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Group Therapy
A Treatment
Improvement
Protocol
TIP
41
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Group Therapy
A Treatment
Improvement
Protocol
TIP
41
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments Electronic Access and
This publication was prepared under contract Printed Copies
number 270997072 by the Knowledge
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Application Program (KAP), a Joint Venture of
loaded from SAMHSA’s Publications
The CDM Group, Inc., and JBS International,
Ordering Web page at
Inc., for the Substance Abuse and Mental Health
http://store.samhsa.gov. Or, please call
Services Administration (SAMHSA), U.S.
SAMHSA at 1877SAMHSA7 (1877726
Department of Health and Human Services
4727) (English and Español).
(HHS). Karl D. White, Ed.D., and Andrea
Kopstein, Ph.D., served as the Contracting
Officer’s Representatives.
Recommended Citation
Center for Substance Abuse Treatment.
Disclaimer Substance Abuse Treatment: Group Therapy.
Treatment Improvement Protocol (TIP)
The views, opinions, and content expressed
Series, No. 41. HHS Publication No. (SMA)
herein are those of the consensus panel and
123991. Rockville, MD: Substance Abuse
do not necessarily reflect the views, opinions,
and Mental Health Services Administration,
or policies of SAMHSA or HHS. No official
2005.
support of or endorsement by SAMHSA or
HHS for these opinions or for particular
instruments, software, or resources is intend
ed or should be inferred. Originating Office
Quality Improvement and Workforce
Development Branch, Division of Services
Improvement, Center for Substance Abuse
Public Domain Notice Treatment, Substance Abuse and Mental
All material appearing in this report is in the Health Services Administration, 1 Choke
public domain and may be reproduced or Cherry Road, Rockville, MD 20857.
copied without permission from SAMHSA.
Citation of the source is appreciated.
However, this publication may not be repro HHS Publication No. (SMA) 123991
duced or distributed for a fee without the spe
cific, written authorization of the Office of First Printed 2005
Communications, SAMHSA, HHS. Revised 2009, 2011, 2012, and 2014
ii Acknowledgments
Contents
What Is a TIP?............................................................................................................vii
Consensus Panel...........................................................................................................ix
KAP Expert Panel and Federal Government Participants ....................................................xi
Foreword ..................................................................................................................xiii
Executive Summary .....................................................................................................xv
Chapter 1—Groups and Substance Abuse Treatment ...........................................................1
Overview......................................................................................................................1
Introduction .................................................................................................................1
Defining Therapeutic Groups in Substance Abuse Treatment ....................................................2
Advantages of Group Treatment ........................................................................................3
Modifying Group Therapy To Treat Substance Abuse..............................................................6
Approach of This TIP .....................................................................................................8
Overview......................................................................................................................9
Introduction .................................................................................................................9
Five Group Models .......................................................................................................12
Specialized Groups in Substance Abuse Treatment................................................................29
Matching Clients With Groups .........................................................................................37
Assessing Client Readiness for Group ................................................................................38
Primary Placement Considerations ...................................................................................40
Stages of Recovery ........................................................................................................43
Placing Clients From Racial or Ethnic Minorities .................................................................44
Diversity and Placement.................................................................................................52
Fixed and Revolving Membership Groups ...........................................................................59
Preparing for Client Participation in Groups.......................................................................61
PhaseSpecific Group Tasks ............................................................................................72
Adjustments To Make Treatment Appropriate......................................................................79
The Early Stage of Treatment ..........................................................................................80
The Middle Stage of Treatment ........................................................................................85
The Late Stage of Treatment............................................................................................88
iii
Chapter 6—Group Leadership, Concepts, and Techniques..................................................91
Overview ....................................................................................................................91
The Group Leader ........................................................................................................92
Concepts, Techniques, and Considerations ........................................................................105
Training ....................................................................................................................123
Supervision................................................................................................................131
iv Contents
Figures
11 Differences Between 12Step SelfHelp Groups and Interpersonal Process Groups ...................4
21 Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models .............11
22 Characteristics of Five Group Models Used in Substance Abuse Treatment ...........................13
23 Group Vignette: Joe’s Argument With His Roommate.......................................................26
24 Joe’s Case in an Individually Focused Group .................................................................27
25 Joe’s Case in an Interpersonally Focused Group .............................................................28
26 Joe’s Case in a GroupAsAWhole Focused Group..........................................................29
27 The SageWind Model for Group Therapy......................................................................33
31 EcoMap ...............................................................................................................38
32 Client Placement by Stage of Recovery .........................................................................43
33 Client Placement Based on Readiness for Change............................................................44
34 What Is Culture? ....................................................................................................45
35 Diversity Wheel ......................................................................................................46
36 When Group Norms and Cultural Values Conflict ...........................................................48
37 Three Resources on Culture and Ethnicity ....................................................................48
38 Guidelines for Clinicians on Evaluating Bias and Prejudice ...............................................49
39 SelfAssessment Guide ..............................................................................................50
310 Preparing the Group for a New Member From a Racial/Ethnic Minority..............................54
311 Culture and the Perception of Conflict ........................................................................57
41 Characteristics of Fixed and Revolving Membership Groups..............................................62
42 The Family Care Program of the Duke Addictions Program ..............................................66
43 SageWind ..............................................................................................................67
44 Examples of Agreements About Time and Attendance ......................................................69
45 Examples of Agreements About Group Participation........................................................71
46 Reminders for Each Group Session .............................................................................74
61 Shame ..................................................................................................................95
62 Confidentiality and 42 C.F.R., Part 2 .........................................................................110
63 Jody’s Arm ..........................................................................................................121
71 How Important Is It for a Substance Abuse Group Leader To Be in Recovery?.....................126
72 Does Online Communication Impede Attachment? .........................................................132
73 Group Experiential Training ....................................................................................133
Contents v
What Is a TIP?
Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment
(CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the
U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topicspe
cific bestpractice guidelines for the prevention and treatment of substance use and mental disorders.
TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various
forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country.
Published TIPs can be accessed via the Internet at http://store.samhsa.gov.
Although each consensusbased TIP strives to include an evidence base for the practices it recommends,
SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind
the innovations pioneered in the field. A major goal of each TIP is to convey "frontline" information
quickly but responsibly. If research supports a particular approach, citations are provided.
vii
Consensus Panel
Note: The information given indicates each participant's affiliation during the time the panel was
convened and may no longer reflect the individual's current affiliation.
x Consensus Panel
KAP Expert Panel and Federal
Government Participants
Note: The information given indicates each participant's affiliation during the time the panel was
convened and may no longer reflect the individual's current affiliation.
xi
Harry B. Montoya, M.A. Consulting Members
President/Chief Executive Officer
Hands Across Cultures
of the KAP Expert Panel
Espanola, New Mexico Paul Purnell, M.A.
Vice President
Richard K. Ries, M.D. Social Solutions, L.L.C.
Director/Professor Potomac, Maryland
Outpatient Mental Health Services
Dual Disorder Programs Scott Ratzan, M.D., M.P.A., M.A.
Seattle, Washington Academy for Educational Development
Washington, DC
Gloria M. Rodriguez, D.S.W.
Research Scientist Thomas W. Valente, Ph.D.
Division of Addiction Services Director, Master of Public Health Program
NJ Department of Health and Senior Services Department of Preventive Medicine
Trenton, New Jersey School of Medicine
University of Southern California
Everett Rogers, Ph.D. Alhambra, California
Center for Communications Programs
Johns Hopkins University Patricia A. Wright, Ed.D.
