per­ prospective group members. sonal strengths and weaknesses in leading d. Group Workers choose techniques and a groups. Group Workers develop and are able leadership style appropriate to the type(s) of to articulate a general conceptual framework to group(s) being offered. guide practice and a rationale for use of tech­ niques that are to be used. Group Workers e. Group Workers have an evaluation plan con­ limit their practice to those areas for which sistent with regulatory, organization and they meet the training criteria established by insurance requirements, where appropriate. the ASGW Training Standards. f. Group Workers take into consideration cur­ rent professional guidelines when using tech­ A.3. Assessment nology, including but not limited to Internet a. Assessment of self. Group Workers actively communication. assess their knowledge and skills related to the specific group(s) offered. Group Workers A.5. Resources assess their values, beliefs, and theoretical orientation and how these impact upon the Group Workers coordinate resources related to group, particularly when working with a the kind of group(s) and group activities to be diverse and multicultural population. provided, such as: adequate funding; the appropriateness and availability of a trained co­ b. Ecological assessment. Group Workers leader; space and privacy requirements for the assess community needs, agency or organiza­ type(s) of group(s) being offered; marketing and tion resources, sponsoring organization mis­ recruiting; and appropriate collaboration with sion, staff competency, attitudes regarding other community agencies and organizations. group work, professional training levels of

160 Association for Specialists in Group Work Best Practice Guidelines A.6. Professional Disclosure insurance usage). Group Workers have the Statement responsibility to inform all group partici­ Group Workers have a professional disclosure pants of the need for confidentiality, poten­ statement which includes information on confi­ tial consequences of breaching confidentiality dentiality and exceptions to confidentiality, the­ and that legal privilege does not apply to oretical orientation, information on the nature, group discussions (unless provided by purpose(s) and goals of the group, the group State statute). services that can be provided, the role and responsibility of group members and leaders, A.8. Professional Development qualifications to conduct the specific group(s), Group Workers recognize that professional specific licenses, certifications and professional growth is a continuous, ongoing, developmental affiliations, and address of licensing/credential­ process throughout their career. ing body. a. Group Workers remain current and increase knowledge and skill competencies through A.7. Group and Member Preparation activities such as continuing education, pro­ fessional supervision, and participation in a. Group Workers screen prospective group personal and professional development members if appropriate to the type of group activities. being offered. When selection of group mem­ bers is appropriate, Group Workers identify b. Group Workers seek consultation and/or group members whose needs and goals are supervision regarding ethical concerns that compatible with the goals of the group. interfere with effective functioning as a group leader. Supervisors have the responsi­ b. Group Workers facilitate informed consent. bility to keep abreast of consultation, group Group Workers provide in oral and written theory, process, and adhere to related ethi­ form to prospective members (when appro­ cal guidelines. priate to group type): the professional dis­ closure statement; group purpose and goals; c. Group Workers seek appropriate profession­ group participation expectations including al assistance for their own personal problems voluntary and involuntary membership; role or conflicts that are likely to impair their expectations of members and leader(s); poli­ professional judgment or work performance. cies related to entering and exiting the group; policies governing substance use; d. Group Workers seek consultation and policies and procedures governing mandated supervision to ensure appropriate practice groups (where relevant); documentation whenever working with a group for which all requirements; disclosure of information to knowledge and skill competencies have not others; implications of out­of­group contact been achieved. or involvement among members; procedures e. Group Workers keep abreast of group for consultation between group leader(s) and research and development. group member(s); fees and time parameters; and potential impacts of group participation. A.9. Trends and Technological c. Group Workers obtain the appropriate con­ Changes sent forms for work with minors and other Group Workers are aware of and responsive to dependent group members. technological changes as they affect society and the profession. These include but are not limit­ d. Group Workers define confidentiality and ed to changes in mental health delivery sys­ its limits (for example, legal and ethical tems; legislative and insurance industry exceptions and expectations, waivers implicit reforms; shifting population demographics and with treatment plans, documentation and

Association for Specialists in Group Work Best Practice Guidelines 161 client needs; and technological advances in B.5. Meaning Internet and other communication and delivery Group Workers assist members in generating systems. Group Workers adhere to ethical meaning from the group experience. guidelines related to the use of developing technologies. B.6. Collaboration Section B: Best Practice in Group Workers assist members in developing individual goals and respect group members as Performing co­equal partners in the group experience. B.1. Self Knowledge B.7. Evaluation Group Workers are aware of and monitor their Group Workers include evaluation (both for­ strengths and weaknesses and the effects these mal and informal) between sessions and at the have on group members. conclusion of the group. B.2. Group Competencies B.8. Diversity Group Workers have a basic knowledge of Group Workers practice with broad sensitivity groups and the principles of group dynamics, to client differences including but not limited to and are able to perform the core group compe­ ethnic, gender, religious, sexual, psychological tencies, as described in the ASGW Professional maturity, economic class, family history, physi­ Standards for the Training of Group Workers. cal characteristics or limitations, and geograph­ Additionally, Group Workers have adequate ic location. Group Workers continuously seek understanding and skill in any group specialty information regarding the cultural issues of the area chosen for practice (psychotherapy, coun­ diverse population with whom they are working seling, task, psychoeducation, as described in both by interaction with participants and from the ASGW Training Standards). using outside resources. B.3. Group Plan Adaptation B.9. Ethical Surveillance a. Group Workers apply and modify knowl­ Group Workers employ an appropriate ethical edge, skills, and techniques appropriate to decisionmaking model in responding to ethical group type and stage, and to the unique challenges and issues and in determining cours­ needs of various cultural and ethnic groups. es of action and behavior for self and group b. Group Workers monitor the group’s members. In addition, Group Workers employ progress toward the group goals and plan. applicable standards as promulgated by ACA, ASGW, or other appropriate professional orga­ c. Group Workers clearly define and maintain nizations. ethical, professional, and social relationship boundaries with group members as appro­ Section C: Best Practice in priate to their role in the organization and the type of group being offered. Group Processing C.1. Processing Schedule B.4. Therapeutic Conditions and Dynamics Group Workers process the workings of the group with themselves, group members, super­ Group Workers understand and are able to visors, or other colleagues, as appropriate. implement appropriate models of group devel­ This may include assessing progress on group opment, process observation, and therapeutic and member goals, leader behaviors and tech­ conditions. niques, group dynamics and interventions,

