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Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 41.)

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Substance Abuse Treatment: Group Therapy.

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3 Criteria for the Placement of Clients in Groups

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

Culture and ethnicity considerations also are of primary importance. This chapter explains ways to facilitate the placement of people from minority cultures and ease such clients into existing groups. From this discussion, clinicians can also assess their readiness to deal with other cultures and become aware of processes that occur in multiethnic groups.

Overview

Matching Clients With Groups

Assessing Client Readiness for Group Primary Placement Considerations

Stages of Recovery

Placing Clients From Racial or Ethnic Minorities Diversity in a Broad Sense

Leader Self‐Assessment

Diversity and Placement

Ethnic and Cultural Matching Other Considerations for Practice

Matching Clients With Groups

Therapy groups, designed to treat substance abuse by resolving persistent life problems, are used frequently, but the individual success of this group experience depends in important respects on appropriate placement. Matching each individual with the right group is critical for success. Before placing a client in a particular group, the provider should consider

  • 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 committed to recovery. A client may move, for example, from a psychoeducational 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.

Assessing Client Readiness for Group

Placement should begin with a thorough assessment of the client’s ability to participate in the group and the client’s needs and desires regarding treatment. This assessment can begin as part of a general assessment of clients entering the program, but the evaluation process should continue after the initial interview and through as long as the first 4 to 6 weeks of group.

Assessment should inquire about all drugs used and look for cross‐addictions. It also is important to match groups to clients’ current needs. In addition to these and other assessment considerations, clients should be asked about the composition of their social networks, types of groups they have been in, their experience in those groups, and the roles they typically have played in those groups (Yalom 1995).

To help assess clients’ relationships and their ability to participate productively in a group, the clinician can have the client draw an eco‐map (see an example in Figure 3-1 ). An eco‐map (sometimes called a sociogram) is a graphic representation that depicts interpersonal relationships (Garvin and Seabury 1997; Hartman 1978). The client occupies the center of the page. Then, circles are added to show each significant relationship. The closer the relationship, the closer it is to the center circle. A solid line between circles indicates a strong, nurturing relationship, while a dotted line depicts a conflicted connection. Arrows drawn on the lines can represent the direction of the relationship. An arrow from the center out means “I care about this person.” An incoming arrow means “This person cares about me.”

Figure 3-1. Eco‐Map.

Figure

Figure 3-1. Eco‐Map. Source: Adapted from Garvin and Seabury 1997; Hartman 1978. Used with permission.

Clients who are inarticulate or withdrawn may welcome the opportunity to present information visually, and clinicians can gather useful information from these diagrams. If the diagram indicates few, distant, and conflicted relationships, the client may require a group that is very structured.

The eco‐map is indicative, but not comprehensive. It only provides the client’s viewpoint. Though it is a useful tool, leaders should be wary of basing placement decisions on this or any other single source of information. Clinical observation and judgments, information from collateral resources, and other assessment instruments all should contribute to a decision on a client’s readiness and appropriateness for group treatment. Either the group leader or another trained staff person should meet with a client before assignment to a group. In this interview, it is important to evaluate how the client reacts to the group leader and to assess current and past interpersonal relationships. The group leader also may hold an orientation group (perhaps educational in nature) to observe how the client relates to others. The client also may be observed in a waiting room with other clients or in a similar social situation to gain insight into how each person relates to others.

The clinician pays such careful attention to the relationships clients can manage at their current stage of recovery because this capacity has everything to do with how able the client is to participate in a group. Whatever their diagnosis, clients in groups—especially interpersonal process groups—need to be able to engage with other people. They need motivation to change, creativity, and dogged perseverance (Brown 1991). Furthermore, the group leader should continue to assess clients as treatment progresses. The clients’ needs and abilities are apt to change—change is part of successful treatment—and the appropriate type of group or the suitability for group in general may shift dramatically.

Not all clients are equally suited for all kinds of groups, nor is any group approach necessary or suitable for all clients with a history of substance abuse. For instance, a person who relapses frequently probably would be inappropriate in a support group of individuals who have attained significant abstinence and who have moved on to resolving practical life problems. It would be equally disadvantageous to place a person in the throes of acute withdrawal from crack cocaine in a group of people with alcoholism who have been abstinent for 3 months. A group usually can be heterogeneous in demographic composition, including men and women, younger and older clients, and people of different races and ethnicities, but clients should be placed in groups with people with similar needs.

