Interventions may be directed to an individual or the group as a whole. They can be used to clarify what is going on or to make it more explicit, redirect energy, stop a process that is not helpful, or help the group make a choice about what should be done. A well-timed, appropriate intervention has the power to•
Help a client recognize blocks to connection with other people•
Discover connections between the use of substances and inner thoughts and feelings•
Understand attempts to regulate feeling states and relationships•
Build coping skills•
Perceive the effect of substance abuse on one's life•
Notice meaningful inconsistencies among thoughts, feelings, and behavior•
Perceive discrepancies between stated goals and what is actually being done
Any verbal intervention may carry important nonverbal elements. For example, different people would ascribe a variety of meanings to the words, “I am afraid that you have used again,” and the interpretation will vary further with the speaker's tone of voice and body language. Leaders should therefore be careful to avoid conveying an observation in a tone of voice that could create a barrier to understanding or response in the mind of the listener.
Generally a counselor leads several kinds of groups. Leadership duties may include a psychoeducational group, in which a leader usually takes charge and teaches content, and then a process group, in which the leader's role and responsibilities should shift dramatically. A process group that remains leader-focused limits the potential for learning and growth, yet all too often, interventions place the leader at the center of the group. For example, a common sight in a leader-centered group is a series of one-on-one interactions between the leader and individual group members. These sequential interventions do not use the full power of the group to support experiential change, and especially to build authentic, supportive interpersonal relationships. Some ways for a leader to move away from center stage:•
In addition to using one's own skills, build skills in participants. Avoid doing for the group what it can do for itself.•
Encourage the group to learn the skills necessary to support and encourage one another because too much or too frequent support from the clinician can lead to approval seeking, which blocks growth and independence. Supporting each other, of course, is a skill that should develop through group phases. Thus, in earlier phases of treatment, the leader may need to model ways of communicating support. Later, if a client is experiencing loss and grief, for example, the leader does not rush in to assure the client that all will soon be well. Instead, the leader would invite group members to empathize with each other's struggles, saying something like, “Joanne, my guess is at least six other people here are experts on this type of feeling. What does this bring up for others here?”•
Refrain from taking on the responsibility to repair anything in the life of the clients. To a certain extent, they should be allowed to struggle with what is facing them. It would be appropriate, however, for the leader to access resources that will help clients resolve problems.
Confrontation is one form of intervention. In the past, therapists have used confrontation aggressively to challenge clients' defenses of their substance abuse and related untoward behaviors. In recent years, however, clinicians have come to recognize that when “confrontation” is equivalent to “attack,” it can have an adverse effect on the therapeutic alliance and process, ultimately leading to failure. Trying to force the client to share the clinician's view of a situation accomplishes no therapeutic purpose and can get in the way of the work.
A more useful way to think about confrontation is “pointing out inconsistencies,” such as disconnects between behaviors and stated goals. William R. Miller explains:
Confrontation in this light is a part of the change process, and therefore part of the helping process. Its purpose is to help clients see and accept reality so they can change accordingly (Miller and Rollnick 1991). With this broader understanding of what interventions that “confront” the client really mean, it is not useful to divide therapy into “supportive” and “confrontative” categories.
Transference means that people project parts of important relationships from the past into relationships in the present. For example, Heather may find that Juan reminds her of her judgmental father. When Juan voices his suspicion that she has been drinking, Heather feels the same feelings she felt when her father criticized all her supposed failings. Within the microcosm of the group, this type of incident not only relates the here-and-now to the past, but also offers Heather an opportunity to learn a different, more self-respecting way of responding to a remark that she perceives as criticism.
The emotion inherent in groups is not limited to clients. The groups inevitably stir up strong feelings in leaders. The therapist's emotional response to a group member's transference is referred to as countertransference. Vannicelli (2001) describes three forms of countertransference:•
Feelings of having been there. Leaders with family or personal histories with substance abuse have a treasure in their extraordinary ability to empathize with clients who abuse substances. If that empathy is not adequately understood and controlled, however, it can become a problem, particularly if the therapist tries to act as a role model or sponsor, or discloses too much personal information.•
Feelings of helplessness when the therapist is more invested in the treatment than the client is. Treating highly resistant populations, such as clients referred to treatment by the courts, can cause leaders to feel powerless, demoralized, or even angry. The best way to deal with this type of countertransference may be to use the energy of the resistance to fuel the session. (See “Resistance in Group,” next section.)•
Feelings of incompetence due to unfamiliarity with culture and jargon. It is helpful for leaders to be familiar with 12-Step programs, cultures, and languages. If a group member uses unfamiliar terms, however, the leader should ask the client to explain what the term means to that person, using a question like, “‘Letting go’ means something a bit different to each person. Can you say a little more about how this relates to your situation?” (Vannicelli 2001, p. 58).