162 Association for Specialists in Group Work Best Practice Guidelines developing understanding, and acceptance of professional research literature. Group meaning. Processing may occur both within Workers follow all applicable policies and sessions and before and after each session, at standards in using group material for time of termination, and later follow up, as research and reports. appropriate. b. Group Workers conduct follow­up contact with group members, as appropriate, to C.2. Reflective Practice assess outcomes or when requested by a Group Workers attend to opportunities to syn­ group member(s). thesize theory and practice and to incorporate learning outcomes into ongoing groups. Group C.4. Consultation and Training Workers attend to session dynamics of mem­ With Other Organizations bers and their interactions and also attend to the relationship between session dynamics and Group Workers provide consultation and leader values, cognition, and affect. training to organizations in and out of their setting, when appropriate. Group Workers seek out consultation as needed with competent C.3. Evaluation and Follow­Up professional persons knowledgeable about a. Group Workers evaluate process and out­ group work. comes. Results are used for ongoing program planning, improvement and revisions of Source: ASGW 1998. Reprinted with current group, and/or to contribute to permission.

Association for Specialists in Group Work Best Practice Guidelines 163

Appendix F: Resource Panel

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the individual's current affiliation.

Candace Baker Edwin M. Craft, Dr.P.H. Clinical Affairs Manager KAP Alternate Project Officer Lesbian, Gay, Bisexual, and Transgender Office of Evaluation, Scientific Analysis Special Interest Group and Synthesis National Association of Alcohol and Drug Center for Substance Abuse Treatment Abuse Counselors Rockville, Maryland Alexandria, Virginia Christina Currier Nancy Bateman, LCSW­C, CAC Public Health Analyst Senior Staff Associate Office of Evaluation, Scientific Analysis Division of Professional Development and and Synthesis Advocacy Center for Substance Abuse Treatment National Association of Social Workers Rockville, Maryland Washington, DC Dorynne Czechowicz, M.D. Carole Chrvala, Ph.D. Medical Officer Senior Program Officer Treatment Development Branch Board on Neuroscience and Behavioral Division of Treatment Research and Health Development Institute of Medicine National Institute on Drug Abuse Washington, DC Bethesda, Maryland

Peggy Clark, M.S.W., M.P.A. Jennifer Fiedelholtz Center for Medicaid and State Operations Public Health Analyst Centers for Medicare and Medicaid Office of Policy and Program Coordination Services Substance Abuse and Mental Health Baltimore, Maryland Services Administration Rockville, Maryland Sandra M. Clunies, M.S., ICADC Derwood, Maryland Hendree E. Jones, Ph.D. Assistant Professor Cathi Coridan, M.A. Department of Psychiatry and Behavioral Senior Director for Substance Abuse Sciences Programs and Policy Johns Hopkins University Center National Mental Health Association Baltimore, Maryland Alexandria, Virginia

165 Edith Jungblut Stanley Smith, M.A., TEP Project Officer Clinical Director Center for Substance Abuse Treatment Mid­Atlantic Chapter Rockville, Maryland American Society of Group Psychotherapy and Psychodrama Tom Leibfried, M.P.A. c/o Adolescence and Family Growth Vice President of Government Relations Center, Inc. National Council for Community Springfield, Virginia Behavioral Healthcare Rockville, Maryland Richard T. Suchinsky, M.D. Associate Chief for Addictive Disorders Emeline Otey, Ph.D. and Psychiatric Rehabilitation Program Official Mental Health and Behavioral Sciences Adult Psychotherapy and Prevention Services Resource Branch Department of Veterans Affairs National Institute of Mental Health Washington, DC Bethesda, Maryland Jan Towers, Ph.D., CRNP Anne Pritchett, M.P.A. Director Policy Analyst Health Policy Executive Office of the President American Academy of Nurse Practitioners Office of National Drug Control Policy Washington, DC Washington, DC

Elizabeth Rahdert, Ph.D. Program Administrator National Institute on Drug Abuse Bethesda, Maryland

166 Resource Panel Appendix G: Cultural Competency and Diversity Network Participants

Note: The information given indicates each participant's affiliation during the time the network was convened and may no longer reflect the individual's current affiliation.