People with significant character pathology (for example, a personality disorder) placed in a group of people who do not have a similar disorder almost certainly would violate the boundaries of the group and of individuals in the group. As a result, both the clients who have and who lack the character disorder would have a negative group experience and limited opportunity for growth. Clients with a personality disorder generally need a group that can place significant limits on their behavior both in and beyond the group setting. In groups treating clients with active psychoses, special adaptations would need to be made for possible psychotic symptoms, delusions, and paranoia. Once such adaptations in technique are made to fit the special circumstances of the population being treated, group therapy—in the hands of a skilled group leader—can be an effective, appropriate form of treatment.

Other types of clients who may be inappropriate for group therapy include

  • Clients who refuse to participate. No one should be forced to participate in group therapy.
  • People who can’t honor group agreements. Sometimes, as noted, these clients may have a disqualifying pathology. In other instances, they cannot attend for logistical reasons, such as a work schedule that conflicts with that of regular group meetings.
  • Clients who, for some reason, are unsuitable for group therapy. Such people might be prone to dropping out, getting and remaining stuck, or acting in ways contrary to the interests of the group.
  • People in the throes of a life crisis. Such clients require more concentrated attention than groups can provide.
  • People who can’t control impulses. Such clients, however, may be suitable for homogeneous groups.
  • People whose defenses would clash with the dynamics of a group. People who can’t tolerate strong emotions or get along with others are examples.
  • People who experience severe internal discomfort in groups.

Primary Placement Considerations

A formal selection process is essential if clinicians are to match clients with the groups best suited to their needs and wants. For each group, different filters are appropriate. Some groups may require only that members be participants in a particular program. Others may require a multidisciplinary panel review of the client’s case history. For many groups, especially interpersonal process groups, pregroup interviews and client preparation are essential.

Client evaluators should not rely solely on the review of forms, but should meet with each candidate for group placement. The interviewer should listen carefully to the client’s hopes, fears, and preferences. Ideally, clients should be offered a menu of appropriate options, since people will be more likely to remain committed to courses of treatment that they have chosen. Client choice also may strengthen the therapeutic alliance and thereby increase the likelihood of a positive treatment outcome (Emrick 1974, 1975; Miller and Rollnick 1991). Naturally, appropriate clinical guidance should also play a part in placement decisions.

After specifying the appropriate treatment level, a therapist meets with the client to identify options consistent with this level of care. More specific screens are needed to determine whether, within the appropriate level of care, the client is appropriate for treatment in a group modality. If so, further screens are needed to determine the most helpful type of group. Considerations include the following.

Women. Recent studies have shown that women do better in women‐only groups than in mixed gender groups. When women have single‐gender group therapy, retention is improved (Stevens et al. 1989). They also are more likely to complete their treatment programs (Grella 1999), use more services during the course of their treatment, and are more likely to feel they are doing well in treatment (Nelson‐Zlupko et al. 1996).

The primary reason same‐sex groups are more effective for women is that women have distinct treatment needs that are different from those of men. Women are more likely than men to have experienced traumatic events, which often lead to depression, anxiety, and posttraumatic stress disorder (PTSD). About three‐quarters of the women in treatment have been child or adult victims of sexual, physical, or emotional abuse (Roberts 1998). Statistically, women with substance use disorders also have experienced more severe types of abuse (such as incest), and perpetrators have abused them for longer periods of time in comparison to women without substance use disorders. The perpetrators are most often male partners, male family members, or male acquaintances. Women are less willing to disclose and discuss their victimization in mixed‐gender groups (Hodgins et al. 1997).

Women further are more likely to be caretakers for minor children or elderly parents and need to balance these family responsibilities with their own treatment needs. They face greater challenges in securing employment, are more likely to have co‐occurring mental illness, and encounter greater stigma for their substance use disorders than men.

Because women are relational by nature and develop a sense of self and self‐worth in relation to others (Miller 1986), groups specifically for women are advisable, particularly in early treatment. Gender‐specific treatment groups provide both the safety women often need to resolve the problems that fuel their substance use disorders and the healing environment they need to develop a healthier development of self and connections to other women.

