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Substance Abuse Treatment: Group Therapy [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 41.)
In This Chapter….
This chapter begins by discussing the varying uses of fixed or revolving groups. Fixed groups generally stay together for a long time, while members in revolving groups remain only until they accomplish their goals. Each is used for different purposes, and each requires different leadership.
As treatment and recovery have stages, group development also changes over time. The first phase pays attention to orientation and establishing safe, effective working relationships. In the middle (and longest) phase, the actual work of the group is done. The end phase is a deliberate, positive termination of group business. Each phase requires attention to specific tasks.
The way groups are developed varies by the type of group. A wide range of therapeutic groups may be used with people who have substance use problems. For the purpose of this discussion, however, groups have been classified into two broad categories, each with the same two subcategories:
Fixed membership groups
Time-limited
Ongoing
Revolving membership groups
Time-limited
Ongoing
Fixed membership groups are relatively small (not more than 15 members); membership is relatively stable. Typically, the therapist screens prospective members, who then receive formal preparation for participation. Any departure from the group occurs through a well-defined process. Two variations of this category are
A time-limited group, in which the same group of people attend a specified number of sessions, generally starting and finishing together
An ongoing group, in which new members fill vacancies in a group that continues over a long period of time
In time-limited groups with fixed membership, learning builds on what has taken place in prior meetings. Thus, members need to be in the group from its start. New members are admitted only in the earliest stages of group development (for example, only during the first week for a daily group or during the first month for a group that meets weekly). Ongoing fixed membership groups may be used for short-term therapy, skill building, psychoeducation, and relapse prevention.
New members enter a revolving membership group when they become ready for the service it provides.
In ongoing groups with fixed membership, the size of the group is set; new members enter only when there is a vacancy. The leader generally is less active than is the leader of a time-limited group, since the interaction among group members is more important than leader-to-member interactions. To conduct this type of group, the leader needs substantial training in group dynamics (such as individuals' boundaries and the roles different members assume) and leadership along with excellent supervisory skills. Examples in this category include interpersonal process groups and some psychoeducational therapy groups.
Fixed groups are rare because they demand a long-term commitment of resources. Most outpatient programs provide only 8–20 sessions, and most inpatient programs are limited to 2–4 weeks.
New members enter a revolving membership group when they become ready for the service it provides. Revolving membership groups frequently are found in inpatient treatment programs. As clients are admitted and discharged, people come and go in the group. Consequently, revolving groups must adjust to frequent, unpredictable membership changes. The two variations of revolving membership groups are
A time-limited group that members generally join for a set number of sessions
An ongoing group that clients join until they accomplish their goals
Revolving membership groups can be larger than fixed membership groups. The temptation to have many members often is strong due to insufficiently trained staff and shortages of funding. While revolving membership groups have no absolute limit on the number of members, it is prudent to keep the group small enough (about 15 or fewer) for participants to feel heard and understood, for the leader to know each of them, and for members to feel a sense of connection and belonging to the group. If a group becomes too large (more than 20), group interaction breaks down and the clients become a class made up of individuals, rather than a single, cohesive, therapeutic body.
Revolving membership groups generally are more structured and require more active leadership than fixed membership groups. Participation and learning are not highly dependent on attendance at previous sessions. In some settings, new members may be brought in at fixed intervals. In a daily group, for instance, new members might enter once a week. Members who have been in the group for a substantial number of meetings often help to orient newer members.
One advantage to revolving membership groups is the stimulation that new members provide.
One advantage to revolving membership groups is the stimulation that new members provide. A potential problem is that new group members may dread joining a group, feeling themselves to be at a disadvantage because existing members already know each other, how the group operates, and what has been discussed in previous sessions. For its part, the group itself may be apprehensive about the new member (Rasmussen 1999).
A related possible problem is the adverse effect that membership changes can have on group cohesion. For these reasons, preparation for revolving groups is of paramount importance: Group leaders need to pay special attention to helping new members become acclimated to the group, and clients chosen to fill a group vacancy should have the capacity to observe and adjust to the dynamics of the group (Rasmussen 1999).