Elmore T. Briggs, CCDC, NCAC II Ford H. Kuramoto, D.S.W. Program Manager National Director Adolescent Recovery Center National Asian Pacific American Families Vanguard Services, Unlimited Against Substance Abuse Arlington, Virginia Los Angeles, California African American Work Group Asian and Pacific Islanders Work Group

Maxine F. Carpenter, M.S. Frank Lemus, Jr., M.A. President/Chief Executive Officer Clinical Director McKinley Group, Inc. SageWind (Oikos, Inc.) Atlanta, Georgia Reno, Nevada African American Work Group Hispanic/Latino Workgroup

Magdalen Chang Ting­Fun May Lai, M.S.W., CSW, CASAC Center Manager Director Bill Pone Memorial Unit Chinatown Alcoholism Center Haight Ashbury Free Clinic Hamilton­Madison House San Francisco, California New York, New York Asian and Pacific Islanders Work Group Asian and Pacific Islanders Work Group

Marty Estrada Tam K. Nguyen, M.D., LMSW, CCJS, DVC, Career Services Specialist MAC General Relief Team President Ventura Intake and Eligibility Center Employee & Family Resources Ventura, California Polk City, Iowa Hispanic/Latino Workgroup Asian and Pacific Islanders Work Group

Adelaida Hernandez, M.S., LCDC Rick Rodriguez M.U.H.E.R.E.S. Program Director Manager/Counselor S.C.A.N., Inc. Services United Laredo, Texas Santa Paula, California Hispanic/Latino Workgroup Hispanic/Latino Work Group

167 Candace Shelton, M.S., CADAC Antony P. Stephen, Ph.D. Clinical Director Executive Director Native American Connections, Inc. Mental Health & Behavioral Sciences Tucson, Arizona New Jersey Asian American Association Lesbian, Gay, Bisexual, and Transgender for Human Services, Inc. Workgroup Elizabeth, New Jersey Asian and Pacific Islanders Workgroup Mariela C. Shirley, Ph.D. Assistant Professor Ednita Wright, Ph.D., M.S.W., CSW Department of Psychology Independent Consultant/Counselor University of North Carolina at Therapist Wilmington Garnett Health Center, Counseling Wilmington, North Carolina Psychological Service Hispanic/Latino Workgroup Ithaca, New York Lesbian, Gay, Bisexual, and Transgender Workgroup

168 Cultural Competency and Diversity Network Participants Appendix H: Field Reviewers

Note: The information given indicates each participant's affiliation during the time the review was conducted and may no longer reflect the individual's current affiliation.

Rosie Anderson­Harper David W. Brook, M.D., CGP Mental Health Manager/Treatment Department of Community and Preventive Coordinator Medicine Division of Alcohol and Drug Abuse Mount Sinai Medical Center Missouri Department of Mental Health New York, New York Jefferson City, Missouri Nina W. Brown, Ed.D. Nancy Bateman, LCSW­C, CAC President Senior Staff Associate Mid­Atlantic Group Psychotherapy Society Division of Professional Development and Virginia Beach, Virginia Advocacy National Association of Social Workers Barry S. Brown, Ph.D. Washington, DC Professor (Adjunct) University of North Carolina at Michele W. Beck, M.S.W., LSBCAC, ICRC Wilmington Acting Director of Treatment Carolina Beach, North Carolina Office for Addictive Disorders State of Louisiana Maxine F. Carpenter, M.S. Baton Rouge, Louisiana President/Chief Executive Officer McKinley Group, Inc. Marion A. Becker, R.N., Ph.D. Atlanta, Georgia Associate Professor Department of Community Health Bruce Carruth, Ph.D., LCSW Louis de la Parte Florida Mental Health Private Practice Institute Boulder, Colorado Tampa, Florida Annabelle Casas, B.A. Janice S. Bennett, M.S., CSAC Family Drug Court Coordinator Program Coordinator 65th District Court Family Drug Court Hawaii Drug Court Program Program Honolulu, Hawaii El Paso, Texas

Elmore T. Briggs, CCDC, NCAC II Magdalen Chang Program Manager Center Manager Adolescent Recovery Center Bill Pone Memorial Unit Vanguard Services Unlimited Haight Ashbury Free Clinic Arlington, Virginia San Francisco, California

169 Sharon D. Chappelle, Ph.D., M.S.W., LCSW Kathleen J. Farkas, Ph.D., LISW, ASCW President/Chief Executive Officer Associate Professor Chappelle Consulting and Training Case Western Reserve University Services, Inc. Cleveland, Ohio Middletown, Connecticut Saul Feldman, Ph.D. David E. Cooper, Ph.D. Chairman/Chief Executive Officer Psychologist/Psychoanalyst United Behavioral Health Former Director of the Lodge Day San Francisco, California Program Chestnut Lodge Hospital Philip J. Flores, Ph.D., COP, FAGPA Private Practice Adjunct Clinical Supervisor Chevy Chase, Maryland Department of Psychology Georgia State University Cathi Coridan, M.A. Atlanta, Georgia Senior Director for Substance Abuse Programs and Policy Marilyn Joan Freimuth, Ph.D. National Mental Health Association Bedford, New York Alexandria, Virginia Byron N. Fujita, Ph.D. Eric Denner Senior Psychologist Clinical Social Worker Clackamas County Mental Health Center San Francisco General Hospital Oregon City, Oregon San Francisco, California Michael Galer, D.B.A., M.B.A., M.F.A. Janice M. Dyehouse, Ph.D., R.N., M.S.N. Westminster, Massachusetts Professor and Department Head College of Nursing Charles Garvin, Ph.D. University of Cincinnati Professor of Social Work Cincinnati, Ohio School of Social Work University of Michigan Marty Estrada Ann Arbor, Michigan Career Services Specialist General Relief Team Jeffrey M. Georgi, M.Div., CGP, CSAC, Ventura Intake and Eligibility Center LPC, CCS Ventura, California Clinical Director Department of Behavioral Science Arthur C. Evans, Ph.D. Duke School of Nursing and Duke Deputy Commissioner University Medical Center Connecticut Department of Mental Health Senior Clinician and Addiction Services Duke Addictions Program Hartford, Connecticut Duke University Medical Center Durham, North Carolina