It is important to help female clients make the transition from an environment supportive of their specific needs to one that is less sensitive to them. Following treatment, they will need an effective support network in their communities to help them sustain the gains of treatment. (See the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women [Center for Substance Abuse Treatment (CSAT) in development b].)

Adolescents. Planning, designing, and operating group therapy services for adolescent clients is a complex undertaking. Adolescents are strikingly different from adults, both psychosocially and developmentally, and require decidedly different services. Local, State, and Federal laws related to confidentiality; infectious disease control; parental permissions and notifications; child abuse, neglect, and endangerment; and statutory rape all can come into play when substance abuse treatment services are delivered to minors. Add the complications related to scheduling around school and the need to include family in the treatment process, and it is no surprise that most group therapy for teens occurs in the context of an overall treatment program or as part of highly specialized, targeted programs (e.g., see the discussion of Cognitive Behavioral Therapy group sessions in Sampl and Kadden 2001). Indeed, to serve as a substance abuse counselor or clinician in the delivery of group therapy to adolescents typically requires prior training and experience with the particular age group to be served.

The complexities related to adolescents and group therapy lie outside the scope of the TIP. Suggested reading for those interested in the rationale for group therapy with adolescents includes, but is not limited to, Sampl and Kadden 2001 or textbooks such as Group Therapy with Children and Adolescents (Kymissis and Halperin 1996), including the chapter by Spitz and Spitz on adolescents who abuse substances, or Adolescent Substance Abuse: Etiology, Treatment, and Prevention (Lawson and Lawson 1992), especially the chapter on group psychotherapy with adolescents by Shaw. Last, a journal article (Pressman et al. 2001) relates the special difficulties group psychotherapy presents for adolescents with both psychiatric and substance abuse problems—another common complexity of providing group therapy for adolescents with substance abuse disorders.

The client’s level of interpersonal functioning, including impulse control. Does the client pose a threat to others? Is the client prepared to engage in the give and take of group dynamics? The client’s “level of psychological functioning and integration” should be considered, as should “the kinds of defenses [used] to maintain abstinence, and the rigidity of [those] defenses” (Vannicelli 1992, p. 31). A client who has not moved beyond sloganism, including “avoid strong feelings,” may not do well in a group that has evolved more sophisticated ways to maintain abstinence (Vannicelli 1992).

Motivation to abstain. Clients with low levels of motivation to abstain should be placed in psychoeducational groups. They can help the client make the transition into the recovery‐ready stage.

Stability. In placement, both the client’s and group’s best interests need to be considered. For example, bringing a new member who is in crisis into treatment may tax the group beyond its ability to function effectively, yet the group might easily manage a person in similar crisis who already is part of the group (Vannicelli 1992). Group stability counts as well. An ongoing group of clients who have gained insight into the management of their feelings can support a new member, helping that person solve problems without getting caught up in feelings of crisis themselves.

Stage of recovery. The five stages of Prochaska and DiClemente’s transtheoretical model of change (discussed briefly in chapter 2 and in greater detail in TIP 35,b Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999b]) map the route that a person abusing substances must travel during the transition from abuse to recovery. The stages of change are best conceived as a cycle, but movement through the cycle is not always a tidy, forward progression. Clients can—and often do—move backward as they struggle with dependence. Varying types of groups will be appropriate for clients at different stages of recovery. For example, an interpersonal process group might be overstimulating for some clients in early stages of recovery, particularly those undergoing detoxification. They would benefit most from a group with a strong primary focus on achieving and maintaining abstinence. Once abstinence and attachment to the recovery process are established, the client is ready to work on such issues as awareness and communication of feelings, conflict resolution, healthy interdependence, and intimacy.

Expectation of success. Every effort should be made to place the client in a group in which the client, and therefore, the program, can succeed.

A poor match between group and client is not always apparent at the outset. Monitoring can ensure that clients are in groups in which they can learn and grow without interfering with the learning and growth of others. Although the primary factor to consider regarding continued participation in group should be a client’s ability to get something out of the experience, it is also important to determine how each person’s participation affects the group as a whole. A client who, for whatever reason, cannot participate may have a profoundly adverse effect on the group’s ability to coalesce and function cohesively. If a client does not interfere with group progress, however, sometimes it is appropriate to keep a nonparticipant in the group and simply allow that person to sit and listen.