In time-limited groups, each member generally is expected to attend a certain number of sessions for a certain number of weeks or months. A psychodrama group (one kind of expressive therapy group), for example, might be offered every spring. Other common examples include psychoeducational groups and some skills-building groups.
Several possible varieties of ongoing groups have revolving membership. Such groups may be (1) open-ended, with clients staying for as many sessions as they wish; (2) repeating sets of topics, with clients staying only until they have completed all of the topics; or (3) a duration-specific format, with clients attending for a set number of weeks (either consecutively or nonconsecutively). An interpersonal process group as part of an intensive outpatient program is an example of an ongoing group with revolving membership. Clients enter this treatment group and attend until the work specified in the treatment plan has been completed.
Other examples of revolving membership groups include inpatient unit groups, continuing care drop-in groups, transition groups for inpatients leaving and moving to outpatient care, psychoeducational groups, expressive therapy groups, and long-term support groups, such as ongoing continuing care groups and maintenance groups. Figure 4-1 (see p. 62) provides the characteristics of fixed and revolving membership groups.
Characteristics of Fixed and Revolving Membership Groups.
Research shows a strong tendency toward relapse early in the substance abuse treatment process. A person early in recovery is at greater risk for returning to use than someone with 3, 6, or even 18 months of abstinence (Johnson 1973; Project MATCH 1997). The better clients are prepared for treatment, however, the longer they stay in treatment. If clinicians ensure that clients come to the group with appropriate expectations, both clinicians and clients can expect a greater degree of success.
Group leaders should conduct initial individual sessions with the candidate for group to form a therapeutic alliance, to reach consensus on what is to be accomplished in therapy, to educate the client about group therapy, to allay anxiety related to joining a group, and to explain the group agreement. These activities may take as little as one meeting or as long as several weeks (Rutan and Stone 2001). Normally, the longer the expected duration of the group, the longer the preparation phase. Clients should have an opportunity to air any concerns, especially if they are apprehensive about their cultural status within the group. During this time, the group facilitator should learn how the client handles interpersonal functions on a day-to-day basis, how the client's family functions, and how the client's culture perceives the substance abuse problem.
The process of preparing the client for participation in group therapy begins as early as the initial contact between the client and the program. Clients' preconceptions about the group, their expectation of how the group will benefit them, their understanding of how they are expected to participate, and whether they have experienced a motivational session prior to the group will all influence members' participation.
Preparation meetings serve a dual purpose. First, they ensure that clients understand expectations and are willing and able to meet them. Second, these meetings help clients become familiar with group therapy processes. Where in-depth, one-on-one meetings are impractical because of group size or other considerations, at least some form of orientation should be provided, perhaps in the form of readings, videotape, group preparation meeting, or discussion with the primary counselor prior to attending a group.
Pregroup interviews are widely used to gather useful information about clients and prepare them for what they can expect from a group. The pregroup interview should cover clients' goals for treatment, the group contract, client behaviors that might present an obstacle to group work, and any other information that clients feel may be pertinent (Vannicelli 1992). Clients should be thoroughly informed about what group therapy will be like. In addition, client preparation should address the following:
Explain how group interactions compare to those in self-help groups, such as Alcoholics Anonymous (AA). Clients should be informed that group therapy differs from 12-Step or other similar recovery groups. In particular, the member-to-member “cross-talk” discouraged in 12-Step groups is an essential part of interactive therapy (Margolis and Zweben 1998). Although clients sometimes perceive a conflict between their AA or Al-Anon experience and group therapy due to these different formats, the therapist should know with certainty that the two are not mutually exclusive, but that they serve different functions and provide support in distinct, complementary ways (Vannicelli 1992). Therapists also should be careful to distinguish treatment groups from AA's self-help approach, which, having no formal leadership, cannot provide meaningful accountability (Vannicelli 1992; Zweben 1995).
Emphasize that treatment is a long-term process. Participants should know in advance that in group therapy, each person's attendance at each session is vital. They should also recognize that while the first 3 months of treatment after detoxification are critical, fully effective treatment takes much longer.
Let new members know they may be tempted to leave the group at times. It should be emphasized that although the work is difficult and even upsetting at times, clients gain a great deal from persistent commitment to the process and should resist any temptation to leave the group. Clients also should be encouraged to discuss thoughts about leaving the group when they arise so that the antecedents of these thoughts can be examined and resolved.