170 Field Reviewers Mary M. Gillespie, Psy.D., CASAC Margaret Mattson, Ph.D. Psychologist Staff Collaborator Private Practice National Institute on Alcohol Abuse and Saratoga Springs, New York Alcoholism Bethesda, Maryland Paolo Giudici, LPCC, LADAC Clinical Director Robert Meyer AYUDANTES, INC. Chief Executive Officer/President Santa Fe, New Mexico Rainbow Recovery Center, Inc. Des Moines, Iowa Paula R. James, M.A. Department of Psychiatry Stacia Murphy Community Support Services President Bellevue Hospital Center National Council on Alcoholism and Drug New York, New York Dependence, Inc. New York, New York Kathryn P. Jett Director Ethan Nebelkopf, Ph.D., MFCC California Department of Alcohol and Clinic Director Drug Programs Family and Child Guidance Center Sacramento, California Native American Health Center Oakland, California Michael W. Kirby, Jr., Ph.D. Chief Executive Officer Thomas E. Nightingale Arapahoe House, Inc. Director Thornton, Colorado Bureau of Addiction Treatment Centers New York State Office of Alcoholism and Ford H. Kuramoto, D.S.W. Substance Abuse Services National Director Albany, New York National Asian Pacific American Families Against Substance Abuse Marlene O’Connell, R.N., M.S.N., LCPC, Los Angeles, California NCC, CCDC Manager Ting­Fun May Lai, M.S.W., CSW, CASAC Behavioral Health Services Benefits Director Healthcare Chinatown Alcoholism Services Great Falls, Montana Hamilton­Madison House New York, New York Gwen M. Olitsky, M.S. Chief Executive Officer Marlana Lalli The Self­Help Institute for Training and Program Manager Therapy Ft. Des Moines OWI Program Lansdale, Pennsylvania Des Moines, Iowa Jerry M. Owens, M.S., LMHC, LMFT Barry Levy Wadle and Associates Executive Director Des Moines, Iowa Community Resource Council Long Beach, California

Field Reviewers 171 Thomas A. Peltz, M.Ed., LMHC, CAS Jocelyn Thevenote, B.A. Therapist Outreach Director Private Practice Office for Addictive Disorders Beverly Farms, Massachusetts Pineville Alexandria Clinic Pineville, Louisiana Nancy A. Piotrowski, Ph.D. Associate Scientist Ernie Turner Alcohol Research Group Director Berkeley, California Division of Alcoholism and Drug Abuse Alaska Department of Health and Social Jeffrey David Roth, M.D., FASAM, FAGPA Services Independent Consultant Juneau, Alaska Chicago, Illinois Judy Tyson, Ph.D., CGP Marvena A. Simmonds, M.P.A. Mid­Atlantic Group Psychotherapy Society Public Health Advisor Bethesda, Maryland Division of State and Community Assistance Karen Urbany Center for Substance Abuse Treatment Public Health Advisor Rockville, Maryland Treatment and Systems Improvement Branch Darren C. Skinner, Ph.D., LSW, CAC Division of Practice and Systems Director Development Gaudenzia, Inc. Center for Substance Abuse Treatment Gaudenzia House West Chester Rockville, Maryland West Chester, Pennsylvania Marsha Lee Vannicelli, Ph.D., FAGPA Antony P. Stephen, Ph.D. Associate Clinical Professor Executive Director Department of Psychiatry Mental Health and Behavioral Sciences Harvard Medical School New Jersey Asian American Association Belmont, Massachusetts for Human Services, Inc. Elizabeth, New Jersey Ralph Varela, M.S.W. Chief Executive Officer Richard T. Suchinsky, M.D. Pinal Hispanic Council Associate Chief for Addictive Disorders Eloy, Arizona and Psychiatric Rehabilitation Mental Health and Behavioral Sciences Albert J. Villapiano, Ed.D. Services Director of Substance Abuse Product Line Department of Veterans Affairs Inflexxion Washington, DC Newton, Massachusetts

Judith S. Tellerman, Ph.D., M.Ed., MAT, Iris Wilkinson, Ed.D. CGP Associate Professor Assistant Clinical Professor Human Services Department College of Medicine School of Applied Studies University of Illinois Washburn University Chicago, Illinois Topeka, Kansas

172 Field Reviewers William H. Williams, Jr., M.A., LCADC Janet Zwick Substance Abuse Program Manager Deputy Director Clinical Plans and Management Division of Substance Abuse and Health Bureau of Medicine and Surgery Promotion Department of Navy Iowa Department of Public Health Washington, DC Des Moines, Iowa

Ednita Wright, Ph.D., M.S.W., CSW Independent Consultant/Counselor Therapist Garnett Health Center, Counseling Psychological Service Cornell University Ithaca, New York

Field Reviewers 173

Appendix I: Acknowledgments

Numerous people contributed to the development of this TIP, including the TIP Consensus Panel (see page ix), the KAP Expert Panel and Federal Government Participants (see page xi), the Federal Resource Panel (see Appendix F), the Cultural Competency and Diversity Network Participants (see Appendix G), and the TIP Field Reviewers (see Appendix H).