Baltimore, Maryland Independent Consultant
Baltimore, Maryland
Jean R. Slutsky, P.A., M.S.P.H.
Senior Health Policy Analyst
Agency for Healthcare Research & Quality
Rockville, Maryland
Clarissa Wittenberg
Director
Office of Communications and Public Liaison
National Institute of Mental Health
Kensington, Maryland
xii KAP Expert Panel and Federal Government Participants
Foreword
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the
U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral
health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on
America’s communities.
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of sub
stance abuse and mental illness on America's communities by providing evidencebased and best practice
guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration
of all relevant clinical and health services research findings, demonstration experience, and implementa
tion requirements. A panel of nonFederal clinical researchers, clinicians, program administrators, and
patient advocates debates and discusses their particular area of expertise until they reach a consensus on
best practices. This panel’s work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory
process have helped bridge the gap between the promise of research and the needs of practicing clinicians
and administrators to serve, in the most scientifically sound and effective ways, people in need of behav
ioral health services. We are grateful to all who have joined with us to contribute to advances in the
behavioral health field.
Daryl W. Kade
Acting Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
xiii
Executive Summary
With the recognition of addiction as a major health problem in this country, demand has increased for
effective treatments of substance use disorders. Because of its effectiveness and economy of scale, group
therapy has gained popularity, and the group approach has come to be regarded as a source of powerful
curative forces that are not always experienced by the client in individual therapy. One reason groups
work so well is that they engage therapeutic forces—like affiliation, support, and peer confrontation—and
these properties enable clients to bond with a culture of recovery. Another advantage of group modalities
is their effectiveness in treating problems that accompany addiction, such as depression, isolation, and
shame.
Groups can support individual members in times of pain and trouble, and they can help people grow in
ways that are healthy and creative. Formal therapy groups can be a compelling source of persuasion,
stabilization, and support. In the hands of a skilled, welltrained group leader, the potential healing pow
ers inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer
reinforcement, act as a forum for selfexpression, and teach new social skills. In short, group therapy can
provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual ther
apy.
Group therapy and addiction treatment are natural allies. One reason is that people who abuse sub
stances are often more likely to stay sober and committed to abstinence when treatment is provided in
groups, apparently because of rewarding and therapeutic benefits like affiliation, confrontation, support,
gratification, and identification. This capacity of group therapy to bond patients to treatment is an impor
tant asset because the greater the amount, quality, and duration of treatment, the better the client’s prog
nosis (Leshner 1997; Project MATCH Research Group 1997).
The primary audience for this TIP is substance abuse treatment counselors; however, the TIP should be
of interest to anyone who wants to learn more about group therapy. The intent of the TIP is to assist
counselors in enhancing their therapeutic skills in regard to leading groups.
The consensus panel for this TIP drew on its considerable experience in the group therapy field. The
panel was composed of representatives from all of the disciplines involved in group therapy and substance
abuse treatment, including alcohol and drug counselors, group therapists, mental health providers, and
State government representatives.
This TIP comprises seven chapters. Chapter 1 defines therapeutic groups as those with trained leaders
and a primary intent to help people recover from substance abuse. It also explains why groups work so
well for treating substance abuse.
xv
Chapter 2 describes the purpose, main charac ly because substance abuse treatment profes
teristics, leadership, and techniques of five sionals commonly use the term “substance
group therapy models, three specialty groups, abuse” to describe any excessive use of addic
and groups that focus on solving a single tive substances. In this TIP, the term refers to
problem. the use of alcohol as well as other substances of
abuse. Readers should attend to the context in
Chapter 3 discusses the many considerations which the term occurs in order to determine
that should be weighed before placing a client what possible range of meanings it covers; in
in a particular group, especially keying the most cases, however, the term will refer to all
group to the client’s stage of change and stage varieties of substance use disorders described
of recovery. This chapter also concentrates on by DSMIV.
issues that arise from client diversity.
The sections that follow summarize the content
Chapter 4 compares fixed and revolving types in this TIP and are grouped by chapter.
of therapy groups and recommends ways to
prepare clients for participation: pregroup
interviews, retention measures, and most Groups and Substance
important, group agreements that specify
clients’ expectations of each other, the leader, Abuse Treatment
and the group. Chapter 4 also specifies the Because human beings by nature are social
tasks that need to be accomplished in the early, beings, group therapy is a powerful therapeutic
middle, and late phases of group development. tool that is effective in treating substance
abuse. The therapeutic groups described in this
Chapter 5 turns to the stages of treatment. In TIP are those groups that have trained leaders
the early, middle, and late stages of treatment, and a specific intent to treat substance abuse.
clients’ conditions will differ, requiring differ This definition excludes selfhelp groups like
ent therapeutic strategies and approaches to Alcoholics Anonymous and Narcotics
leadership. Anonymous.
Chapter 6 is the howto segment of this TIP. It Group therapy has advantages over other
explains the characteristics, duties, and con modalities. These include positive peer sup
cepts important to promote effective group port; a reduction in clients’ sense of isolation;
leadership in treating substance abuse, includ reallife examples of people in recovery; help
ing how confidentiality regulations for alcohol from peers in coping with substance abuse and
and drug treatment apply to group therapy. other life problems; information and feedback
Chapter 7 highlights training opportunities from peers; a substitute family that may be
available to substance abuse treatment profes healthier than a client’s family of origin; social
sionals. The chapter also recommends the skills training and practice; peer confrontation;
supervisory group as an added measure that a way to help many clients at one time; struc
improves group leadership and gives counselors ture and discipline often absent in the lives of
in the group insights about how clients may people abusing substances; and finally, the
experience groups. hope, support, and encouragement necessary
to break free from substance abuse.
Throughout this TIP, the term “substance
abuse” has been used to refer to both sub
stance abuse and substance dependence (as
defined by the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition, Text
Revision [DSMIVTR] [American Psychiatric
Association 2000]). This term was chosen part
xvi Executive Summary
Appropriate placement begins with a thorough
Groups Commonly assessment of the client’s needs, desires, and
Used in Substance ability to participate. Evaluators rely on forms
and interviews to determine the client’s level of
Abuse Treatment interpersonal functioning, motivation to
Five group models are common in substance abstain, stability, stage of recovery, and expec
abuse treatment: tation of success in the group.
• Psychoeducational groups, which educate Most clients can function in a group that is het
clients about substance abuse erogeneous, that is, members may be mixed in
• Skills development groups, which cultivate age, gender, culture, and so on. What is essen
the skills needed to attain and sustain absti tial, however, is that all clients in a group
nence, such as those needed to manage anger should have similar needs. Some clients, such
or cope with urges to use substances as those with a severe personality disorder, will
need to be placed in homogeneous groups, in
• Cognitive–behavioral groups, which alter
which members are alike in some way other
thoughts and actions that lead to substance
than their dependence problem. Such groups
abuse
may include people of a particular ethnicity, all
• Support groups, which buoy members and women, or a particular age group.
provide a forum to share pragmatic informa
tion about maintaining abstinence and man Some clients probably are not suitable for
aging daytoday, chemicalfree life certain groups, or group therapy in general,
• Interpersonal process groups, which delve including
into major developmental issues that con • People who refuse to participate
tribute to addiction or interfere with recovery
• People who cannot honor group agreements,
Three other specialized types of groups that do including preserving privacy and confiden
not fit neatly into the fivemodel classification tiality of group members in accordance with
nonetheless are common in substance abuse the Federal regulations (42 C.F.R., Part 2)
treatment. They are designed specifically to • People who make the therapist very uncom
prevent relapse, to bring a specific culture’s fortable
healing practices to bear on substance abuse,
• People who are prone to dropping out or who
or to use some form of art to express thoughts
continually violate group norms
that otherwise would be difficult to communi
cate. Groups also can be formed to help clients • People in the throes of a life crisis
who share a specific problem, such as anger or • People who cannot control impulses
shyness, that contributes to their substance • People who experience severe internal
abuse. discomfort in groups
Professional judgment is also essential and
Criteria for the should consider characteristics such as sub
Placement of Clients stances abused, duration of use, treatment
setting, and the client’s stage of recovery. For
in Groups example, a client in a maintenance stage may
Not everyone is suited to every kind of group. need to acquire social skills for interacting in
Moreover, because recovery is a long, nonlin new ways, address emotional difficulties, or
ear process, the type of therapy chosen always become reintegrated into a community or
should be subject to reevaluation. culture of origin.