When countertransference occurs, the clinician needs to bring all feelings associated with it to awareness and manage them appropriately. Good supervision can be really helpful. Countertransference is not bad. It is inevitable, and with the help of supervision, the group leader can use countertransference to support the group process (Vannicelli 2001).
Resistance arises as an often unconscious defense to protect the client from the pain of self-examination. These processes within the client or group impede the open expression of thoughts and feelings, or block the progress of an individual or group. The effective leader will neither ignore resistance nor attempt to override it. Instead, the leader helps the individual and group understand what is getting in the way, welcoming the resistance as an opportunity to understand something important going on for the client or the group. Further, resistance may be viewed as energy that can be harnessed and used in a variety of ways, once the therapist has helped the client and group understand what is happening and what the resistant person or persons actually want (Vannicelli 2001).
In groups that are mandated to enter treatment, members often have little interest in being present, so strong resistance is to be expected. Even this resistance, however, can be incorporated into treatment. For example, the leader may invite the group members to talk about the difficulties experienced in coming to the session or to express their outrage at having been required to come. The leader can respond to this anger by saying, “I am impressed by how open people have been in sharing their feelings this evening and in being so forthcoming about really speaking up. My hope is that people will continue to be able to talk in this open way to make our time together as useful as possible” (Vannicelli 2001, p. 55).
Leaders should recognize that clients are not always aware that their reasons for nonattendance or lateness may be resistance. The most helpful attitude on the clinician's part is curiosity and an interest in exploring what is happening and what can be learned from it. Leaders need not battle resistance. It is not the enemy. Indeed, it is usually the necessary precursor to change.
It would be a serious mistake, however, to imagine that resistance always melts away once someone calls attention to it. “Resistance is always there for a reason, and the group members should not be expected to give it up until the emotional forces held in check by it are sufficiently discharged or converted, so that they are no longer a danger to the safety of the group or its members” (Flores 1997, p. 538).
When a group (rather than an individual) is resistant, the leader may have contributed to the creation of this phenomenon and efforts need to be made to understand the leader's role in the problem. Sometimes, “resistance can be induced by leaders who are passive, hostile, ineffective, guarded, weak, or in need of constant admiration and excessive friendliness” (Flores 1997, p. 538).
For the group leader, strict adherence to confidentiality regulations builds trust. If the bounds of confidentiality are broken, grave legal and personal consequences may result. All group leaders should be thoroughly familiar with Federal laws on confidentiality (42 C.F.R. Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records; see Figure 6-2) and relevant agency policies. Confidentiality is recognized as “a central tenet of the practice of psychotherapy” (Parker et al. 1997, p. 157), yet a vast majority of States either have vague statutes dealing with confidentiality in group therapy or have no statutes at all. Even where a privilege of confidentiality does exist in law, enforcement of the law that protects it is often difficult (Parker et al. 1997). Clinicians should be aware of this legal problem and should warn clients that what they say in group may not be kept strictly confidential. Some studies indicate that a significant number of therapists do not advise group members that confidentiality has limits (Parker et al. 1997).
One set of confidentiality issues has to do with the use of personal information in a group session. Group leaders have many sources of information on a client, including the names of the client's employer and spouse, as well as any ties to the court system. A group leader should be clear about how information from these sources may and may not be used in group.
Clinicians consider the bounds of confidentiality as existing around the treatment enterprise, not around a particular treatment group. Clients should know that everyone on the treatment team has access to relevant information. In addition, clinicians should make it clear to clients that confidentiality cannot be used to conceal continued substance abuse, and the therapist will not be drawn into colluding with the client to hide substance use infractions. Clinicians also should advise clients of the exact circumstances under which therapists are legally required to break confidentiality (see Figure 6-2).