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM), and JBS International, Inc. (JBS), for the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

Christina Currier served as the SAMHSA TIPs Task Leader. Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP Executive Deputy Project Director. Shel Weinberg, Ph.D., served as the CDM KAP Senior Research/Applied Psychologist. Other CDM KAP per­ sonnel included Raquel Witkin, M.S., Deputy Project Manager; Susan Kimner, Managing Editor; James Girsch, Ph.D., Editor/Writer; Michelle Myers, Quality Assurance Editor; and Sonja Easley, Editorial Assistant. In addition, Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Jonathan Max Gilbert, M.A., Susan Hills, Ph.D., and Mary Lou Rife, Ph.D., were writers.

Acknowledgments 175

Index

Notes: Because the entire volume is about substance abuse treatment and group therapy, the use of these terms as entry points has been minimized in this index. Reference locators for information contained in figures appear in italics.

12­Step groups, 111–113 American Psychological Association, 127 as different from interpersonal process American Society of Addiction Medicine, 127. groups, 4, 6–7, 63 See also ASAM PPC­2R 42 C.F.R. Part 2, 31, 70, 108–109, 110, 130 anger reduction, 19 anxiety alleviation, 15, 20, 63, 120 A APA. See American Psychiatric Association, AA. See Alcoholics Anonymous American Psychological Association AASWG. See Association for the ASAM PPC­2R, 42–43 Advancement of Social Work with Groups ASGW. See Association for Specialists in action stage, overview of, 10 Group Work active listening, 92 assessment, 38–40 adaptation of trainee skills, 135 of group therapy to substance abuse Association for the Advancement of Social treatment, 7–8 Work with Groups, 127 of instruction to learning style, 15 Association for Specialists in Group Work, Addiction Technology Transfer Centers, 131 99, 128 adolescents, 41 best practice guidelines, 159–163 adult patient placement criteria, 149–150 Association for Supervision and Curriculum Development, 15 advantages of group treatment, 3–6 attachment theory, 83 affect, 86, 98–99, 102, 104–105 ATTCs. See Addiction Technology Transfer Agazarian Systems­Centered Therapy for Centers Group, 28 AGPA. See American Group Psychotherapy B Association beginning phase of group, 72–76 agreements, group, 68–69, 69, 71, 73, 97, behavior modeling by leaders, 96 151–152 benefits of groups, 1 A.K. Rice Institute, 130 best practice guidelines, 159–163 Alcoholics Anonymous, 6–7, 63, 112 Bion’s primary assumption groups, 28 American Group Psychotherapy Association, biopsychosocial issues, 111–114 126–127 boredom, group leader, 17 American Psychiatric Association, 127 boundaries, 100–101, 103, 118

Index 177 C confrontation, 6, 86–87, 106–107 characteristics of group models, 13 constancy, 92 cognitive–behavioral groups, 18–19 contact outside the group, 71–72 communal and culturally specific contemplation stage groups, 32 overview of, 10 expressive groups, 34 and psychoeducational groups, 12, 14 fixed and revolving membership cotherapy, 96–97 groups, 62 countertransference, 107–108 problem­focused groups, 35 cultural sensitivity, 33, 98 psychoeducational groups, 13–14 culture relapse prevention groups, 30 definitions of, 45 skills development groups, 16 of recovery, 81, 87 support groups, 20–21 resources on, 48 client D defensive features, 7 defensive features of clients, 7 not suited for group, 39–40, 118 disruptive behavior, 117–118 motivation, 65, 100 distance learning, 131, 132 retention, 64–66 diversity, 44–48 client placement, 37, 96 diversity wheel, 46 based on readiness for change, 44 dual relationships, 99–100 cognitive–behavioral groups, 3 characteristics of, 18–19 E leadership skills and styles, 19 early recovery stage, 43, 80–85 purpose of, 18 eco­map, 38 techniques used in, 19 emotionality, 86, 98–99, 102, 104–105 cognitive capacity, 85 empathy cognitive restructuring, 18 of group members, 64 cohesion, 73–74, 82 of leaders, 85, 93–94 communal and culturally specific treatment end phase of group, 76–78 groups, 10, 31–34 enmeshment, 98 characteristics of, 32 ethical issues, 97–98 leadership characteristics and styles, ethnicity, 47, 48 32–33 matching client and counselor, 55–56 purpose of, 32 etiologies of dependency, 18 techniques used in, 34 exclusion from group, 69 communication among group members, 105 experiential learning, 129–130, 133 confidentiality, 31, 41, 70, 108–109, 110, 130 experiential pretraining, 65 conflict, 48, 57, 74, 97, 99, 115–116 expressive groups, 10, 34–35, 130