Ethnicity and culture can have a profound
effect on treatment. The greater the mix of
Executive Summary xvii
ethnicities in a group, the more likely it is that • Stability
biases will emerge and require mediation. • Stage of recovery
Special attention may be warranted, too, if
• Expectation of success
clients do not speak English fluently because
they may be unable to follow a fastflowing Throughout the initial group therapy sessions,
discussion. Programs should ensure that group clients are particularly vulnerable to relapse
members are fluent in the language for their and discontinuation of treatment. The first
specific demographic area, which may or may month appears to be especially critical
not be English. Further, while it might be desir (Margolis and Zweben 1998). Retention rates
able to match the group leader and all group in a group are enhanced by client preparation,
members ethnically, the reality is that it is sel maximum client involvement, feedback,
dom feasible. Thus, it is crucial for the group prompts to encourage attendance, and the pro
leader to understand how ethnicity affects vision of wraparound services (such as child
substance abuse and group participation. care and transportation). The timing and
duration of groups also affect retention.
Group Development While group leaders have many responsibilities
in preparing clients for participation in groups,
and PhaseSpecific clients have obligations, too. A group agree
Tasks ment establishes the expectations that group
Group membership may be fixed, with a stable members have of each other, the leader, and
and relatively small number of clients. the group itself. It specifies the circumstances
Alternatively, membership may revolve, with under which clients may be barred from group
new members entering a group when they are and explains policies regarding confidentiality,
ready for the service it provides. Either type physical contact, substance use, contact outside
can run indefinitely or for a set time. the group, group participation, financial
responsibility, and termination. A group mem
The preparation of clients for group participa ber’s acceptance of the contract prior to enter
tion commences when the group leader meets ing a group has been described as the single
individually with each prospective group mem most important factor contributing to the suc
ber to begin to form a therapeutic alliance, cess of outpatient therapy groups.
reach consensus on what is to be accomplished
in therapy, educate the client about group ther The tasks in the beginning phase of a group
apy, allay anxiety related to joining a group, include introductions, review of the group
and explain the group agreement. In these pre agreement, establishment of an emotionally
group interviews, it is important to be sensitive safe environment and positive group norms,
to people who differ significantly from the rest and focusing the group toward its work. In the
of the group whether by age, ethnicity, gender, middle phase, clients interact, rethink their
disorder, and so on. It is important to assure behaviors, and move toward productive
clients that a difference is not a deficit and can change. The end phase concentrates on reach
be a source of vitality for the group. ing closure.
Selection of group members is based on the
client’s fit with a specific group modality. Stages of Treatment
Considerations include the client’s As clients move through different stages of
recovery, treatment must move with them. That
• Level of interpersonal functioning, including
is, therapeutic strategies and leadership roles
impulse control
will change with the condition of the clients.
• Motivation to abstain from drug or alcohol
abuse In the early phase of treatment clients tend to
be ambivalent about ending substance use,
xviii Executive Summary
rigid in their thinking, and limited in their abil identity, confidence, spontaneity, integrity,
ity to solve problems. Resistance is a challenge trust, humor, and empathy.
for the group leader at this time.
Leaders should be able to
The art of treating addiction in the early phase
is in the defeat of denial and resistance. Groups • Adjust their professional styles to the
are especially effective at this time since people particular needs of different groups
with dependencies often have had adversarial • Model groupappropriate behaviors
relationships with people in authority. Thus, • Resolve issues within ethical dimensions
information from peers in a group is more
• Manage emotional contagion
easily accepted than that from a lone therapist.
• Work only within modalities for which they
People with addictions remain vulnerable are trained
during the middle phase of treatment. Though • Prevent the development of rigid roles in the
cognitive capacity usually begins to return to group
normal, the mind can still play tricks. Clients
may remember distinctly the comfort of their • Avoid acting in different roles inside and out
past use of substances, yet forget just how bad side the group
the rest of their lives were. Consequently, the • Motivate clients in substance abuse treatment
temptation to relapse remains a concern. • Ensure emotional safety in the group
Because people with dependencies usually are
• Maintain a safe therapeutic setting (which
isolated from healthy social groups, the group
involves deflecting defensive behavior with
helps to acculturate clients into a culture of
out shaming the offender, recognizing and
recovery. The leader draws attention to posi
countering the resumption of substance use,
tive developments, points out how far clients
and protecting physical boundaries according
have traveled, and affirms the possibility of
to group agreements)
increased connection and new sources of
satisfaction. • Curtail emotion when it becomes too intense
for group members to tolerate
In the late phase of treatment clients are stable • Stimulate communication among group
enough to face situations that involve conflict members
or deep emotion. A processoriented group may
become appropriate for some clients who final Key concepts and techniques used in group
ly are able to confront painful realities, such as therapy for substance abuse follow.
being an abused child or an abusive parent.
Other clients may need groups to help them Interventions are any action by a leader to
build a healthier marriage, communicate more intentionally affect the processes of the group.
effectively, or become a better parent. Some Interventions may be used, for example, to
may want to develop new job skills to increase clarify understanding, redirect energy, or stop
employability. a damaging sequence of interactions. Effective
leaders do not overdo intervention. To do so
would result in a leadercentered group, which
Group Leadership, is undesirable because in therapy groups, the
healing comes from the connections forged
Concepts, and between group members. One type of interven
Techniques tion, confrontation, deftly points out inconsis
tencies in clients’ thinking.
Effective group leadership requires a
constellation of specific personal qualities and Confidentiality restricts the information that
professional practices. The personal qualities providers can reveal about clients and that
necessary are constancy, active listening, firm clients may reveal about each other. Group
Executive Summary xix
leaders and clients should understand the exact
provisions of this important boundary.
Training and
Supervision
Diversity plays a highly important role in
group therapy, for it may affect critical aspects National professional organizations are a rich
of the process, such as what clients expect of source of training. Through conferences or
the leader and how clients may interpret other regional chapters, national associations provide
clients’ behavior. Clinicians should be open to training—both experiential and direct instruc
learning about other belief systems, should not tion—geared to the needs of a wide range of
assume that every person from a specific group persons, from graduate students to highly expe
shares the same characteristics, and should rienced therapists. More training options are
avoid appearing as if they are trying to persuade usually available in large urban areas. It is
clients to renounce their cultural characteristics. likely, however, that online training will make
some types of professional development accessi
Many people in treatment for substance abuse ble to a greater number of counselors in remote
have other complex problems, such as co areas.
occurring mental disorders, homelessness, or
involvement with the criminal justice system. Clinical supervision as it pertains to group
For many clients, group therapy may be one therapy often is best carried out within the con
element in a larger plan that also marshals text of group supervision. Group dynamics and
biopsychosocial and spiritual interventions to group process facilitate learning by setting up a
address important life issues and restore faith microcosm of a larger social environment. Each
or belief in some force beyond the self. group member’s style of interaction will
inevitably show up in the group transactions.