Give prospective and novice members an opportunity to express anxiety about group work, and help allay their fears with information. For some prospective members, group process work may need to be demythologized. Misperceptions should be countered to keep them from interfering with group participation. Some providers conduct a short-term group to prepare clients for upcoming participation in other kinds of groups. This approach enables leaders to assess clients' suitability for various types of group work.
Recognize and address clients' therapeutic hopes. With help, clients can explain how they think group work can help them, identify their preferences, and articulate realistic goals. Leaders can use this information to be sure that clients are placed in groups most likely to fulfill their aspirations.
For a sample dialog that takes place in a preparation interview, see “Preparing the Patient for Group Psychotherapy” (Hoffman 1999).
In preparing prospective members for a group experience, it is important to be sensitive to people who are different from the majority of the other participants in some way. Such a person may be much older or younger than the rest of the group, the lone woman, the only member with a particular disorder, or the person from a distinctive ethnic or cultural minority. The leader should consult privately with people who stand out in the group to determine from their unique perspective how they are experiencing the group. They should always be allowed to be the experts on their own situation. Further, clients should be encouraged to define the extent of their identification with the groups to which they belong and to determine what that identification implies.
The fixed membership format provides more time to discuss issues of difference prior to joining a group. A person unlike the rest of the group may be asked by the other group members:
How do you think you would feel in a group in which you differ from other group members?
What would it be like to be in a group where everyone else is a strong believer in something, such as AA, and you are not?
Such questions might be coupled with positive comments that stress the benefits that a unique perspective may bring to the group.
It is important to explore issues of difference in advance of group placement. It similarly is important to acknowledge cultural or ethnic backgrounds and to emphasize that differences can be strengths that can contribute to the group. If a client believes that a particular group situation would be uncomfortable, however, the counselor may offer the client other treatment options.
The counselor also is responsible for raising the level of group members' sensitivity and empathy. It is important at times, for instance, to prepare group members for situations in which others have symptoms that could offend or repel them. The therapist can initiate discussion by asking questions such as, “What would it be like for you to be with people who sometimes cut themselves?”
While group leaders have many responsibilities to prepare clients for participation in groups, the clients have obligations, too. Their responsibilities are specified in group agreements, discussed later in this chapter.
Throughout the initial sessions of therapy, clients are particularly vulnerable to return to substance use and to discontinue treatment. The first month appears to be especially critical (Margolis and Zweben 1998). Yalom (1995) writes that premature termination usually “stems from problems caused by deviancy, sub-grouping, conflicts in intimacy and disclosure, the role of the early provocateur, external stress, complications of concurrent individual and group therapy, inability to share the leader, inadequate preparation, and emotional contagion” (p. 315) (a concept discussed later in chapter 6).
Retention rates are affected positively by client preparation, maximum client involvement during the early stages of treatment, the use of feedback, prompts to encourage attendance, and the provision of wraparound services (such as child care and transportation) to make it possible or easier for clients to attend regularly. Consideration needs to be given to the timing and length of groups, too, because these factors affect retention.
To achieve maximum involvement in group therapy during this period, motivational techniques, such as psychoeducation and attendance prompts, may be used to engage the client. Evidence suggests that if people are self-motivated, they will persist longer in behaviors consistent with recovery, and will attach more value to their quest than they would in response to external pressure. Incorporating motivational elements in pregroup preparation or offering groups that focus on motivation is likely to increase compliance with continuing care requirements (Foote et al. 1999).
Some pretreatment techniques that appear to reduce the incidence of dropping out include the following:
Role induction uses formats such as interviews, lectures, and films to educate clients about the reasons for therapy, setting realistic goals for therapy, expected client behaviors, and so on.
Vicarious pretraining using interviews, lectures, films, or other settings demonstrates what takes place during therapy so the client can experience the process vicariously.
Experiential pretraining uses group exercises to teach client behaviors like self-disclosure and examination of emotions.
Motivational interviews use specific listening and questioning strategies to help the client overcome doubt about making changes (Walitzer et al. 1999).