A second set of confidentiality issues has to do with the group leader's relationships with clients and clients with one another. When counseling a client in both individual therapy and a group context, for example, the leader should know exactly how information learned in individual therapy may be used in the group context. In almost every case, it is more beneficial for the client to divulge such information than for the clinician to reveal it. In an individual session, the therapist and the client can plan how the issue will be brought up in group. This preparation gives clients ample time to decide what to say and what they want from the group. The therapist can prompt clients to share information in the group with a comment like, “I wonder if the group understands what a hard time you've been having over the last 2 weeks?” On the other hand, therapists should reserve the right to determine what information will be discussed in group. A leader may say firmly, “Understand that whatever you tell me may or may not be introduced in group. I will not keep important information from the group, if I feel that withholding the information will impede your progress or interfere with your recovery.“
Still other confidentiality issues arise when clients discuss information from the group beyond its bounds. Violations of confidentiality among members should be managed in the same way as other boundary violations; that is, empathic joining with those involved followed by a factual reiteration of the agreement that has been broken and an invitation to group members to discuss their perceptions and feelings. In some cases, when this boundary is violated, the group may feel a need for additional clarification or addenda to the group agreement. The leader may ask, both at the beginning of the group or when issues arise, whether the group feels it needs additional agreements in order to work safely. Such amendments, however, should not seek to renegotiate the terms of the original group agreement. See Figure 6-2 (see p. 110) for helpful information on confidentiality and the law.
Because a group facilitator generally is part of the larger substance abuse treatment program, it is recommended that the group facilitator take a practical approach to exceptions. This practical approach is to have the group facilitator discuss the potential application of the exceptions with the program director or member of the program staff who is the lead on the confidentiality regulation.
Substance use disorders include a wide range of symptoms with different levels of associated disability. Clients always bring into treatment vulnerabilities other than their alcohol or illicit drug dependencies. Group interventions may be needed to resolve psychological problems, physical ailments, social stresses, and perhaps, spiritual emptiness or bankruptcy. In short, successful treatment for substance use disorders should address the whole person, including that person's spiritual growth.
While the group experience is a powerful tool in the treatment of substance use disorders, it is not the only tool. Other interventions, such as individual therapy, psychological interventions, pharmacological supports, and intensive case management, may all be necessary to achieve long-term remission from the symptoms of addictive disorders.
For example, people who are homeless with a co-occurring mental disorder have three complicated sets of problems that require a continuous and comprehensive care system—one that integrates or coordinates interventions in (1) the mental health system, (2) the addiction system, and (3) the social service system for homeless persons. In group therapy, each condition should be regarded as a primary interactive problem; that is, one in which each problem develops independently but contributes to both of the others (Minkoff and Drake 1992).
One model offered for treating homeless persons with substance use disorder is a modified training group designed to accommodate a large number of members whenever a traditional small group is not possible. In this model, participants meet in a large group with the clinician and then break into smaller groups to discuss, practice, or role-play the particular topic.
Each group has a client leader, and the clinician circulates among the groups to ensure that the topic is understood and that discussion is proceeding. The clinician does not participate in the groups. Researchers describing this model note that because the clinicians step back from assuming leadership roles in the groups, the clients become empowered to take group sessions in the necessary direction and demonstrate feelings and insights that might not occur in a group formally led by a clinician (Goldberg and Simpson 1995).
It is well known that 12-Step programs are an important part of many therapeutic programs (Page and Berkow 1998). While 12-Step programs have a proven record of success in helping people overcome substance use disorders, there is a basic conflict inherent in them that group therapists need to reconcile. In the 12-Step program, people are urged to cede control to a higher power. Yet, in group, the clinician is prompting clients to take control of their emotions, behavior, and lives.
As a result, some researchers have stated that it is “impossible to integrate psychotherapy and AA approaches dealing with addictions without compromising one approach or the other” (Page and Berkow 1998, pp. 1–2). Another researcher has argued that “the AA approach is consistent with existential philosophy” because both stress that people should accept their “human limitations and security-seeking behaviors” (Page and Berkow 1998, p. 2). Although the literature currently has few straightforward discussions of spirituality and its role in the dynamics of group therapy, most clinicians would agree that the spiritual well-being of the client is essential to breaking free of substance abuse.