Integrated care from diverse sources requires As this process unfolds, group members, guid
cooperation with other healthcare providers. ed by the supervisor, learn to model effective
For example, it is critical that all providers behavior in an accepting group context.
working with clients with multiple disorders
know what medications they are taking and why. Supervisory groups reduce, rather than esca
late, the level of threat that can accompany
Two aspects of group management relate to supervision. In place of isolation and alien
conflict and subgroups. Properly managed, ation, group participation gives counselors a
conflict can promote learning about respect for sense of community. They find that others
different viewpoints, managing emotions, and share their worries, fears, frustrations, tempta
negotiation. Part of the therapist’s job as a tions, and ambivalence. This reassurance is of
conflict manager is to reveal covert conflicts particular benefit to novice group counselors.
and expose repetitive and predictable argu
ments. The therapist also reveals covert sub
groups and intervenes to reconfigure negative
subgroups that threaten the group’s progress.
Various types of disruptive behavior may
require the group leader’s attention. Such
problems include clients who talk nonstop,
interrupt, flee a session, arrive late or skip ses
sions, decline to participate, or speak only to
the problems of others. The leader also should
have skills to handle people with psychological
emergencies or people who are anxious about
disclosing personal information.
xx Executive Summary
1 Groups and Substance
Abuse Treatment
Overview
In This
The natural propensity of human beings to congregate makes group
therapy a powerful therapeutic tool for treating substance abuse, one
Chapter…
that is as helpful as individual therapy, and sometimes more successful.
One reason for this efficacy is that groups intrinsically have many
Introduction
rewarding benefits—such as reducing isolation and enabling members
to witness the recovery of others—and these qualities draw clients into
Defining
a culture of recovery. Another reason groups work so well is that they
Therapeutic
are suitable especially for treating problems that commonly accompany
Groups in
substance abuse, such as depression, isolation, and shame.
Substance Abuse
Treatment
Although many groups can have therapeutic effects, this TIP concen
trates only on groups that have trained leaders and that are designed to
Advantages of
promote recovery from substance abuse. Great emphasis is placed on
Group Treatment
interpersonal process groups, which help clients resolve problems in
Modifying Group
relating to other people, problems from which they have attempted to
Therapy To Treat
flee by means of addictive substances. While this TIP is not intended
Substance Abuse
as a training manual for individuals training to be group therapists, it
provides substance abuse counselors with insights and information that
Approach of
can improve their ability to manage the groups they currently lead.
This TIP
Introduction
The lives of individuals are shaped, for better or worse, by their experi
ences in groups. People are born into groups. Throughout life, they join
groups. They will influence and be influenced by family, religious, social,
and cultural groups that constantly shape behavior, selfimage, and both
physical and mental health.
Groups can support individual members in times of pain and trouble,
and they can help people grow in ways that are healthy and creative.
However, groups also can support deviant behavior or influence an
individual to act in ways that are unhealthy or destructive.
1
Because our need for human contact is biologi The effectiveness of group therapy in the treat
cally determined, we are, from the start, social ment of substance abuse also can be attributed
creatures. This propensity to congregate is a to the nature of addiction and several factors
powerful therapeutic tool. Formal therapy associated with it, including (but not limited to)
groups can be a compelling source of persua depression, anxiety, isolation, denial, shame,
sion, stabilization, and support. Groups orga temporary cognitive impairment, and charac
nized around therapeutic goals can enrich ter pathology (personality disorder, structural
members with insight and guidance; and during deficits, or an uncohesive sense of self).
times of crisis, groups can comfort and guide Whether a person abuses substances or not,
people who otherwise might be unhappy or these problems often respond better to group
lost. In the hands of a skilled, welltrained treatment than to individual therapy (Kanas
group leader, the potential curative forces 1982; Kanas and Barr 1983). Group therapy is
inherent in a group can be harnessed and also effective because people are fundamentally
directed to foster healthy attachments, provide relational creatures.
positive peer rein
forcement, act as a
forum for self Defining Therapeutic
expression, and
Groups provide teach new social
Groups in Substance
skills. In short, Abuse Treatment
positive peer group therapy can All groups can be therapeutic. Anytime some
provide a wide range one becomes emotionally attached to other
of therapeutic ser
support and group members, a group leader, or the group
vices, comparable as a whole, the relationship has the potential to
in efficacy to those influence and change that person. Identifying a
pressure to abstain delivered in individ group as “therapy” does not imply that other
ual therapy. In some groups are not therapeutic. In preparing this
from substances cases, group therapy TIP, the consensus panel debated at length
can be more benefi what constitutes “group therapy” and what
of abuse. cial than individual distinguishes therapy groups from other types
therapy (Scheidlinger of groups.
2000; Toseland and
Siporin 1986). Although many types of groups can have thera
peutic elements and effects, the group types
Group therapy and addiction treatment are included in this TIP are based on the goals and
natural allies. One reason is that people who intentions of the groups, as well as the intended
abuse substances often are more likely to audience of the TIP (especially substance abuse
remain abstinent and committed to recovery treatment counselors and other substance
when treatment is provided in groups, appar abuse treatment professionals). Thus, this TIP
ently because of rewarding and therapeutic is limited to groups that (1) have trained lead
forces such as affiliation, confrontation, sup ers and (2) intend to produce some type of
port, gratification, and identification. This healing or recovery from substance abuse. This
capacity of group therapy to bond patients to TIP describes (in chapter 2) five models of
treatment is an important asset because the group therapy currently used in substance
greater the amount, quality, and duration of abuse treatment:
treatment, the better the client’s prognosis
(Leshner 1997; Project MATCH Research • Psychoeducational groups, which teach about
Group 1997). substance abuse.
2 Groups and Substance Abuse Treatment
• Skills development groups, which hone the achieve that purpose. Figure 11 (see p. 4)
skills necessary to break free of addictions. shows other differences between selfhelp
• Cognitive–behavioral groups, which rear groups and interpersonal process groups. In
range patterns of thinking and action that most aspects, the comparison would apply to
lead to addiction. the other four group models as well.
• Support groups, which comprise a forum
where members can debunk each other’s
excuses and support constructive change.
Advantages of Group
• Interpersonal process group psychotherapy Treatment
(referred to hereafter as “interpersonal pro Treating adult clients in groups has many
cess groups” or “therapy groups”), which advantages, as well as some risks. Any treat
enable clients to recreate their pasts in the ment modality—group therapy, individual
hereandnow of group and rethink the rela therapy, family therapy, and medication—can
tional and other life problems that they have yield poor results if applied indiscriminately or
previously fled by means of addictive sub administered by an unskilled or improperly
stances. trained therapist. The potential drawbacks of
group therapy, however, are no greater than
Treatment providers routinely use the first four for any other form of treatment.
models and various combinations of them. The
last is not as widely used, chiefly because of the Some of the numerous advantages to using
extensive training required to lead such groups groups in substance abuse treatment are
and the long duration of the groups, which described below (Brown and Yalom 1977;
demands a high degree of commitment from Flores 1997; Garvin unpublished manuscript;
both providers and clients. All the same, many Vannicelli 1992).
people enter substance abuse treatment with a
long history of failed relationships exacerbated • Groups provide positive peer support and
by substance use. In these cases, an extended pressure to abstain from substances of abuse.
period of therapy is warranted to resolve the Unlike AA, and, to some degree, substance
client’s problems with relationships. The reality abuse treatment program participation,
that extended treatment is not always feasible group therapy, from the very beginning, elic
does not negate its desirability. its a commitment by all the group members to
attend and to recognize that failure to attend,
This TIP does not discuss multifamily and mul to be on time, and to treat group time as spe
ticouple groups, which are discussed in TIP 39, cial disappoints the group and reduces its
Substance Abuse Treatment and Family effectiveness. Therefore, both peer support
Therapy (Center for Substance Abuse and pressure for abstinence are strong.