Prompts to remind clients of upcoming group sessions are another important way to engage group members during the first 3 months of treatment (Lash and Blosser 1999). One successful strategy increased the number of clients who began continuing care group therapy and nearly doubled the attendance at group sessions (Lash and Blosser 1999). The plan included:
An explanation to each client of the importance of continuing care in maintaining sobriety and the use of a continuing care participation contract.
An appointment card and an automated telephone message reminder of each upcoming group session.
A note from the therapist following the first session saying that he was glad the client chose to attend the group and was looking forward to seeing the client at upcoming sessions.
At least two follow-up phone calls after missed sessions (Lash and Blosser 1999).
Yalom (1995) notes that it is common practice for therapists to try to forestall premature termination by persuading clients who plan to leave group to attend just one more session. The hope is that other group members will persuade the restless member not to drop out. This tactic rarely works, however. Instead, during the preparation of clients for group, Yalom suggests emphasizing that periods of discouragement are likely to occur during therapy.
Another effective way to retain clients can be used in groups that have a few veteran members. When new members join, the old members are asked to predict which new member will be the first to drop out. This prediction paradoxically increases the probability that it will not be fulfilled (Yalom 1995).
To achieve maximum involvement in group therapy during this period, motivational techniques may be used.
Researchers note that these simple initiatives, which make so much difference in continuing care engagement, and the outcomes of treatment, “required minimal clinical and clerical time to conduct” (Lash and Blosser 1999, p. 58). However, while automated phone reminders might be useful for highly structured skills-building groups early in recovery or for groups of low-functioning clients, in interpersonal process groups with higher functioning clients, the prompts might set up norms that place too much responsibility on the leader and too little on group members.
Practical problems, such as a lack of suitable childcare or transportation, deter many clients from participation in substance abuse counseling services. Many programs find that when they provide wraparound services to meet these and other practical needs, they retain clients in therapy longer. As a result, clients are more likely to develop new behaviors and thought processes that enable them to remain abstinent. Two examples of programs that provide such services are described in Figures 4-2 and 4-3.
The Family Care Program of the Duke Addictions Program.
SageWind.
The first step toward wraparound services is to document the need for them. The next step is to recognize that wraparound services seldom flourish in isolation. A thorough search of existing community resources may identify services already in place that could meet some needs. Services still needed can be provided by initiating cooperative ventures with organizations that have similar interests and complementary capabilities. Note all the cooperation between and among organizations described in Figures 4-2 and 4-3.
A group agreement establishes the expectations that group members have of each other, the leader, and the group itself. For example, many leaders require that group members entering long-term fixed membership groups commit to remain in the group for a set period. Another common provision of group contracts stipulates that sessions will start and end at specific times. The leader should make sure that these time boundaries are observed, both by clients and the leader. Group members cannot be expected to abide by the group agreement if the leader does not.
It is important to present the contract in a way that causes clients to view it as a true commitment and not a mere formality.
A group member's acceptance of the contract before entering a group has been described as the single most important factor contributing to the success of outpatient therapy groups (Flores 1997). Consequently, it is important to present the contract in a way that causes clients to view it as a true commitment and not a mere formality. Particularly with people referred to treatment through the criminal justice system, it is important to make therapeutic contracts that are explicit and clear, and that carry a firm expectation that the agreement is to be honored by all members of the group.
To reinforce the importance of the agreement as the basis for group activities, group members can be asked to recall specific agreements during the first session. To an appropriate response, the leader can reply, “Yes, that's an important one.” Responses that are distorted may be referred to the group to determine how others recall the agreement (Vannicelli 1992).
The agreement provides for “a mutual understanding of the common task and the conditions under which it will be pursued. It is through the contract that the leader derives his authority to work: to propose activities, to confront a member, to make interpretations. And it is by virtue of the contract that certain other activities can be declared ‘out of bounds’ by either leader or member” (Singer et al. 1975, p. 147).