When clients join self-help groups, they sometimes hear from individuals who strongly oppose the use of any medication. Some people in 12-Step programs erroneously believe, for example, that the use of pharmacological adjuncts to therapy is a violation of the program's principles. They consequently oppose methadone maintenance, the use of Antabuse, or the use of medications needed to control co-occurring disorders.
Clinicians should be prepared to handle these misapprehensions. One way to help would be to refer apprehensive clients to the pamphlet, The AA Member—Medications and Other Drugs: A Report from a Group of Physicians in AA (Alcoholics Anonymous World Services 1984). It stresses the value of appropriate medication prescribed by a physician who understands addictive disorders and reassures clients that such use of medication is wholly consistent with AA and Narcotics Anonymous' 12-Step programs.
Many clients enrolled in a process group for persons with substance use disorders are likely participating in a 12-Step program or other self-help groups as well. On occasion, apparently conflicting messages can be an issue. For instance, many people with addiction histories try to use AA and its jargon as material for resistance. Such problems can readily be managed, provided the therapist is thoroughly familiar with the self-help group. Matano and Yalom (1991) strongly recommend that group leaders become thoroughly familiar with AA's language, steps, and traditions because misconceptions about the program, whether by the client or therapist, can raise barriers to recovery.
Recent research has clearly demonstrated the ability of self-help groups to improve outcomes (Tonigan et al. 1996). Research also has shown that clients receiving mental health services as well as participating in 12-Step meetings have an even better prognosis (Ouimette et al. 1998). Marilyn Freimuth's research on integrating group psychotherapy and 12-Step work has shown that “if mere co-participation in psychotherapy and 12-Step groups supports a client's recovery, it is reasonable to expect that a more integrated approach will provide further benefits” (Freimuth 2000, p. 298). Both activities “support abstinence and emotional growth” (Freimuth 2000, p. 301). Together, the two modalities supply multiple relationship models, potentially of immense value to the client.
Some suggestions for maximizing the therapeutic potential of participation in both process and 12-Step groups follow:
Orientation should prepare new group members who are also members of 12-Step groups for differences in the two groups. A key difference will be the fact that members interact with each other. Such “cross talk” is discouraged at 12-Step meetings. “The new psychotherapy group member may need to be told that the topic of conversation is much wider than the 12-Step meeting's focus on addiction and recovery, and that it includes feelings and reactions toward other group members” (Freimuth 2000, p. 300; see also Vannicelli 1992).
During early recovery, it is particularly important to avoid making the 12-Step program's encouragement of “unquestioning acceptance” a focus of analysis in group therapy. Too critical an interpretation offered too early may disrupt the 12-Step program's status as an “ideal object,” belief in which “is critical to maintaining early abstinence” (Dodes 1988; Freimuth 2000, p. 305).
Sometimes clients experience “splitting”—seeing “the [12-Step] program as the all-good parent and all others, including the therapist/group as the all-bad/ambivalent object.” Later, the split may be just the opposite (Freimuth 2000). The group leader should be attuned to this potential and should be prepared to work through these perceptions and the feelings underlying them. Further, when the process group is perceived as the “less than” modality and the client enthusiastically quotes insights from a 12-Step group, the therapist should watch for possible countertransference and bear in mind the benefits the client is receiving from both programs.
Sponsors of 12-Step members may distrust therapy and discourage group member from continuing in treatment. The leader should be prepared to respond to a variety of potential issues in ways that avoid appearing to compete with the self-help group. For example, if a client says, “In my AA group, they say I don't need to be here. As long as I'm not drinking, my life is fine.” The therapist might acknowledge the importance of continued sobriety, but remind the client of depression experienced before the onset of heavy drinking.
Group leaders should beware of their possible biases against 12-Step groups that may be based on inaccurate information. For example, it is not true that the 12-Step philosophy opposes therapy and medication, as AA World Service pamphlets clarify. It also is a misconception that 12-Step programs encourage people to abdicate responsibility for substance use. AA, however, does urge people with addiction problems to attend meetings in the early stages of recovery, even though they may still be using alcohol or illicit drugs. Finally, some clinicians believe that 12-Step programs discourage strong negative emotions. On the contrary, “there is no unilateral discouragement of negative affects within [12-Step] program philosophy; only when anger threatens sobriety is it considered necessary to circumvent negative feelings” (Freimuth 2000, p. 308).