Treatment 2004). Even though multifamily and • Groups reduce the sense of isolation that
multicouple groups typically are made up of most people who have substance abuse disor
unrelated groups of families, they focus on ders experience. At the same time, groups
family relations as they affect and are affected can enable participants to identify with oth
by a member with a substance use disorder. ers who are struggling with the same issues.
This TIP concentrates on therapy groups, Although AA and treatment groups of all
which have a distinctively different focus. types provide these opportunities for sharing,
for some people the more formal and deliber
Also outside the scope of this TIP is the use of
ate nature of participation in process group
peerled selfhelp groups such as Alcoholics
therapy increases their feelings of security
Anonymous (AA) or group activities like social
and enhances their ability to share openly.
events, religious services, sports, and games.
Any or all may have one or more therapeutic • Groups enable people who abuse substances
effects, but are not specifically designed to to witness the recovery of others. From this
Groups and Substance Abuse Treatment 3
Figure 11
Differences Between 12Step SelfHelp Groups
and Interpersonal Process Groups
Self-Help Group Interpersonal Process Group
Size Unlimited (often large) Small (8–15 members)
• Peer leader or individual in recovery • Trained professional
• Leadership is earned over time • Appointed leader
Leadership
• Implicit hierarchical leadership • Formal hierarchical leadership
structure structure
Participation Voluntary Voluntary and involuntary
Group Selfgoverning Leader governed
Government
• Environmental factors, no • Examination of intragroup behavior
examination of group interaction and extragroup factors
• Emphasis on similarities among • Emphasis on differences and
Content members similarities among members
• Hereandnow focus • Hereandnow focus plus
historical focus
Screening None Always
Interview
Universality, empathy, affective sharing, Cohesion, mutual identification,
selfdisclosure (public statement of education, catharsis, use of group
Group problem), mutual affirmation, morale pressure to encourage abstinence
Processes building, catharsis, immediate positive and retention of group membership,
feedback, high degree of persuasiveness outside socialization (depending on
the group contract or agreement)
• Positive goal setting, behaviorally • Ambitious goals: immediate problem
Group oriented plus individual personality issues
Goals • Focus on the group as a whole and • Individual as well as group focus
the similarities among members
• Educator/role model, catalyst • Responsible for directing
Leader
for learning therapeutic group experience
Activity
• Less membertoleader distance • More membertoleader distance
Use of
Psycho- No Yes
dynamic
Techniques
Anonymity strongly emphasized and
Confiden-
Anonymity preserved includes everything that occurs in the
tiality
group, not just the identity of group
members
4 Groups and Substance Abuse Treatment
Self-Help Group Interpersonal Process Group
Sponsorship
Program Yes (usually same sex) None
• Members may leave group at their own • Predetermined minimal term of group
Determina- choosing membership
tion of Time
in Group • Members may avoid selfdisclosure or • Avoidance of discussion seen as
discussion of any subject possible “resistance”
Involvement Yes—eclectic models
in Other Yes
Therapies No—psychodynamic models
Time Unlimited group participation possible
Often timelimited group experiences
Factors over years
Frequency Active encouragement of daily Meets less frequently (often once or
of Meetings participation twice weekly)
Source: Adapted from Spitz 2001. Used with permission.
inspiration, people who are addicted to cantly during different stages of treatment
substances gain hope that they, too, can and recovery and often reveals the set of
maintain abstinence. Furthermore, an inter traits that makes the system of a person’s self
personal process group, which is of long as altogether unique.
duration, allows a magnified witnessing of • Groups provide feedback concerning the
both the changes related to recovery as well values and abilities of other group members.
as group members’ intra and interpersonal This information helps members improve
changes. their conceptions of self or modify faulty,
• Groups help members learn to cope with distorted conceptions. In terms of process
their substance abuse and other problems by groups in particular, as specific themes
allowing them to see how others deal with emerge in a client’s group experience, repeti
similar problems. Groups can accentuate this tive feedback from multiple group members
process and extend it to include changes in and the therapist can chip away at those
how group members relate to bosses, parents, faulty or distorted conceptions in slightly
spouses, siblings, children, and people in different ways until they not only are
general. correctable, but also the very process of
• Groups can provide useful information to correction and change is revealed through
clients who are new to recovery. For exam the examination of the group processes.
ple, clients can learn how to avoid certain • Groups offer familylike experiences. Groups
triggers for use, the importance of abstinence can provide the support and nurturance that
as a priority, and how to selfidentify as a may have been lacking in group members’
person recovering from substance abuse. families of origin. The group also gives mem
Group experiences can help deepen these bers the opportunity to practice healthy ways
insights. For example, selfidentifying as a of interacting with their families.
person recovering from substance abuse can
be a complex process that changes signifi
Groups and Substance Abuse Treatment 5
• Groups encourage, coach, support, and
reinforce as members undertake difficult or
Modifying Group
anxietyprovoking tasks. Therapy To Treat
• Groups offer members the opportunity to Substance Abuse
learn or relearn the social skills they need to
cope with everyday life instead of resorting to Modifying group therapy to make it applicable
substance abuse. Group members can learn to and effective with clients who abuse sub
by observing others, being coached by oth stances requires three improvements. One is
ers, and practicing skills in a safe and sup specific training and education for therapists so
portive environment. that they fully understand therapeutic group
work and the special characteristics of clients
• Groups can effectively confront individual with substance use disorders. The importance
members about substance abuse and other of understanding the curative process that
harmful behaviors. Such encounters are occurs in groups cannot be underestimated.
possible because groups speak with the com
bined authority of people who have shared Most substance abuse counselors have respond
common experiences and common problems. ed by adapting skills used in individual therapy.
Confrontation often plays a part of substance Counselors have also sought direction, clinical
abuse treatment groups because group training, and practical suggestions. Despite
members tend to deny their problems. individual efforts, however, group therapy often
Participating in the confrontation of one is conducted as individual therapy in a group.
group member can help others recognize and
defeat their own denial. Individual therapy is not equivalent to group
therapy. Some principles that work well with
• Groups allow a single treatment professional
individuals are inappropriate for group therapy.
to help a number of clients at the same time.