A number of different assessment models can be used to allow meaningful dialog between client and program representatives during the screening and placement phase, even when resources are limited. The ASAM PPC‐2R treatment criteria (ASAM 2001) commonly are used for client placement. The criteria are arranged in two sets, one for adults and one for adolescents. Each set covers five levels of service:

  • Level 0.5 Early Intervention
  • Level I Outpatient Treatment
  • Level II Intensive Outpatient Treatment/Partial Hospitalization
  • Level III Residential/Inpatient Treatment
  • Level IV Medically Managed Intensive Inpatient Treatment

On each level of care ASAM’s criteria describe appropriate treatment settings, staff and services, admission, continued service, and discharge criteria for six “dimensions”:

  • Potential for acute intoxication or withdrawal
  • Biomedical conditions and complications
  • Emotional and behavioral conditions or complications
  • Treatment acceptance or resistance
  • Relapse and continued use potential
  • Recovery environment

On the five levels of care, ASAM also provides a brief overview of the services available for particular severities of addiction and related problems. Another commonly used assessment tool, the Addiction Severity Index, can be found in appendix D of TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000).

Some States require providers to use the ASAM PPC‐2R for patient placement, continuing stay, and discharge decisions. For placement in group therapy, a provider can also consider

  • A client’s stage of recovery (see next section)
  • The progression of the disease
  • The client’s stage of readiness for change

Although no single set of criteria is sufficient to evaluate a client’s proper placement, this document presents a chart (see Figure 3-2 ) that summarizes the types of group treatment most appropriate for clients at different stages of recovery. Clinicians can use the chart as a guide to determine the type of group most appropriate for a client.

When different dimensions of evaluation conflict in their placement indications, the clinician will need to break the impasse with clinical judgment. Actual client placement should take into account characteristics such as substances abused, duration of use, treatment setting, and the client’s stage of change. For example, a client in a maintenance stage may need to acquire social skills to interact in new ways, may need to address emotional difficulties, or may need to be reintegrated into a community and culture of origin. Only an additional level of assessment will determine which of these groups (or combination of groups) is best for the client.

Stages of Recovery

A number of classification systems have been applied to the stages of recovery from substance abuse. The most common, however, classifies clients as being in an early, middle, or late stage of recovery:

  • Early recovery. The client has moved into treatment, focusing on becoming abstinent and then on staying sober. Clients in this stage are fragile and particularly vulnerable to relapse. This stage generally will last from 1 month to 1 year.
  • Middle recovery. The client feels fairly secure in abstinence. Cravings occur but can be recognized. Nonetheless, the risk of relapse remains. The client will begin to make significant lifestyle changes and will begin to change personality traits. This stage generally will take at least a year to complete, but can last indefinitely. Some clients never progress to the late recovery/maintenance stage. Sometimes they relapse and revert to an early stage of recovery.
  • Late recovery/maintenance. Clients work to maintain abstinence while continuing to make changes unrelated to substance abuse in their attitudes and responsive behavior. The client also may prepare to work on psychological issues unrelated to substance abuse that have surfaced in abstinence. Since recovery is an ongoing process, this phase has no end.

Figure 3-2. Client Placement by Stage of Recovery

Psychoedu‐ cation Skills‐ Building Cognitive– Behavioral Support Interpersonal Relapse Prevention Expressive Culture‐Specific
Early+++++ ++++++ *
Middle+++ +++++++ ++++ *
Late and Maintenance ++++++ *
Key:
Blank Generally not appropriate
+ Sometimes necessary
++ Usually necessary
+++ Necessary and most important
* Depends on the culture and the context of treatment
Source: Consensus Panel.

Figure 3-3 uses Prochaska and DiClemente’s stages of change model to relate group placements to the client’s level of motivation for change.

Figure 3-3. Client Placement Based on Readiness for Change

Psycho‐ education Skill Building Cognitive– Behavioral Support Interpersonal Process Relapse Prevention Expressive Culture
Precontemplation ++++
Contemplation +++++++
Preparation +++++++
Action ++++++++
Maintenance +++++++
Recurrence +++++++
Source: Consensus Panel; Prochaska and DiClemente 1984.