The following vignette illustrates a typical intervention intended to clarify and harmonize appropriate participation in 12-Step and process groups:
No matter what the modality, however, group therapy is sure to remain an integral part of substance abuse treatment.
Substance abuse affects every aspect of life: home, family, friends, job, health, emotional well-being, and beliefs. As clients move into recovery, the wide range of issues they should face may overwhelm them. Leaders need to help clients rank the importance of the challenges, taking care to make the best possible use of the resources the client and the leader can bring to bear.
Naturally, clients will vary in their ability to address many concerns simultaneously; capacity for change also is variable. For example, some individuals with cognitive impairments will have a much harder time than others engaging in a change process. In the early stage of treatment, such clients need simple ideas, structures, and principles.
As the client moves forward, the clinician can keep in mind the issues that a client is not ready or able to manage. As this process goes on, the leader should remember that the client's priorities matter more than what the leader thinks ought to come next. Unless both client and leader operate in the same motivational framework the leader will not be able to help the client make progress.
No matter what is missing—even if it is a roof over the client's head—it is possible to engage the client in treatment. A client never should be told to come back after problems other than substance abuse have been resolved. On some front, constructive work can always be done. Of course, this assertion does not mean that critical needs can be ignored until treatment for substance abuse is well underway. The therapist should recognize that a client preoccupied with the need to find a place to sleep will not be able to engage fully in treatment until urgent, practical needs are met.
Life issues facing the client provide two powerful points of therapeutic leverage that leaders can use to motivate the client to pursue recovery. First, group leaders should be aware that people with alcoholism and other addictions will not give up their substance use until the pain it brings outweighs the pleasure it produces. Consequently, they should be helped to see the way alcohol and drugs affect important areas of their lives. Second, early in treatment, group leaders should learn what is important to each client that continued substance abuse might jeopardize. For some individuals, it is their job. For others, it is their spouse, health, family, or self-respect. In some cases, it might be the threat of incarceration. Such knowledge can be used to encourage, and even coerce, individuals to utilize the tools of treatment, group, or AA (Flores 1997).
While spirituality and faith may offer to some the hope, nurturing, sense of purpose and meaning, and support needed to move toward recovery, people obviously interpret spiritual matters in diverse ways. It is important not to confuse spirituality with religion. Even if clients are not religious, their spiritual life is important. Some clinicians mistakenly conclude that their own understanding of spirituality will help the client. Other clinicians err in the opposite direction and are overly reluctant to address spiritual beliefs. Actually, a middle ground is preferable. The leader should explore the importance of spiritual life with the group, and if the search for spiritual meaning is important, the clinician can incorporate it into group discussions.
For clients who lack meaningful connection to anything beyond themselves, the group may be the first step toward a search for meaning or a feeling of belonging to something greater than the self. The clinician's role in group therapy simply is to create an environment within which such ego-transcending connections can be experienced.
Professionals within the entire healthcare network need to become more aware of the role of group therapy for people abusing substances. To build the understanding needed to support people in recovery, group leaders should educate others serving this population as often as opportunities arise, such as when clinicians from different sectors of the healthcare system work together on a case. Similar needs for understanding exist with probation officers, families, and primary care physicians.
It is common for a client to be in both individual and group therapy simultaneously. The dual relationship creates both problems and opportunities. Skilled therapists can use what they discover in group about the client's style of relatedness to enhance individual therapy. Conversely, the individual alliance can help the client use the group effectively. So long as the therapist does not collude consciously or unconsciously with the client to keep what is said as a secret between them, most obstacles can be overcome.
In conjoint treatment, that is, a situation in which one therapist sees a client individually while another therapist treats the same client in a group, the therapists should be in close communication with each other. Clinicians should coordinate the treatment plan, keeping important interpersonal issues alive in both settings. The client should know that this collaboration routinely occurs for the client's benefit.
Clinicians need general knowledge of common medications used to assist in recovery, relapse prevention, and co-occurring disorders. Group leaders should be aware of various medication needs of clients, the type of medications prescribed, and potential side effects. Prescribing medication involves striking a balance between therapeutic and detrimental pharmacological effects. For example, benzodiazepines can reduce anxiety, but they can be sedating and might lead to dependency.