Using the wrong approach may lead to several
In addition, as a group develops, each group
undesirable results. First, the rich potential of
member eventually becomes acculturated to
groups––selfunderstanding, psychological
group norms and can act as a quasitherapist
growth, emotional healing, and true intimacy––
himself, thereby ratifying and extending the
will be left unfulfilled. Second, group leaders
treatment influence of the group leader.
who are unfamiliar with and insensitive to
• Groups can add needed structure and disci issues that manifest themselves in group thera
pline to the lives of people with substance use py may find themselves in a difficult situation.
disorders, who often enter treatment with Third, therapists who think they are doing
their lives in chaos. Therapy groups can group therapy when they actually are not may
establish limitations and consequences, which observe the poor results and conclude that
can help members learn to clarify what is group therapy is ineffective. Compounding all
their responsibility and what is not. these difficulties is the fact that group therapy
• Groups instill hope, a sense that “If he can is so ubiquitous. Thus, poorly conceived
make it, so can I.” Process groups can approaches are being used frequently.
expand this hope to dealing with the full
range of what people encounter in life, Group therapy also is not equivalent to 12Step
overcome, or cope with. program practices. Many therapists who lack
full qualifications for group work have adapted
• Groups often support and provide encourage practices from AA and other 12Step programs
ment to one another outside the group set for use in therapeutic groups. To say that this
ting. For interpersonal process groups, borrowing is inadvisable is not to say that the
though, outside contacts may or may not be principles of AA are inadequate. On the con
disallowed, depending on the particular trary, many people seem to be unable to recov
group contract or agreements. er from dependency without AA or a program
6 Groups and Substance Abuse Treatment
similar to it. For this reason, most effective A second major improvement needed if people
treatment programs make attendance at AA or who have addictions are to benefit from group
another 12Step program a mandatory part of therapy is a clear answer to the question,
the treatment process. By the same token, AA “Why is group therapy so effective for people
and other 12Step programs are not group with addictions?” We already have part of the
therapy. Rather, they are complementary com answer, and it lies in the individual with addic
ponents to the recovery process. TwelveStep tion, a person whose character style often
programs can help keep the individual who involves a defensive posture commonly referred
abuses substances abstinent while group thera to as denial. Addiction is, in fact, frequently
py provides opportunities for these individuals referred to as a disease of denial.
to understand and explore the emotional and
interpersonal conflicts that can contribute to The individual who is
substance abuse. chemically dependent
usually comes into
Progress toward optimal group therapy has treatment with an
also been hindered by the misconception that uncommonly complex Groups instill
group therapy with clients who have addictions set of defenses and
does not require specially qualified leaders. character pathology.
This notion is false. Therapy groups cannot Any group leader who
hope, a sense that
just take care of themselves. Group therapy, intends to help people
properly conducted, is difficult. One reason who have addictions
“If he can make it,
that it is challenging has to do with the nature benefit from treat
unique problems for the group therapy leader. clear understanding
A second reason is the complexity of group of each group mem
therapy; the leader requires a vast amount of ber’s defensive pro
specialized knowledge and skills, including a cess and character
clear understanding of group process and the dynamics. More than
stages of development of group dynamics. Such 20 years ago, John Wallace (1978) wrote about
mastery only comes with extended training and this important issue in an informative essay on
experience leading groups. the defensive style of the individual who is
addicted to alcohol. He referred to these char
Many groups led by untrained or poorly acterrelated defensive features as the pre
trained leaders have not fulfilled their potential ferred defense system of the individual addict
and may even have had negative effects on a ed to alcohol.
client’s recovery. It matters little whether the
inadequately trained group therapist is a per A third major modification needed is the adap
son who once abused substances or someone tation of the group therapy model to the treat
who developed knowledge in a traditional ment of substance abuse. The principles of
course of academically based training. Where group therapy need to be tailored to meet the
problems exist, they usually relate to one of two realities of treating clients with substance use
deficiencies: a lack of effective group therapy disorders.
training or use of a group therapy model that is
inadequate for clients who are chemically For the most part, group therapy has been
dependent. Additional training and education based on a model derived from outpatient ther
is needed to produce therapists who are well apy for clients whose problems may or may not
qualified to lead therapy groups composed pri include substance abuse. The theoretical
marily of individuals who are chemically underpinnings and practical applications of
dependent. general group therapy are not always applica
ble to individuals who abuse substances.
Groups and Substance Abuse Treatment 7
Substance abuse treatment sometimes is imple A further negative result is that the clients who
mented as a grab bag of strategies, approaches, have addictions may be unfairly viewed as poor
and techniques that were not tailored for peo treatment risks—people resistant to treatment
ple with substance use disorders. Further, the and unmotivated to change.
common characteristics and typical dynamics
seen in this population have not always been Time also is an important factor in a person’s
evaluated adequately, and this lapse has inhib recovery. What a group leader does in group
ited the development of effective methods of therapy with clients in an inpatient setting in a
treatment for these clients. hospital during the first few days or weeks of
recovery will differ dramatically from what
This model suitability problem is further com that same group therapist will do with the same
plicated by the fact that clients with substance recovering person in a continuing care group 6
use disorders, and even staff members, often months into abstinence with the expectation
become confused about the different types of that the person will remain in the group at least
group treatment modalities. For instance, in another 6 to 12 months.
the course of their treatment, clients may
engage in AA, Narcotics Anonymous, other
12Step groups, discussion groups, educational Approach of This TIP
groups, continuing care groups, and support While this TIP does not provide the training
groups. Given this mix, clients often become needed to become an interpersonal process
confused about the group therapist, the point of view, attitudes,
purpose of group and considerations of these group therapists
therapy, and the infuse the discussions throughout this TIP. The
treatment staff some panel hopes that this TIP will help counselors
This TIP will help times underestimates expand their awareness and comprehension
the impact that of dynamics that might be going on in their
counselors expand group therapy can current substance abuse treatment groups.
make on an individ These insights will help counselors become bet
their awareness ual’s recovery. ter prepared to manage their groups and their
individual members, inform group members’
The upshot of these
and comprehen problems has been
individual therapists of possible issues that
need resolution, record dynamics and issues
partial or complete
sion of dynamics for use in treatment during later stages of
failure; that is, the
recovery, and improve retention by appropri
techniques and
occurring in their ately acknowledging issues that are outside the
strategies that usual
scope of the group. The TIP will achieve its
ly work with the gen
purpose to the extent that it assists counselors
treatment groups. eral psychiatric pop
as they juggle immediate client needs, interac
ulation often do not
tions in groups, tasks leading to recovery, and
work with people
sheer human complexity.
abusing substances.
8 Groups and Substance Abuse Treatment
2 Types of Groups
Commonly Used in
Substance Abuse
Treatment
Overview
In This
This chapter presents five models of groups used in substance abuse
treatment, followed by three representative types of groups that do not
Chapter…
fit neatly into categories, but that, nonetheless, have special significance
in substance abuse treatment. Finally, groups that vary according to
Five Group Models specific types of problems are considered. The purpose of the group,
Psychoeducational Groups
its principal characteristics, necessary leadership skills and styles, and
Skills Development Groups
typical techniques for these groups are described.
Cognitive–Behavioral
Groups
Support Groups Introduction
Interpersonal Process
Group Psychotherapy Substance abuse treatment professionals employ a variety of group
treatment models to meet client needs during the multiphase process of
Specialized Groups recovery. A combination of group goals and methodology is the primary
in Substance Abuse way to define the types of groups used. This TIP describes five group
Treatment therapy models that are effective for substance abuse treatment:
Relapse Prevention
Communal and
• Psychoeducational groups
Culturally Specific Groups • Skills development groups
Expressive Groups
• Cognitive–behavioral/problemsolving groups
Groups Focused on
• Support groups
Specific Problems
• Interpersonal process groups
Each of the models has something unique to offer to certain populations;
and in the hands of a skilled leader, each can provide powerful thera
peutic experiences for group members. A model, however, has to be
matched with the needs of the particular population being treated; the
goals of a particular group’s treatment also are an important determi
nant of the model that is chosen.