Placing Clients From Racial or Ethnic Minorities

Diversity in a Broad Sense

In all aspects of group work for substance abuse treatment, clinicians need to be especially mindful of diversity issues. Such considerations are key in any form of substance abuse treatment, but in a therapeutic group composed of many different kinds of people, diversity considerations can take on added importance. As group therapy proceeds, feelings of belonging to an ethnic group can be intensified more than in individual therapy because, in the group process, the individual may engage many peers who are different, not just a single therapist who is different (Salvendy 1999).

While the word “diversity” often is used to refer to cultural differences, it is used here in a broader sense. It is taken to mean any differences 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 background, sexual orientation, and ability level are all extremely important, as are less apparent factors such as social class, education level, religious background, parental status, and justice system involvement. Figure 3-4 provides several definitions around culture.

Figure 3-4. 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 cross‐cultural situations.
Source: Giachello 1995; Office of Minority Health 2001.

To help clinicians understand the range of diversity issues and the importance of these issues, this volume adapts a diversity wheel from Loden and Rosener (1991) (see Figure 3-5 ). The wheel depicts two kinds of characteristics that can play an important role in understanding client diversity: The inner wheel includes permanent characteristics such as age or race; the outer wheel lists a number of secondary characteristics that can be altered. Note that primary characteristics are not necessarily more important than secondary ones and that this figure does not include a comprehensive list of secondary characteristics.

Figure 3-5. Diversity Wheel.

Figure

Figure 3-5. Diversity Wheel. Source: Adapted from Loden and Rosener 1991. Used with permission.

It is important for clinicians to realize that diversity issues affect everyone. All individuals have unique characteristics. Further, how people view themselves and how the dominant culture may view them are frequently different. In any event, no one should be reduced to a single characteristic in an attempt to understand that person’s identity. All people have multiple characteristics that define who they are.

While ideas of difference are social constructions, they do have a real‐world effect. For example, members of groups tend to act in different ways when with members of their own group than they would in a heterogeneous group. Further, the dominant culture’s attitudes and beliefs about people (based on age, race, sexual preference, and so on) influence everyone.

A culturally homogeneous group quite naturally will tend to adopt roles and values from its culture of origin (Tylim 1982). These ways should be understood, accepted, respected, and used to promote healing and recovery. However, group leaders should also be aware of the possibility that these group roles and values might conflict with treatment requirements, and therefore clinicians need to be prepared to provide more direction to group members when required (Salvendy 1999). For example, a group composed of Southeast Asian refugees might give authority to older men in the group, who may never be challenged, contradicted, or disagreed with because to do so would show disrespect (Kinzie et al. 1988). These older, adult males can assist in group leadership. However, the opinions of female group members, particularly younger ones, might be ignored, and a group leader should be able to compensate for this tendency. As another example, many Hispanics/Latinos may be suspicious of rules and the people who enforce them. Consequently, group leaders regarded as authority figures (that is, not compadres) unwittingly may represent discrimination and encroachments on freedom (Torres‐Rivera et al. 1999).

Cultural practices also affect communication among group members. Many traditionally raised Asians, for example, will be reluctant to disagree openly with their elders or even voice a personal opinion in their presence (Chang 2000). Gender‐specific cultural roles, too, may be played out in groups. For example, women may hold emotional energy for men or nurture them. Therapists should be alert to assumptions and roles that may inhibit the development of individuals or the group as a whole.

Unfortunately, little research reveals how group therapy should be adapted to meet such differences, and many of the findings that do exist are contradictory. Further, any generalizations about cultural groups may not apply to individuals because of variance in levels of acculturation and other experiential factors. A particular Latino youth, for example, may identify with the dominant culture and not think of himself as Latino. The client is always to be considered the expert on what culture, ethnicity, and gender identity mean to that person. If a leader believes that cultural traditions might be a factor in a client’s participation in group or in misunderstandings among group members, the leader should check the accuracy of that perception with the client involved. Therapists should be aware, however, that individuals may not always be able to perceive or articulate their cultural assumptions.

Group leaders should be able to anticipate a particular group’s characteristics without automatically assigning them to all individuals in that group. It would be a mistake, for instance, if an institution assigned all immigrants or people of color to a single group, assuming they would be more comfortable together. Members of such groups may not have anything in common. An Asian‐American woman assigned to the only Asian‐American therapist in the institution might resent her placement and protest in strong terms. She would want the best therapist for her, not an automatic matchmaking based on ethnicity.