The pregroup interview for long-term groups should ask what medications group members are taking and the names of prescribing physicians so cooperative treatment is possible. For example, if a client is awake all night with drug cravings, the therapist might talk with the physician to determine whether appropriate medication could help the client through the difficult period following substance abuse cessation. Therapists should be wary, however. From former days of active substance abuse, clients may have ties to careless physicians who enabled addiction by providing cross-addictive medications. If an evaluation of prescription medications is needed, counselors should refer the client to a consulting physician working with the agency or to a physician knowledgeable about chemical dependency. Attention needs to be paid to medications prescribed for physical illnesses as well. For example, it would be important for the group leader to know that a group member has diabetes and requires medication.
Conflict in group therapy is normal, healthy, and unavoidable. When it occurs, the therapist's task is to make the most of it as a learning opportunity. Conflict can present opportunities for group members to find meaningful connections with each other and within their own lives.
Handling anger, developing empathy for a different viewpoint, managing emotions, and working through disagreements respectfully are all major and worthwhile tasks for recovering clients. The leader's judgment and management are crucial as these tasks are handled. It is just as unhelpful to clients to let the conflict go too far as it is to shut down a conflict before it gets worked through. The therapist must gauge the verbal and nonverbal reactions of every group member to ensure that everyone can manage the emotional level of the conflict.
The clinician also facilitates interactions between members in conflict and calls attention to subtle, sometimes unhealthy patterns. For example, a group may have a member, Mary, who frequently disagrees with others. Group peers regard Mary as a source of conflict, and some of them have even asked Mary (the scapegoat) to leave so that they can get on with group work. In such a situation, the therapist might ask, “Do you think this group would learn more about handling this type of situation if Mary left the group or stayed in the group?” An alternative tack would be, “I think the group members are avoiding a unique opportunity to learn something about yourselves. Giving in to the fantasy of getting rid of Mary would rob each of you of the chance to understand yourself better. It would also prevent you from learning how to deal with people who upset you.”
Conflicts within groups may be overt or covert. The therapist helps the group to label covert conflicts and bring them into the open. The observation that a conflict exists and that the group needs to pay attention to it actually makes group members feel safer. The therapist is not responsible, however, for resolving conflicts. Once the conflict is observed, the decision to explore it further is made based on whether such inquiry would be productive for the group as a whole. In reaching this decision, the therapist should consider the function the conflict is serving for the group. It actually may be the most useful current opportunity for growth in the group.
On the other hand, as Vannicelli (1992) points out, conflicts can be repetitive and predictable. When two members are embroiled in an endless loop of conflict, Vannicelli suggests that the leader may handle the situation by asking, “John, did you know what Sally was likely to say when you said X?” and “Sally, did you know what John was likely to say when you said Y?” “Since both participants are likely to answer, ‘Yes, of course,’ the therapist would then inquire what use it might serve for them to engage in this dialogue when the expected outcome is so apparent to both of them (as well as to other members of the group). This kind of distraction activity or defensive maneuver should come to signal to group members that something important is being avoided. It is the leader's task to help the group figure out what that might be and then to move on” (Vannicelli 1992, p. 121).
Group leaders also should be aware that many conflicts that appear to scapegoat a group member are actually displaced anger that a member feels toward the therapist. When the therapist suspects this kind of situation, the possibility should be forthrightly presented to the group with a comment such as, “I notice, Joe, that you have been upset with Jean quite a bit lately. I also know that you have been a little annoyed with me a since couple weeks ago about the way I handled that phone call from your boss. Do you think some of your anger belongs with me?”
Individual responses to particular conflicts can be complex, and may resonate powerfully according to a client's personal values and beliefs, family, and culture. Therefore, after a conflict, it is important for the group leader to speak privately with group members and see how each is feeling. Leaders also often use the last 5 minutes of a session in which a conflict has occurred to give group members an opportunity to express their concerns.
In any group, subgroups inevitably will form. Individuals always will feel more affinity and more potential for alliance with some members than with others. One key role for the therapist in such cases is to make covert alliances overt. The therapist can involve the group in identifying subgroups by saying, “I notice Jill and Mike are finding they have a good deal in common. Who else is in Jill and Mike's subgroup?”