178 Index F Institute of the American Group Psychotherapy Association, 125 faith in a group setting, 114 integrating care, 114–115 families and psychoeducational groups, 12 Interactional Model, 25 Family Care Program of the Duke Addictions Program, The, 66 interpersonal dynamics, 23 feedback, 17, 76 interpersonal process groups, 3, 22–25 financial responsibility, 72 characteristics of, 24 fixed membership groups, 60, 62 as different from self­help groups, 4–5 focal conflict model, 28 leadership skills and styles, 24–25 Foundation Center, 136 purpose of, 22–23 FRAMES, 100 techniques used in, 25 Freudian psychoanalysis, 22–23 theoretical approaches, 22–23 funding for training programs, 136 Interpersonal Process Group Psychotherapy, 24 G interpersonally focused groups, 27–28, 28 gender­specific groups, 40 interventions, 25–29, 105–107, 111 group­as­a­whole interviews, pregroup, 63 dynamics, 23 intrapsychic dynamics, 23 focused groups, 28–29, 29 IPGP. See Interpersonal Process Group group Psychotherapy advantages of, 3–6 K agreements, 68–69, 69, 71, 73, 97, Kwanzaa, 32 151–152 benefits of, 1 L cohesion, 73–74, 82 late recovery/maintenance stage, 44, 88–89 contact outside of, 71–72 leader exclusion from, 69 avoiding a leader­centered group, 106 influence of, 1–2 boredom, 17 model characteristics, 13, 13–14, 16 personal qualities of, 92–94 stability, 41–42 self­assessment for cultural issues, 49, 50–52 types not covered, 3 who is in recovery, 125, 126 types related to models, 11 leadership guidelines to evaluating leader bias and prej­ udice, 49 cognitive–behavioral group, 19 H communal and culturally specific group, 32–33 hope as a therapeutic factor, 82 early treatment, 84–85 I expressive group, 34–35 impulse control, 41 interpersonal process group, 24–25 inappropriate placement of clients, 39–40 late­stage treatment, 89 individually focused groups, 26–27, 27 middle­stage treatment, 86–88

Index 179 problem­focused group, 36 NMHIC. See National Mental Health psychoeducational group, 14–15 Information Center relapse prevention group, 31 norms, 74–75 skills development group, 16–17 P support group, 20–21 participant feedback, 17, 76 levels of care, ASAM, 42 peer support, 3 life issues, 113–114 physical contact, 70, 103–104 listening skills, 92 placement considerations, 37, 40–43, 96 M for adolescents, 41 maintenance stage, overview of, 10 criteria, 42–43 matching client and counselor ethnicity, and cultural issues, 47, 52–53, 54 55–56 for women, 40–41 middle phase of group, 76 posttraumatic stress disorder, 18–19 middle recovery stage, 44, 85–88 precontemplation stage models related to group types, 11 overview of, 10 Modern Analytic Approach, 27 and psychoeducational groups, 12, 14 mood­altering substances, 70–71 pregroup interviews, 63 motivation, client, 65, 100 premature termination, 72 motivational interviews, 65 forestalling, 65, 89 N preparation stage, overview of, 10 NAADAC. See National Association of preparing clients for group, 63–64 Alcohol and Drug Abuse Counselors pretreatment techniques, 65 NABSW. See National Association of Black problem­focused groups, 35 Social Workers problemsolving exercises, 15 NASW. See National Association of Social psychodynamics, 23 Workers psychoeducational groups, 9, 12 National Association of Alcohol and Drug characteristics of, 13–14 Abuse Counselors, 128, 131 leadership skills and styles of, 14–15 National Association of Black Social Workers, 128 purpose of, 12 National Association of Social Workers, 128 techniques used in, 15–16 National Clearinghouse for Alcohol and Drug psychological emergencies, 119–120 Information, 129 PTSD. See posttraumatic stress disorder National Mental Health Information Center, Q 129 qualities needed in a group leader, 92–94 National Registry of Certified Group Psychotherapists, 128–129 R NCADI. See National Clearinghouse for Alcohol and Drug Information recurrence stage, overview of, 10 neuropsychological issues, 16 refusal skills, 16

180 Index relapse, 102 overview of, 10 relapse prevention groups, 10, 29–31 stages of recovery, 43–44, 80 characteristics of, 30 subgroups, 117 leadership skills and styles, 31 supervision, 125, 131, 134–135 purpose of, 30 support groups, 3, 12, 20 techniques used in, 31 characteristics of, 20–21 resistance, 20, 81, 100, 108 as different from interpersonal process retention of clients in group, 64–66 groups, 20 revolving membership groups, 60–61, 62 leadership skills and styles, 21–22 role purpose of, 20 induction, 65 techniques used in, 22 flexibility, 99 T playing, 15, 26 Tavistock’s Group­as­a­Whole, 28 S techniques used safety, 101–104 in cognitive–behavioral groups, 19–20 SageWind, 33, 67, 68 in communal and culturally specific treatment groups, 34 same­sex groups, 40 in expressive groups, 35 scapegoating, 55, 99, 101, 116 in interpersonal process groups, 25 self­disclosure, 96 in problem­focused groups, 36 self­help groups, 111–112 in psychoeducational groups, 15–16 as different from group therapy in general, 63 in relapse prevention groups, 31 as different from interpersonal process in skills development groups, 17 groups, 4–5 in support groups, 22 as different from support groups, 20 termination, 72, 76–78 sensitivity training, 27 T­groups, 27 shame, 74, 94, 95, 101 theoretical approaches, 10–11, 27, 28 silence, 118–119 therapeutic groups, definition, 2 skills development groups, 3 therapeutic factors characteristics of, 16 in early recovery, 81–84 leadership skills and styles, 16–17 in late recovery, 88–89 purpose of, 16 in middle recovery, 85–86 techniques used in, 17 therapeutic services, 2 smoking cessation, 30 therapeutic styles of leaders, 94–96 spirituality, 114 time as a factor in recovery, 8 stability of groups, 41–42 TIPs cited stages of change, 42, 80, 100 Brief Interventions and Brief Therapies and client placement, 44 for Substance Abuse Treatment (TIP 34), 17, 26, 30, 36