Sometimes, obtaining compliance to the group agreement requires flexibility and ingenuity. In some cultures, for example, time is a process, not a concept represented by a number. Of course, it remains important to maintain time boundaries. However, when many group members share a culture or ethnicity with a markedly relaxed attitude toward time, it may be appropriate to design and adhere to a structure appropriate for that group. For example, SageWind accommodates its Hispanic/Latino clients' flexible view of time and traditions of sociability. One model moves clients from a shared lunch to group. By the time group starts, all its members have arrived and are ready to begin group work. Another tactic is to schedule longer group times that enable members to move into group work from a socializing phase, usually including rituals of food or music.
The group agreement is intended to inspire clients to accept the basic rules and premises of the group and to increase their determination and ability to succeed. These agreements are not meant to provide a basis for excluding or punishing anyone. On the contrary, the leader should understand that few group members are able to meet all stipulations in the agreement throughout their recovery. When provisions of the group agreement are violated, the leader should avoid assuming an authoritarian role and instead ask questions that refer infractions to the group. The violation becomes important and useful material for group members to discuss as part of the group process. The errant behavior should be understood as a meaningful deviation and approached with interest and curiosity, not with an air of reproach. See Figures 4-4 and 4-5 (see p. 71) for examples of group agreement stipulations.
Examples of Agreements About Time and Attendance.
Examples of Agreements About Group Participation.
The terms under which clients will be excluded from the group should be made explicit in the group agreement, so exclusion does not come as a surprise. Some stipulations in the group agreement might have to incorporate legal requirements since court-mandated treatment groups may have attendance criteria set by the State. If so, the State will set forth the consequences for failure to attend the requisite number of sessions.
Group members should be asked not to discuss anything outside the group that could reveal the identity of other members. The leader should emphasize that confidentiality is critical and should strongly encourage group members to honor their pledge of confidentiality. The principle that “what is said in the group stays in the group” is a way of delineating group boundaries and increasing trust in the group. This atmosphere of trust is essential for group members to feel safe enough to disclose their feelings and problems.
Though group members are precluded from identifying other members of the group or discussing anything they say, members can discuss the themes of the group and what they personally have said. In fact, talking about the group with a significant other or therapist in a way that does not violate the confidentiality of others can be important to a client's growth.
Under some circumstances, as defined by the Federal confidentiality regulation or by more stringent State regulation, certain information may be shared. However, the information shared without consent is restricted by the minimum necessary clause. Refer to 42 C.F.R., Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records to identify the specific circumstances under which these exceptions apply. Group members should know what information about them might be shared and why, how, and when this sharing occurs, so they do not feel betrayed when someone outside the group knows about something said within the group.
Group leaders need to be familiar with confidentiality requirements in their programs and their States.
Except in situations specified in Federal law, programs may not disclose information about the services a client receives without the client's written consent. The law is explained in detail in Confidentiality of Patient Records for Alcohol and Other Drug Treatment (Lopez 1994).
The leader should emphasize how to structure consent and disclosure, especially through discussion of the minimum necessary principle. Only specific information can be disclosed. Legal requirements commonly require, for example, that the therapist report instances of elder or child abuse and take action when clients threaten to harm themselves or others. Actions might include the hospitalization of the prospective perpetrator and/or a warning to the intended victim. Group leaders need to be familiar with confidentiality requirements in their programs and their States. See chapter 6 for a discussion of confidentiality.
Touch in a group is never neutral. People have different personal histories and cultural backgrounds that lead to different interpretations of what touch means. Consequently, the leader should evaluate carefully any circumstance in which physical contact occurs, even when it is intended to be positive. In most groups, touch (handholding or hugs) as part of group rituals is not recommended, though in others (such as an expressive therapy or dance group), touch may be acceptable and normative. Naturally, group agreements always should include a clause prohibiting physical violence.
Some programs, especially ones connected to the judicial system, have policies that require expulsion of group members who are using drugs of abuse. Counselors are required to report these violations. Part of client preparation and orientation is to explain all legally mandated provisions and consequences for failure to comply with group and treatment guidelines.
Many in the substance abuse treatment field believe that such rules lead to withholding of information (Vannicelli 1992). They reason that clients cannot be open and honest about substance use if their candor is punished. A reasonable requirement, many believe, is that clients “must be in an appropriate condition to participate in order to be at the group. This allows the therapist to make a clinical judgment on a case-by-case basis, as to whether or not a client who has slipped may benefit from being in the group that night” (Vannicelli 1992, pp. 59–60). Members also should pledge to discuss a return to use promptly after it occurs (providing that group rules permit and encourage such disclosures).