Subgroups can sometimes provoke anxiety, especially when a therapy group is made up of individuals acquainted before becoming group members. Group members may have used drugs together, slept together, worked together, or experienced residential substance abuse treatment together. Obviously, such connections are potentially disruptive, so when groups are formed, group leaders should consider whether subgroups would exist.
When subgroups somehow stymie full participation in the group, the therapist may be able to reframe what the subgroup is doing. At other times, a change in the room arrangement may be able to reconfigure undesirable combinations. On occasion, however, subtle approaches fail. For instance, adolescents talking among themselves or making obscene gestures during the session should be told factually and firmly that what they are doing is not permissible. The group leader might say, “We can't do our work with distractions going on. Your behavior is disrespectful and it attempts to shame others in the group. I won't tolerate any abuse of members in this group.”
Subgroups are not always negative. The leader for example may intentionally foster a subgroup that helps marginally connected clients move into the life of the group. This gambit might involve a question like, “Juanita, do you think it might help Joe if you talked some about your experience with this issue?” Further, to build helpful connections between group members, a group member might be asked, “Bob, who else in this group do you think might know something about what you've just said?”
When a client talks on and on, he or she may not know what is expected in a therapy group. The group leader might ask the verbose client, “Bob, what are you hoping the group will learn from what you have been sharing?” If Bob's answer is, “Huh, well nothing really,” it might be time to ask more experienced group members to give Bob a sense of how the group works. At other times, clients tend to talk more than their share because they are not sure what else to do. It may come as a relief to have their monolog interrupted (Vannicelli 1992, p. 167).
If group members exhibit no interest in stopping a perpetually filibustering client, it may be appropriate to examine this silent cooperation. The group may be all too willing to allow the talker to ramble on, to avoid examining their own past failed patterns of substance abuse and forge a more productive future. When this motive is suspected, the leader should explore what group members have and have not done to signal the speaker that it is time to yield the floor. It also may be advisable to help the talker find a more effective strategy for being heard and understood (Vannicelli 1992).
Interruptions disrupt the flow of discussion in the group, with frustrating results. The client who interrupts is often someone new to the group and not yet accustomed to its norms and rhythms. The leader may invite the group to comment by saying, “What just happened?” If the group observes, “Jim seemed real anxious to get in right now,” the leader might intervene with, “You know, Jim, my hunch is that you don't know us well enough yet to be certain that the group will pay adequate attention to your issues; thus, at this point, you feel quite a lot of pressure to be heard and understood. My guess is that when other people are speaking you are often so distracted by your worries that it may even be hard to completely follow what is going on” (Vannicelli 1992, p. 170).
Clients who run out of a session often are acting on an impulse that others share. It would be productive in such instances to discuss these feelings with the group and to determine what members can do to talk about these feelings when they arise. The leader should stress the point that no matter what is going on in the group, the therapeutic work requires members to remain in the room and talk about problems instead of attempting to escape them (Vannicelli 1992). If a member is unable to meet this requirement, reevaluation of that person's placement in the group is indicated.
Sometimes, clients are unable to participate in ways consistent with group agreements. They may attend irregularly, come to the group intoxicated, show little or no impulse control, or fail to take medication to control a co-occurring disorder. Though removing someone from the group is very serious and should never be done without careful thought and consultation, it is sometimes necessary. It may be required because of a policy of the institution, because the therapist lacks the skills needed to deal with a particular problem or condition, or because an individual's behavior threatens the group in some significant and insupportable way.
Though groups do debate many issues, the decision to remove an individual is not one the group makes. On the contrary, the leader makes the decision and explains to the group in a clear and forthright manner why the action was taken. Members then are allotted time to work through their responses to what is bound to be a highly charged event. Anger at the group leader for acting without group input or acting too slowly is common in expulsion situations, and should be explored.
Sometimes, addiction counselors view the client who comes to group late as a person who, in some sense, is behaving badly. It is more productive to see this kind of boundary violation as a message to be deciphered. Sometimes this attempt will fail, and the clinician may decide the behavior interferes with the group work too much to be tolerated.
A group member who is silent is conveying a message as clearly as one who speaks. Silent messages should be heard and understood, since nonresponsiveness may provide clues to clients' difficulties in connecting with their own inner lives or with others (Vannicelli 1992).