Clinicians working primarily with other cultural or ethnic groups should be open and ready to learn all they can about their clients’ culture. For example, a therapist working with Salvadoran immigrants should be prepared to learn not only about the country and culture of El Salvador, but also about all the events and influences that have shaped this population’s experience, including social conditions in El Salvador and the experience of immigration.

Accommodating cultural and ethnic characteristics is not a simple matter. These adaptations should be made, however, because ethnicity and culture can have a profound effect on many aspects of treatment. For instance, pressures to conform to the dominant culture represented in the group can be intense. The norms of the group may also be in painful conflict with an individual’s traditional cultural values. An example is shown in Figure 3-6. Figure 3-7 provides three suggested resources on culture and ethnicity; however, this list is by no means exhaustive.

Figure 3-6. When Group Norms and Cultural Values Conflict

A middle‐aged, 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 debilitating 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 3-7. Three Resources on Culture and Ethnicity

Culture and Psychotherapy: A Guide to Clinical Practice is a resource for mental health professionals treating people of widely varying cultural backgrounds. Case studies include the story of an American‐ Indian 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 society 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 cross‐cultural orientation and one on specific cultures, including African‐American, Hispanic/Latino, American‐Indian, 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).

Leader Self‐Assessment

Group leaders should be aware that their own ethnicities and standpoints can affect their interpretation of group members’ behavior. The group leader brings to the group a sense of identity, as well as feelings, assumptions, thoughts, and reactions. Leaders should be conscious of how their own backgrounds affect their ability to work with particular populations. For example, a female therapist who has survived domestic violence may have severe difficulties working with spouse abusers. Another example is that male group leaders 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 all members equally, regardless of gender. Clinicians also need to evaluate how competent they are managing issues of cultural diversity. In cases where cultural or language barriers are very strong, a group leader may need to refer a client to another group or make special accommodations to allow the client to participate.

Reed and her colleagues (1997) have developed a list of principles for group leaders to evaluate their own attitudes about diversity (see Figure 3-8 ). Figure 3-9 is a self‐assessment guide for group counselors working with diverse populations.

Figure 3-8. 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 professional’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 feedback 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 disputes between group members.
Source: Adapted from Reed et al. 1997. Used with permission.

Figure 3-9. Self‐Assessment Guide

The questions that follow can serve as a guide and self‐assessment 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 uncertain 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?
  • 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 community‐based 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 cross‐cultural 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, socioeconomic 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?
  • 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 traveling 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

In many groups, the composition of members will be heterogeneous; for example, a majority of Caucasians placed with a minority of ethnically or racially different members. The greater the mix of ethnicities, the more likely that biases will emerge and require mediation (Brook et al. 1998). Whatever a client’s belief system or origin, “neither the therapist nor the group should ask any group member to give up or renounce any ethnic/cultural beliefs, feelings, or attitudes. Rather, group members are encouraged to share these feelings and beliefs verbally and overtly, even if this may be upsetting to some or all of the group’s members” (Brook et al. 1998, p. 77). Although therapists may be uncomfortable when group members talk about subjects like racism and discrimination, such expression sometimes is an important part of an individual’s recovery process.

First‐generation immigrants who speak little or no English usually are underrepresented in group therapy because of their limited fluency. While an immigrant may be able to communicate adequately in individual therapy with a single healthcare professional, that newcomer may be unable to follow a fast‐flowing group discussion.

As previously mentioned, before placing a client in a particular group, the therapist needs to understand the influence of culture, family structure, language, identity processes, health beliefs and attitudes, political issues, and the stigma associated with minority status for each client who is a potential candidate for a group. In addition, the therapist will need to do the following:

Address the substance abuse problem in a manner that is congruent with the client’s culture. Each culture incorporates beliefs and values that guide the behavior of everyone identified with the culture and that govern experiences related to the use of substances. Some cultures, for instance, use chemical substances as part of rituals, some of them religious. This entwinement of substance use and culture does not mean that the therapist cannot discuss the issue of this substance use with a client. Some clients, of their own volition, will reduce or eliminate the use of substances once they examine their beliefs and experiences.