Generally speaking, the group agreement should discourage personal contact outside the group. The reality is, however, that clients who have bonded in group are likely to communicate outside the group and may encounter each other on occasions like AA meetings. Under some circumstances, it may even be desirable to encourage individuals who support each other's efforts to abstain from substance abuse. The group members need to be told and reminded that new intimate relationships are hazardous to early recovery and are therefore discouraged. Further, any contacts outside the group should be discussed openly in the group.
The group agreement should specify what group members are expected to divulge. For example, group members should be willing to discuss, in an honest way, the issues that brought them to the group. Instructions to participants should emphasize that they are responsible for maintaining their personal boundaries, and they should participate at the pace and level they find comfortable. They should not be required to share personal information until they feel safe enough to do so.
In the group agreement, members agree to pay their bills at a specified time. The agreement also may specify (1) a commitment to discuss any problems that occur in making payments (Vannicelli 1992) and (2) the circumstances under which a group member will be held responsible for payments. For example, group members should know ahead of time that they will be financially responsible for missed sessions if that is the agency policy.
Group agreements should specify how group members should handle termination or occasions when they are considering termination. Sometimes, a group member close to an emotionally charged issue may decide to terminate rather than to confront the uncomfortable feelings. Because group members often are tempted to leave the group prematurely instead of working toward the necessary changes in their lives, the agreement should emphasize the need to involve the group in termination decisions. Ultimately, however, the group members should make their own choice about discontinuing treatment.
Premature termination (dropping out) may have serious consequences for some clients.
Premature termination (dropping out) may have serious consequences for some clients. Court-referred clients (those on parole, probation, and so on) must be reported if they drop out of treatment. The group agreement should clearly state all requirements for reporting and all consequences established by the referring agency. Members of the group should all clearly understand what behaviors might lead to a premature termination.
Every group has a beginning, middle, and end. These phases occur at different times for different types of groups. One or two sessions of a particular revolving membership group may cover all three stages of group therapy for a particular client, while for a long-term fixed membership group, several sessions may be only part of the beginning phase. Whatever the type or length of a group, the group leader is responsible for attending to certain key elements at each of these points. (Note that this discussion focuses on phases of group development, not phases of treatment.)
During the beginning phase of group therapy, issues arise around topics such as orientation, beginners' anxiety, and the role of the leader. The purpose of the group is articulated, working conditions of the group are established, members are introduced, a positive tone is set for the group, and group work begins. This phase may last from 10 minutes to a number of months. In a revolving group, this orientation will happen each time a new member joins the group.
Even in short-term revolving membership groups, it is important for the leader to connect with each member. This joining can be as simple as a friendly smile and a one-word welcome. At this time, all members, at the very least, should have an opportunity to give their names and say something about themselves. Some leaders ask members to introduce themselves. Others let the group figure out how to get acquainted. One cautionary note, however, is that many clients treated for substance abuse also have histories of emotional and physical abuse. Merely directing attention toward them can trigger feelings of shame. Thus, while it is extremely important to make connections between and among group members and to involve them in the process, the sensitive leader will not insist on recitations. Emotional safety always should be foremost in the group leader's mind.
At the first meeting of a fixed membership group, group members also may be asked if they know anyone else in the group. If there are connections that might cause difficulties, they will be discovered at the start.
Each new member who joins the group is entering the beginning phase of the group—for that individual. It is not easy to find one's place in an already established group. The leader can help build bridges between old and new members by pointing out that it is difficult to be the new member and by encouraging old members to help the new one join the group. In long-term fixed membership groups, the group will require careful preparation to receive a new member graciously. Even in revolving membership groups, which provide less opportunity for preparation, the leader should let members know when to expect membership changes, introduce new members, and help build bridges—for example, by inviting existing members to say something about the group and how it works.
Ideally, membership changes should be held to a minimum, especially in fixed membership groups, though as members graduate, new members will need to enter to ensure survival of the group. In contrast, revolving membership groups may have frequent changes because of the demands of treatment payment guidelines or admission and discharge procedures. Careful thought should be given to the pace and timing of membership changes for particular group types.