Special consideration is sometimes necessary for clients who speak English as a second language (ESL). Such clients may be silent, or respond only after a delay, because they need time to translate what has just been said into their first language. Experiences involving strong feelings can be especially hard to translate, so the delay can be longer. Further, when feelings are running high, even fluent ESL speakers may not be able to find the right words to say what they mean or may be unable to understand what another group member is saying about an intense experience.
When the group is in progress and clients seem present in body but not in mind, it helps to tune into them just as they are tuning out. The leader should explore what was happening as an individual became inattentive. Perhaps the person was escaping from specific difficult material or was having more general difficulties connecting with other people. It may be helpful to involve the group in giving feedback to clients whose attention falters. It also is possible, however, that the group as a whole is sidestepping matters that have to do with connectedness. The member who tunes out might be carrying this message for the group (Vannicelli 1992).
Even when group members are disclosing little about themselves, they may be gaining a great deal from the group experience, remaining engaged around issues that others bring up. To encourage a member to share more, however, a leader might introduce the topic of how well members know each other and how well they want to be known. This topic could be explored in terms of percentages. For instance, a man might estimate that group members know about 35 percent about him, and he would eventually like them to know 75 percent. Such a discussion would yield important information about how much individuals wish to be known by others (Vannicelli 1992).
As Vannicelli (1992) notes, sometimes clients avoid opening up because they are afraid they might break down in front of others—a fear particularly common in the initial phases of groups. When this restraint becomes a barrier to clients feeling acute pain, the therapist should help them remember ways that they have handled strong feelings in the past.
For example, if a female client says she might “cry forever” once she begins, the leader might gently inquire, “Did that ever happen?” Clients are often surprised to realize that tears generally do not last very long. The therapist can further assist this client by asking, “How were you able to stop?” (Vannicelli 1992, p. 152).
When a client's fears of breaking down or becoming unable to function may be founded in reality (for example, when a client has recently been hospitalized), the therapist should validate the feelings of fear, and should concentrate on the strength of the person's adaptive abilities (Vannicelli 1992).
Since clients know that the group leader is contractually bound to end the group's work on time, they often wait intentionally until the last few minutes of group to share emotionally charged information. They may reveal something particularly sad or difficult for them to deal with. It is important for the leader to recognize they have deliberately chosen this time to share this information. The timing is the client's way of limiting the group's responses and avoiding an onslaught of interest. All the same, the group members or leader should point out this self-defeating behavior and encourage the client to change it.
Near the end of a session, for example, a group leader has an exchange with a group member named Lan, who has been silent throughout the session:
Leader: Lan, you've been pretty quiet today. I hope we will hear more about what is happening with you next week.
Lan: I don't think you'll see me next week.
Further exploration reveals that Lan intends to kill herself that night. In view of the approaching time boundary, what should the leader do?
In such a situation, the group leader has dual responsibilities. First, the leader should respond to Lan's crisis. Second, the incident should be handled in a way that reassures other group members and preserves the integrity of the group. Group members will have a high level of anxiety about such a situation. Because of their concern, some group leaders are willing to extend the time boundary for that session only, provided that all members are willing and able to stay. Others feel strongly that the time boundary should be maintained and that the leader should pledge to work with Lan individually right after the session. Whatever the decision and subsequent action, the leader should not simply drift casually and quietly over the time boundary. The important message is that boundaries should be honored and that Lan will get the help she needs. The group leader can say explicitly that Lan's needs will be addressed after group.
Figure 6-3 shows that group leaders should be prepared to deal not only with substance abuse issues, but with co-occurring psychiatric concerns as well.
Clients may feel great anxiety after disclosing something important, such as the fact that they are gay or incest victims. Often, they wonder about two possibilities: “Does this mean that I have to keep talking about it? Does this mean that if new people come into the group, I have to tell them too?” (Vannicelli 1992, p. 160).
To the first question, the therapist can respond with the assurance, “People disclose in here when they are ready.” To the second, the member who has made the disclosure can be assured of not having to reiterate the disclosure when new clients enter. Further, the disclosing member is now at a different stage of development, so the group leader could say, “Perhaps the fact that you have opened up the secret a little bit suggests that you are not feeling that it is so important to hide it any more. My guess is that this, itself, will have some bearing on how you conduct yourself with new members who come into the group” (Vannicelli 1992, p. 160 & p. 161).