Appreciate that particular cultures use substances, usually in moderation, at specified types of social occasions. For many people, occasional, moderate use of substances might be part of a meaningful social/cultural ritual, but for people with substance use disorders such use, even when culturally accepted, is contraindicated because it might provoke relapse, binges, or other destructive reactions. Again, a culturally sensitive discussion of this issue with clients may result in individual decisions to abstain on these occasions, despite considerable cultural pressure to use substances of abuse. In contrast, some cultures have beliefs in direct opposition to the client’s use of substances. Helping the client redirect behavior to come into accord with these beliefs may be an important treatment approach.

Assess the behaviors and attitudes of current group members to ascertain whether the new client would match the group. From the start of a multicultural therapy group, members should feel that race is a safe topic to discuss (Salvendy 1999). Because group members are less restricted to their usual social circles and customary ethnic and cultural boundaries, the group is potentially a social microcosm within which members may safely try out new ways of relating (Matsukawa 2001). Even so, potential problems between a candidate and existing group members should be identified and counteracted to prevent dropout and promote engagement cohesion among members.

Understand personal biases and prejudices about specific cultural groups. A group leader should be conscious of personal biases to be aware of countertransference issues, to serve as a role model for the group, and to create group norms that permit discussion of prejudice and other topics relevant to a multicultural setting.

Understanding the cultural characteristics of major racial and ethnic populations—particularly their history, acculturation level, family and community roles and relationships, health beliefs, and attitudes toward substance abuse—will permit better‐informed decisions about the placement of individuals from these populations into existing therapy groups. Naturally, no group leader can know everything about every culture, but a good counselor can be aware of major characteristics of cultural groups. This knowledge can guide the placement of clients into appropriate groups and help a leader anticipate relationships and tensions that may arise within a group.

Figure 3-10 provides tools to prepare both the group and the minority client for the client’s entry and integration into an established therapeutic group.

Figure 3-10. 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 backgrounds 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 maintaining their self‐esteem.
  • 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 feedback, encourage more participation.

One researcher cites four major dynamic processes that occur within a multiethnic group (Matsukawa 2001). Identifying these processes as they function in a group may help a therapist predict whether a possible placement will support a cohesive social microcosm or create a threatening and disruptive environment.

  1. Symbolism and nonverbal communication. In some cultural groups, direct expression of thoughts and feelings is considered unseemly. Matsukawa (2001) points out that among the Japanese, a highly valued trait is the ability to sense what another person wants without explicitly stated cues. In such a culture, symbolic gestures (a gift, perhaps) or nonverbal signals (the author describes a woman who showed her craft work without comment) are used to communicate indirectly and acceptably. In such a situation, Matsukawa says, the therapeutic approach is modified to perceive and permit a Japanese‐American woman to present herself tacitly without pressing for verbal elaboration. Therapists also should intervene if nonverbal communications are misinterpreted.
  2. Cultural transference of traits from one person of a certain culture to another person of that culture. If a group member has had experiences (usually negative) with people of the same ethnicity as the therapist, the group member may transfer to the therapist the feelings and reactions developed with others of the therapist’s ethnicity. In short, Matsukawa (2001) says, the group member jumps to conclusions and assigns traits to the therapist based on ethnicity alone. The therapist first should detect these misconceptions and then reveal them for what they are to dispel them.
  3. Cultural countertransference, the therapist’s (often subconscious) emotional reaction to a client. Therapists also can jump to conclusions. Countertransference of culture occurs when a therapist’s response to a current group member is based on experience with a former group member of the same ethnicity as the new client. Matsukawa (2001) cautions therapists to exercise restraint when in the middle of a “countertransference storm.”
  4. Ethnic prejudice. “Stereotypes become prejudice,” Matsukawa (2001, p. 256) writes, “when they are hard to modify and when one’s interactions, or lack thereof, with another person are based on preconceived feelings and judgments about the person’s race, without enough knowledge, understanding, or experience.” In multiethnic groups, it is vital to develop an environment in which it is safe to talk about race. Not to do so will result in scapegoating or division along racial lines (Matsukawa 2001).

In practice, people connect and diverge in ways that cannot be predicted solely on the basis of ethnic or cultural identity. Two people from different ethnic backgrounds may share many other common experiences that provide a basis for identification and mutual support. All the same, it is possible to rule out some combinations. For example, two elderly men, one Korean and the other Japanese, may not blend well since their cultures have clashed in the past many times. Similarly, a single 17‐year‐old girl would not mix well with a group made up primarily of middle‐aged males. Potentially undesirable and distracting group dynamics could easily be foreseen. Leaders are responsible for considering carefully the positions of people who are different in some way, especially when planning fixed‐membership groups.