This chapter describes the group’s purpose, principal characteristics,
leadership requisites, and appropriate techniques for each type of
group. Also discussed are three specialized types of groups that do not fit
9
into the five model categories, but that function • Recurrence. Many clients will relapse and
as unique entities in the substance abuse treat return to an earlier stage, but they may move
ment field: quickly through the stages of change and may
have gained new insights into problems that
• Relapse prevention treatment groups defeated their former attempts to quit sub
• Communal and culturally specific treatment stance abuse (such as unrealistic goals or
groups frequenting places that trigger relapse).
• Expressive groups (including art therapy,
For a detailed description of the stages of
dance, psychodrama)
change, see TIP 35, Enhancing Motivation for
Figure 21 lists some groups commonly used in Change in Substance Abuse Treatment (Center
substance abuse treatment and classifies them for Substance Abuse Treatment [CSAT] 1999b).
into the fivemodel framework used in this TIP.
The client’s stage of change will dictate which
This list of groups is by no means exhaustive,
group models and methods are appropriate at a
but it demonstrates the variety of groups found
particular time. If the group is composed of
in substance abuse treatment settings.
members in the action stage who have clearly
Occasionally, discussions in this TIP refer to identified themselves as substance dependent,
the stages of change delineated by Prochaska the group will be conducted far differently
and DiClemente (1984). They examined 18 psy from one composed of people who are in the
chological and behavioral theories of how precontemplative stage. Priorities change with
change occurs, including the components of a time and experience, too. For example, a group
biopsychosocial framework for understanding of people with substance use disorders on their
substance abuse. Their result was a continuum second day of abstinence is very different from
of six categories for understanding client moti a group with 1 or 2 years of sobriety.
vation for changing substance abuse behavior.
Theoretical orientations also have a strong
The six stages are:
impact on the tasks the group is trying to
• Precontemplation. Clients are not thinking accomplish, what the group leader observes
about changing substance abuse behavior and responds to in a group, and the types of
and may not consider their substance abuse interventions that the group leader will initiate.
to be a problem. Before a group model is applied in treatment,
the group leader and the treating institution
• Contemplation. Clients still use substances,
should decide on the theoretical frameworks to
but they begin to think about cutting back or
be used, because each group model requires
quitting substance use.
different actions on the part of the group lead
• Preparation. Clients still use substances, but er. Since most treatment programs offer a vari
intend to stop since they have recognized the ety of groups for substance abuse treatment, it
advantages of quitting and the undesirable is important that these models be consistent
consequences of continued use. Planning for with clearly defined theoretical approaches.
change begins.
• Action. Clients choose a strategy for discon In practice, however, groups can, and usually
tinuing substance use and begin to make the do, use more than one model, as shown in
changes needed to carry out their plan. This Figure 21. For example, a therapy group in an
period generally lasts 3–6 months. intensive early recovery treatment setting might
combine elements of psychoeducation (to show
• Maintenance. Clients work to sustain how drugs have ravaged the individual’s life),
abstinence and evade relapse. From this skills development (to help the client maintain
stage, some clients may exit substance use abstinence), and support (to teach individuals
permanently. how to relate to other group members in an
honest and open fashion). Therefore, the
10 Types of Groups Commonly Used in Substance Abuse Treatment
Figure 21
Groups Used in Substance Abuse Treatment
and Their Relation to Six Group Models
Group Types
æ Group Model or Combination of Models
Skills Cognitive– Inter- Support Specialized Psycho-
Develop- Behavioral personal Group* educa-
ment Therapy Process tional
Anger/feelings management • • •
Cooccurring disorders • •
Skillsbuilding • •
Conflict resolution • • •
Relapse prevention • • • •
12Step psychoeducational • •
Psychoeducational •
Trauma (abuse, violence) • • •
Early recovery • • • •
Substance abuse education •
Spiritualitybased •
Cultural • •
Psychodynamic • •
Ceremonial healing practices •
Support •
Family roles (psychoeducational) •
Expressive therapy •
Relaxation training •
Meditation •
Multiplefamily • • •
Gender specific • •
Life skills training • •
Health and wellness •
Cognitive–behavioral • • •
Psychodrama •
Adventurebased •
Marathon •
Humanistic/existential • •
Source: Consensus Panel. *See “Specialized Groups in Substance Abuse Treatment” on p. 29.
Types of Groups Commonly Used in Substance Abuse Treatment 11
descriptions of the groups in this chapter are of prompt people using substances to take action
ideal, pure forms that rarely stand alone in on their own behalf, such as entering a treat
practice. It must be acknowledged, too, that ment program. While psychoeducational
the terms used to describe groups are not alto groups may inform clients about psychological
gether clearcut and consistent. In different issues, they do not aim at intrapsychic change,
treatment settings, programs, and regions of though such individual changes in thinking and
the country, a term like “support group” may feeling often do occur.
be used to refer to different types of treatment
groups, including a relapse prevention group. Purpose. The major purpose of psychoeduca
tional groups is expansion of awareness about
Despite such discrepancies between neat theory the behavioral, medical, and psychological con
and untidy practice, little difficulty will arise if sequences of substance abuse. Another prime
the group leader exercises sound clinical judg goal is to motivate the client to enter the recov
ment regarding models and interventions to be eryready stage (Martin et al. 1996; Pfeiffer et
used. One exception to this assurance, however, al. 1991). Psychoeducational groups are pro
should be noted. Close adherence to the theory vided to help clients incorporate information
that dictates the way an interpersonal process that will help them establish and maintain
group should be conducted has crucial implica abstinence and guide them to more productive
tions for its success. choices in their lives.
These groups also can be used to counteract
Five Group Models clients’ denial about their substance abuse,
increase their sense of commitment to contin
Figure 22 summarizes the characteristics of
ued treatment, effect changes in maladaptive
five therapeutic group models used in sub
behaviors (such as associating with people who
stance abuse treatment. Variable factors
actively use drugs), and supporting behaviors
include the focus of group attention, specificity
conducive to recovery. Additionally, they are
of the group agenda, heterogeneity or homo
useful in helping families understand substance
geneity of group members, openended or
abuse, its treatment, and resources available
determinate duration of treatment, level of
for the recovery process of family members.
facilitator or leader activity, training required
for the group leader, length of sessions, and Some of the contexts in which psychoeducation
preferred arrangement of the room. al groups may be most useful are
• Helping clients in the precontemplative or
Psychoeducational Groups contemplative level of change to reframe the
Psychoeducational groups are designed to edu impact of drug use on their lives, develop an
cate clients about substance abuse, and related internal need to seek help, and discover
behaviors and consequences. This type of group avenues for change.
presents structured, groupspecific content, • Helping clients in early recovery learn more
often taught using videotapes, audiocassette, or about their disorders, recognize roadblocks
lectures. Frequently, an experienced group to recovery, and deepen understanding of the
leader will facilitate discussions of the material path they will follow toward recovery.