Index 181 Enhancing Motivation for Change in development), 41 Substance Abuse Treatment (TIP 35), Substance Abuse Treatment and Domestic 42, 100 Violence (TIP 25), 110 Guide to Substance Abuse Services for Substance Use Disorder Treatment for Primary Care Clinicians (TIP 24), People With Physical and Cognitive A, 124 Disabilities (TIP 29), 14, 32 Improving Cultural Competence in training and education, 6–7, 99, 124–126, Substance Abuse Treatment (in 129–130 development), 32, 56 funding for, 136 Integrating Substance Abuse Treatment transference, 107–108 and Vocational Services (TIP 38), 43 treatment criteria, ASAM, 42–43 Intensive Outpatient Treatment for Alcohol and Other Drug Abuse U (TIP 8), 110 universality as a therapeutic factor, 82, 86 Screening and Assessing Adolescents for Substance Use Disorders (TIP 31), V 124 vicarious pretraining, 65 Simple Screening Instruments for W Outreach for Alcohol and Other women, and placement considerations, 40–41 Drug Abuse and Infectious Diseases (TIP 11), 124 wraparound services, 66 Substance Abuse Treatment: Addressing the Specific Needs of Women (in

182 Index SAMHSA TIPs and Publications Based on TIPs

What Is a TIP? Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP) to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system. What Is a Quick Guide? A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information. What Are KAP Keys? Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-struments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted fre-quently. The Keys allow you, the busy clinician or program administrator, to locate information easily and to use this information to enhance treatment services. Ordering Information Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—Replaced by TIP 13 Role and Current Status of Patient Placement TIP 43 Criteria in the Treatment of Substance Use Disorders TIP 2 Pregnant, Substance-Using Women —Replaced by Quick Guide for Clinicians TIP 51 Quick Guide for Administrators TIP 3 Screening and Assessment of Alcohol- and Other KAP Keys for Clinicians Drug-Abusing Adolescents—Replaced by TIP 31 TIP 14 Developing State Outcomes Monitoring Systems for TIP 4 Guidelines for the Treatment of Alcohol- and Other Alcohol and Other Drug Abuse Treatment Drug-Abusing Adolescents—Replaced by TIP 32 TIP 15 Treatment for HIV-Infected Alcohol and Other Drug TIP 5 Improving Treatment for Drug-Exposed Infants Abusers—Replaced by TIP 37

TIP 6 Screening for Infectious Diseases Among Substance TIP 16 Alcohol and Other Drug Screening of Hospitalized Abusers—Archived Trauma Patients Quick Guide for Clinicians TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice KAP Keys for Clinicians System—Replaced by TIP 44 TIP 17 Planning for Alcohol and Other Drug Abuse TIP 8 Intensive Outpatient Treatment for Alcohol and Treatment for Adults in the Criminal Justice System Other Drug Abuse—Replaced by TIPs 46 and 47 —Replaced by TIP 44 TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues TIP 9 Assessment and Treatment of Patients With for Alcohol and Other Drug Abuse Treatment Coexisting Mental Illness and Alcohol and Other Providers—Archived Drug Abuse—Replaced by TIP 42 TIP 19 Detoxification From Alcohol and Other Drugs— TIP 10 Assessment and Treatment of Cocaine- Abusing Replaced by TIP 45 Methadone-Maintained Patients—Replaced by TIP 43 TIP 20 Matching Treatment to Patient Needs in Opioid TIP 11 Simple Screening Instruments for Outreach for Substitution Therapy—Replaced by TIP 43 Alcohol and Other Drug Abuse and Infectious Diseases—Replaced by TIP 53 TIP 21 Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the TIP 12 Combining Substance Abuse Treatment With Justice System Intermediate Sanctions for Adults in the Criminal Quick Guide for Clinicians and Administrators Justice System—Replaced by TIP 44

183 TIP 22 LAAM in the Treatment of Opiate Addiction— TIP 31 Screening and Assessing Adolescents for Substance Replaced by TIP 43 Use Disorders See companion products for TIP 32. TIP 23 Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing TIP 32 Treatment of Adolescents With Substance Use Quick Guide for Administrators Disorders Quick Guide for Clinicians TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians KAP Keys for Clinicians Concise Desk Reference Guide TIP 33 Treatment for Stimulant Use Disorders Quick Guide for Clinicians Quick Guide for Clinicians KAP Keys for Clinicians KAP Keys for Clinicians