The group agreement should be reviewed in an interactive way, involving the group members in discussion of the terms. The group leader should ask members if they are aware of concerns that might require additional group agreement provisions to make the group a safe place to share and grow. Group members should have an opportunity to suggest and discuss further stipulations. In addition, the group agreement should be reviewed periodically.
Ideally, membership changes should be held to a minimum, especially in fixed membership groups.
During the beginning phase of the group, all members should feel that they have a part to play in the group and have something in common with other members. This cohesion, both among clients and between the clients and the group leader, will affect the productivity of work throughout the therapeutic process. Among the many components of group cohesion are “connectedness of the group demonstrated by working toward a common therapeutic goal; acceptance, support, and identification with the group; affiliation, acceptance, and attractiveness of the group; and engagement” (Marziali et al. 1997, p. 476).
In the beginning phase, the leader ordinarily needs to be more supportive and active than will be necessary once the group gets underway. If particular members have spoken very little, it helps to let them know that their contributions are welcome. The leader might say something like, “We haven't heard much from you tonight, Jane, but perhaps next week the group will have a chance to get to know you a little bit more” (Vannicelli 1992, p. 48).
To help group members bond with each other, the leader should encourage the connections members begin to make on their own and should point out similarities. The leader might say, for instance, “It seems that Sue and Bob, and perhaps others in here as well, are struggling with very similar problems with their anger” (Vannicelli 1992, pp. 48–49).
The leader also is responsible for ensuring that early in the group, emotional expression stays at a manageable level. Otherwise, members quickly may feel emotionally overloaded and begin to withdraw. Care always should be taken not to shame group members or to allow others in the group to engage in shaming behaviors.
The leader also should bear in mind that in the beginning phase, the group is unable to withstand much conflict. Before the group develops trust and cohesion, conflict is likely to disrupt proceedings or even to threaten a group's existence, so it is unwise to permit confrontation. Instead the group leader should encourage interaction that minimizes aggression and hostility. Later, when the group is more stable, group members may be urged to risk more provocative positions (Flores 1997).
It is up to the leader to make sure that healthy group norms are established and that counterproductive norms are precluded, ignored, or extinguished. The leader shapes norms not only through responses to events in the group, but also by modeling the behavior expected of others. For example, norms to be encouraged in a process group include honesty, spontaneity, a high level of attentive involvement, appropriate self-disclosure, the desire for insight into one's own behavior, nonjudgmental acceptance of others, and the determination to change unhealthy practices (Flores 1997). Unhealthy norms that could hamper a process group include a tendency to become leader-centered, one-dimensional (that is, all-loving or all-attacking), or so tightly knit that the group is hostile to new members (Flores 1997). The leader should respond quickly and clearly to habits that impede group work and that threaten to become normative.
The leader facilitates the work of the group, whether by providing information in a psychoeducational group or by encouraging honest exchanges among members in other types of groups. Most leaders strive to keep the focus on the here and now as much as possible. The leader also may need to prompt a new group with questions such as, “You seem to be responding to what Jane was sharing. Can you tell us something about what was going on for you as she was talking?” (Vannicelli 1992, p. 50).
Termination is a particularly important opportunity for members to honor the work they have done.
The group in its middle phase encounters and accomplishes most of the actual work of therapy. During this phase, the leader balances content, which is the information and feelings overtly expressed in the group, and process, which is how members interact in the group. The therapy is in both the content and process. Both contribute to the connections between and among group members, and it is those connections that are therapeutic.
Many new leaders focus strongly on content, but thoughtful attention to group process is extremely important. Even in an educational group, tension in the room, rolling eyes, or side conversations can interfere with messages that need attention. In a process group, these cues are part of the work and need to be explored actively, but even in more content-oriented groups, nonverbal cues are indicative and should not be ignored.
The group, then, is a forum where clients interact with others. In this give and take of therapy, clients receive feedback that helps them rethink their behaviors and move toward productive changes. The leader helps group members by allocating time to address the issues that arise, by paying attention to relations among group members, and by modeling a healthy interactional style that combines honesty with compassion. Figure 4-6 (p. 74) suggests some ways in which a group leader can help the group accomplish its middle-phase tasks.