Ethnic and Cultural Matching

Although arguments for matching the ethnicity of the therapist with that of the group members treated may have some merit, the reality is that such a course seldom is feasible. Health care providers from culturally and linguistically diverse groups are underrepresented in the current service delivery system, so it is likely that a group leader will be from the mainstream culture (Cohen and Goode 1999). While it might be ideal to match all participants by ethnicity in a therapeutic group, the most important determinants of success are the values and attitudes shared by the therapist and group members (Brook et al. 1998).

It should be noted that recent research suggests that an ethnic match between therapist and client does not “consistently improve outcomes” (Salvendy 1999, p. 437). Other research (Atkinson and Lowe 1995) suggests that, while the ethnicity of the therapist is a factor that can influence treatment, it is by no means the most important factor. Culturally specific homogeneous groups should be used only when someone’s “cultural, religious, or political beliefs are very different from the mainstream and they are not open to adjustments,” as, for example, with recent immigrants or refugees (Brook et al. 1998; Ivey et al. 1993; Salvendy 1999, p. 457; Silverstein 1995; Takeuchi et al. 1995; Yeh et al. 1994).

If less acculturated people with limited language skills are treated in groups, the program should provide bilingual clinicians who are sensitive to gender and culture. Therapists should focus on problem‐oriented, short‐term treatment; should consider employing a proactive therapeutic style; and should be aware that clients may view them as authority figures (Brook et al. 1998).

In culturally specific groups, a member of the focus culture usually runs the group, although this ideal situation is not always possible. If a trained clinician who also belongs to the group is not available, it may be advantageous to add a cofacilitator who belongs to the population, understands the population’s specific problems and strengths, and can serve as a role model to assist the clinician. Of course, if the program is not specifically focused on cultural or community issues and is simply incorporating some cultural elements, the staffing requirements are not as stringent. In such cases, the presence of a member of the culture that developed the practice or knowledge is desirable, but not vital.

“Children often accompany their parents to therapeutic encounters to translate and provide support” for immigrant parents, but relying on “the children in this way actually perpetuates isolation and decreases pressure to build a network of supports. Finding an interpreter who not only speaks the language but also who may share the values and the migration experience is crucial to further the acculturation and therapy process” (Nakkab and Hernandez 1998, p. 98).

Other Considerations for Practice

Groups may include people who have varying

  • Expectations of leaders
  • Experience in decisionmaking and conflict resolution
  • Understanding of gender roles, families, and community
  • Values

All these differences, and many others, will affect individual and group experiences. Group leaders should be keenly aware of ways in which ethnicity and culture can affect participation in interactive therapy. One of the most profound ways that different cultural backgrounds may affect individuals in groups is in expectations of the leader. For example, many African Americans look to leaders as problemsolvers. In Hispanic/Latino culture, people are equals until proven otherwise—roles do not automatically constitute a supervisor/subordinate relationship (Wilbur and Roberts‐Wilbur 1994).

Differences that may influence an individual’s perception of a leader’s role should be explored in the pregroup interview. The interviewer can explain how the leader’s role may differ from what the client might expect. Later, in group, leaders need to be alert to unexpected differences in interpretation of their actions. For example, a group member who expects the leader to exercise authority might view a leader’s attempt to empower the group as shirking responsibility. The leader can help by being explicit about his or her role and responsibilities in the group.

Group leaders also should be aware that people manage conflict in culturally diverse ways. A native New Yorker might have an in‐your‐face approach to conflict, while some Asian Americans may find a raised voice offensive. Cultural factors may frame a client’s perception of conflict in a way not readily apparent to the group. For an example, see Figure 3-11 .

Figure 3-11. Culture and the Perception of Conflict

A 33‐year‐old single, second‐generation Chinese‐Canadian woman joined a group after proper preparation. She was one of two non‐Caucasians in this long‐term, interpersonally focused, slow‐turnover 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 discomfort 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 anxiety was accepted as genuine and not seen as resistance by the therapist, who provided 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 Chinese‐Canadian 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 matter. 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.

For more detailed information on cultural diversity in client placement, see the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (CSAT in development a).

Once placement decisions are completed, group development begins. Chapter 4 explains this process.

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