TIP 25 Substance Abuse Treatment and Domestic Violence TIP 34 Brief Interventions and Brief Therapies for Substance Linking Substance Abuse Treatment and Domestic Abuse Violence Services: A Guide for Treatment Providers Quick Guide for Clinicians Linking Substance Abuse Treatment and Domestic KAP Keys for Clinicians Violence Services: A Guide for Administrators Quick Guide for Clinicians TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment KAP Keys for Clinicians Quick Guide for Clinicians TIP 26 Substance Abuse Among Older Adults KAP Keys for Clinicians Substance Abuse Among Older Adults: A Guide for Treatment Providers TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues Substance Abuse Among Older Adults: A Guide for Social Service Providers Quick Guide for Clinicians Substance Abuse Among Older Adults: Physician’s KAP Keys for Clinicians Guide Helping Yourself Heal: A Recovering Woman’s Guide to Quick Guide for Clinicians Coping With Childhood Abuse Issues KAP Keys for Clinicians Also available in Spanish Helping Yourself Heal: A Recovering Man’s Guide to TIP 27 Comprehensive Case Management for Substance Coping With the Effects of Childhood Abuse Abuse Treatment Also available in Spanish Case Management for Substance Abuse Treatment: A Guide for Treatment Providers TIP 37 Substance Abuse Treatment for Persons With Case Management for Substance Abuse Treatment: A HIV/AIDS Guide for Administrators Quick Guide for Clinicians

Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators Drugs, Alcohol, and HIV/AIDS: A Consumer Guide

TIP 28 Naltrexone and Alcoholism Treatment—Replaced by Also available in Spanish TIP 49 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for African Americans TIP 29 Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities TIP 38 Integrating Substance Abuse Treatment and Vocational Services Quick Guide for Clinicians

Quick Guide for Administrators Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators KAP Keys for Clinicians TIP 30 Continuity of Offender Treatment for Substance Use Disorders From Institution to Community TIP 39 Substance Abuse Treatment and Family Therapy Quick Guide for Clinicians Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators Family Therapy Can Help: For People in Recovery From Mental Illness or Addiction

184 TIP 40 Clinical Guidelines for the Use of Buprenorphine in TIP 50 Addressing Suicidal Thoughts and Behaviors in the Treatment of Opioid Addiction Substance Abuse Treatment Quick Guide for Physicians Quick Guide for Clinicians KAP Keys for Physicians Quick Guide for Administrators

TIP 41 Substance Abuse Treatment: Group Therapy TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women Quick Guide for Clinicians KAP Keys for Clinicians TIP 42 Substance Abuse Treatment for Persons With Co- Quick Guide for Clinicians Occurring Disorders Quick Guide for Administrators Quick Guide for Clinicians Quick Guide for Administrators TIP 52 Clinical Supervision and Professional Development of the Substance Abuse Counselor KAP Keys for Clinicians Quick Guide for Clinical Supervisors TIP 43 Medication-Assisted Treatment for Opioid Addiction Quick Guide for Administrators in Opioid Treatment Programs Quick Guide for Clinicians TIP 53 Addressing Viral Hepatitis in People With Substance Use Disorders KAP Keys for Clinicians Quick Guide for Clinicians and Administrators TIP 44 Substance Abuse Treatment for Adults in the KAP Keys for Clinicians Criminal Justice System Quick Guide for Clinicians TIP 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders KAP Keys for Clinicians Quick Guide for Clinicians TIP 45 Detoxification and Substance Abuse Treatment KAP Keys for Clinicians

Quick Guide for Clinicians You Can Manage Your Chronic Pain To Live a Good Quick Guide for Administrators Life: A Guide for People in Recovery From Mental KAP Keys for Clinicians Illness or Addiction TIP 55 Behavioral Health Services for People Who Are TIP 46 Substance Abuse: Administrative Issues in Homeless Outpatient Treatment Quick Guide for Administrators TIP 56 Addressing the Specific Behavioral Health Needs of Men TIP 47 Substance Abuse: Clinical Issues in Outpatient Quick Guide for Clinicians Treatment KAP Keys for Clinicians

Quick Guide for Clinicians TIP 57 Trauma-Informed Care in Behavioral Health KAP Keys for Clinicians Services Quick Guide for Clinicians TIP 48 Managing Depressive Symptoms in Substance Abuse KAP Keys for Clinicians Clients During Early Recovery TIP 58 Addressing Fetal Alcohol Spectrum Disorders TIP 49 Incorporating Alcohol Pharmacotherapies Into (FASD) Medical Practice TIP 59 Improving Cultural Competence Quick Guide for Counselors Quick Guide for Physicians KAP Keys for Clinicians

185

Substance Abuse Treatment: Group Therapy

This TIP, Substance Abuse Treatment: Group Therapy, presents an overview of the role and efficacy of group therapy in substance abuse treatment planning. This TIP offers research and clinical find- ings and distills them into practical guidelines for practitioners of group therapy modalities in the field of substance abuse treatment. The TIP describes effective types of group therapy and offers a theo- retical basis for group therapy’s effectiveness in the treatment of sub- stance use disorders. This work also will be a useful guide to supervi- sors and trainers of beginning counselors, as well as to experienced counselors. Finally, the TIP is meant to provide researchers and clini- cians with a guide to sources of information and topics for further inquiry.

Collateral Products Based on TIP 41 Quick Guide for Clinicians

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration

HHS Publication No. (SMA) 15-3991 Printed 2005 Revised 2009, 2011, 2012, 2014, and 2015