Reminders for Each Group Session.
Termination is a particularly important opportunity for members to honor the work they have done, to grieve the loss of associations and friendships, and to look forward to a positive future. Group members should learn and practice saying “good-bye,” understanding that it is necessary to make room in their lives for the next “hello.”
“Termination,” Yalom (1995, pp. 361–362) observes, “is more than the end of therapy; it is … an important force in the process of change … a stage in the individual's career of growth.” The group begins this work of termination when the group as a whole reaches its agreed-upon termination point or a member determines that it is time to leave the group. In either case, termination is a time for
Putting closure on the experience
Examining the impact of the group on each person
Acknowledging the feelings triggered by departure
Giving and receiving feedback about the group experience and each member's role in it
Completing any unfinished business
Exploring ways to carry on the learning the group has offered
Departing clients have been classified into three groups. Completers have finished the work they came into group to do. Plateauers are not really finished, but their progress has slowed or stopped for the time being. Fleers feel an irresistible need to escape as rapidly as possible, often because they have encountered an upsetting reality in the group or in their lives outside the group (Vannicelli 1992).
The group may be invited to explore the proposal that a member leave the group. In addition, the leader might ask clients about to terminate to classify themselves as completers, plateauers, or fleers. If the client is a fleer, that person might be asked a hypothetical question: If you remained in group, what do you think you might work on? Such a query might bring to light the issue the fleer wants very much to avoid. To dissuade a person departing prematurely, it may also help to comment, “One of the characteristics of a good decision is that it remains a good decision even after consideration a few weeks later” (Vannicelli 1992, p. 179). Then ask the client if, by that standard, his decision to leave will be a good one.
Whatever attempts are made to dissuade premature termination, some people with substance abuse problems inevitably will leave groups abruptly, for a variety of reasons. Groups should be forewarned that sudden changes may take place, and leaders should be prepared to help group members cope with these changes.
Completing a group successfully can be an important event for group members, when they see the conclusion of a difficult but successful endeavor (Flores 1997). The termination of a group also is an opportunity for clients to practice parting, with the understanding that a departure leads to the next opportunity for connection.
Even positive, celebrated departures, however, can raise strong feelings, so soon-to-depart members of an ongoing group should give ample advance notice (perhaps 4 weeks) to give the group time to process the feelings associated with the leave-taking (Flores 1997). Group members should be given permission to examine existential issues like loss, growth, death, the shortness of time, the unfairness of life, and other thoughts that can prey on the mind (Yalom 1995). So often, clients who used drugs or alcohol to anesthetize their grief over losses come to confront their grief in early sobriety. Every group facilitator working with substance abuse therefore should understand the grief process and should be prepared to deal with grieving clients.
It is natural for individuals and groups to try to hold onto each other. “Some isolated patients may postpone termination because they have been using the therapy group for social reasons rather than as a means for developing the skills to create a social life for themselves in their home environment. The therapist should help these members focus on transfer of learning and encourage risk taking outside the group” (Yalom 1995, p. 363). Alternatively, groups (and therapists) may subtly pressure a particular group member to remain because they value the departing member's contributions and will miss him or her. When a senior member leaves, however, another ordinarily will assume the role just vacated (Yalom 1995).
In general, the longer members have been with the group, the longer they may need to spend on termination.
Some client feelings may concern parting from the therapist. Some clients who are exquisitely sensitive to abandonment, for example, may deny the gains they have made. They need reassurance that, once they improve, they no longer will need the therapist.
In other reluctant clients, symptoms may recur. These people need help seeing the apparent setback for what it really is: fear of termination (Yalom 1995).
Under no circumstances should the therapist “collude in the denial of termination” (Yalom 1995, p. 365). The client has to come to grips with the reality of leaving and not routinely 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).
In general, the longer members have been with the group, the longer they may need to spend on termination. The group leader plays an important role in termination, either facilitating an individual's good-bye to the group or the group's good-bye to itself (if the group is ending). Although group leaders cannot say good-bye for the group, they can encourage the group to fashion its own farewell.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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