(Galanter et al. 1998). Psychoeducational • Helping families understand the behavior of
groups provide information designed to have a a person with substance use disorder in a
direct application to clients’ lives—to instill way that allows them to support the individu
selfawareness, suggest options for growth and al in recovery and learn about their own
change, identify community resources that can needs for change.
assist clients in recovery, develop an under
standing of the process of recovery, and • Helping clients learn about other resources
that can be helpful in recovery, such as
12 Types of Groups Commonly Used in Substance Abuse Treatment
Figure 22
Characteristics of Five Group Models Used in Substance Abuse Treatment
meditation, relaxation training, anger
coping skills (such as anger management or the
management, spiritual development, and
use of “I” statements) normally taught in a
nutrition.
skills development group often accompany this
Principal characteristics. Psychoeducational learning.
groups generally teach clients that they need to Psychoeducational groups are considered
learn to identify, avoid, and eventually master a useful and necessary, but not sufficient, com
the specific internal states and external circum ponent of most treatment programs. For
stances associated with substance abuse. The instance, psychoeducation might move clients
Types of Groups Commonly Used in Substance Abuse Treatment 13
in a precontemplative or perhaps contempla may need special considerations. Psycho
tive stage to commit to treatment, including educational groups also have been shown to be
other forms of group therapy. For clients who effective with clients with cooccurring mental
enter treatment through a psychoeducational disorders, including clients with schizophrenia
group, programs should have clear guidelines (Addington and elGuebaly 1998; Levy 1997;
about when members of the group are ready Pollack and Stuebben 1998). For more infor
for other types of group treatment. mation on making accommodations for clients
with disabilities, see TIP 29, Substance Use
Often, a psychoedu Disorder Treatment for People With Physical
cational group inte and Cognitive Disabilities (CSAT 1998b).
grates skills devel
Psychoeducational opment into its pro Leadership skills and styles. Leaders in psy
gram. As part of a choeducational groups primarily assume the
groups are highly larger program, roles of educator and facilitator. Still, they
psychoeducational need to have the same core characteristics as
structured and groups have been other group therapy leaders: caring, warmth,
used to help clients genuineness, and positive regard for others.
often follow a reflect on their own
behavior, learn new Leaders also should possess knowledge and
ways to confront skills in three primary areas. First, they should
manual or a understand basic group process—how people
problems, and
increase their self interact within a group. Subsets of this knowl
preplanned edge include how groups form and develop,
esteem (La Salvia
1993). how group dynamics influence an individual’s
curriculum. behavior in group, and how a leader affects
Psychoeducational group functioning. Second, leaders should
groups should work understand interpersonal relationship dynam
actively to engage ics, including how people relate to one another
participants in the group discussion and in group settings, how one individual can influ
prompt them to relate what they are learning to ence the behavior of others in group and some
their own substance abuse. To ignore group basic understanding of how to handle problem
process issues will reduce the effectiveness of atic behaviors in group (such as being with
the psychoeducational component. drawn). Finally, psychoeducational group lead
ers need to have basic teaching skills. Such
Psychoeducational groups are highly struc skills include organizing the content to be
tured and often follow a manual or a pre taught, planning for participant involvement in
planned curriculum. Group sessions generally the learning process, and delivering information
are limited to set times, but need not be strictly in a culturally relevant and meaningful way.
limited. The instructor usually takes a very
active role when leading the discussion. Even To help clients get the most out of psychoeduca
though psychoeducational groups have a for tional sessions, leaders need basic counseling
mat different from that of many of the other skills (such as active listening, clarifying, sup
types of groups, they nevertheless should meet porting, reflecting, attending) and a few
in a quiet and private place and take into advanced ones (such as confronting and termi
account the same structural issues (for nating) (Brown 1998). It also helps to have
instance, seating arrangements) that matter in leadership skills, such as helping the group
other groups. get started in a session, managing (though not
necessarily eliminating) conflict between group
As with any type of group, accommodations members, encouraging withdrawn group mem
may need to be made for certain populations. bers to be more active, and making sure that
Clients with cognitive disabilities, for example,
14 Types of Groups Commonly Used in Substance Abuse Treatment
all group members have a chance to participate. standing of the content before expressing their
As the group unfolds, it is important that group views. Techniques such as role playing, group
leaders are nondogmatic in their dealings with problemsolving exercises, and structured experi
group members. Finally, the group leader ences all foster active learning.
should have a firm grasp of material being
communicated in the psychoeducational group. Second, the leader should encourage group
participants to take responsibility for their
During a session, the group leader should be learning rather than passing on that responsi
mindful both of the group’s need and the spe bility to the group leader. From the outset of
cific needs of each member. The group leader the group, the leader can emphasize group self
will need to understand group member roles ownership by allowing members to participate
and how to manage problem clients. Except in in setting agreements and other group bound
unusual circumstances, efforts should be made aries. The leader can emphasize member
to increase members’ comfort and to reduce responsibility for honest, respectful interaction
anxiety in the group. Leaders will use a variety among all members and can deemphasize the
of resources to impart knowledge to the group, leader role in determining group life.
so each session also requires preparation and
familiarization with the content to be delivered. Third, because many people have pronounced
preferences for learning through a particular
Group leaders should have ongoing training sense (hearing, sight, touch/movement), it is
and formal supervision. Supervision benefits essential to use a variety of learning methods
all group leaders of all levels of skill and train that call for different kinds of sensory experi
ing, as it helps to assure them that people in ence. Excellent material on adapting instruc
positions of authority are interested in their tion to learning styles is available through the
development and in their work. If direct super Association for Supervision and Curriculum
vision is not possible (as may be the case in Development Web site. To access the many arti
remote, rural areas), then Internet discussions cles and book chapters, enter “learning styles”
or regular telephone contact should be used. into the search function and click the “Go”
button.
Techniques. Techniques to conduct psychoedu
cational groups are concerned with (1) how Most people, at one time or another, have had
information is presented, and (2) how to assist unpleasant experiences in traditional, formal
clients to incorporate learning so that it leads to classroom environments. The resulting shame,
productive behavior, improved thinking, and rejection, and selfdeprecation strongly moti
emotional change. Adults in the midst of crises vate people to avoid situations where these
in their lives are much more likely to learn experiences might be brought back into aware
through interaction and active exploration than ness. Therefore it is critically important for the
they are through passive listening. As a result, it group leader to be sensitive to the anxiety that
is the responsibility of the group leader to can be aroused if the client is placed in an envi
design learning experiences that actively engage ronment that replicates a disturbing scene from
the participants in the learning process. Four the past. To allay some of these concerns, lead
elements of active learning can help. ers can acknowledge the anxieties of partici
pants, prevent all group participants from
First, the leader should foster an environment mocking others’ comments or ideas, and show
that supports active participation in the group sensitivity to the meaning of a participant’s
and discourages passive note taking. withdrawal in the group. Overall, leaders
Accordingly, leader lecturing should be limited should create an environment where partici
in duration and extent. The leader should con pants who are having difficulty with the
centrate instead on facilitating group discussion, psychoeducational group process can express
especially among clients who are withdrawn and their concerns and receive support.
have little to say. They need support and under
Types of Groups Commonly Used in Substance Abuse Treatment 15
Fourth, people with alcoholism and other becomes a natural treatment of choice for skills
addictive disorders are known to have subtle, development. Members can practice with each
neuropsychological impairments in the early other, see how different people use the same
stage of abstinence. Verbal skills learned long skills, and feel the positive reinforcement of a
ago (that is, crystallized intelligence) are not peer group (rather than that of a single profes
affected, but fluid intelligence, needed to learn sional) when they use skills effectively.
some kinds of new information, is impaired. As
a result, clients may seem more able to learn Principal characteristics. Because of the
than they actually are. Therapists who are degree of individual variation in client needs,
teaching new skills should be mindful of the particular skills taught to a client should
this difficulty. depend on an assessment that takes into
account individual characteristics, abilities,
and background. The suitability of a client for
Skills Development Groups a skills development group will depend on the
Most skills development groups operate from a unique needs of the individual along with the
cognitive–behavioral orientation, although skills being taught. Most clients can benefit
counselors and therapists from a variety of from developing or enhancing certain general
orientations apply skills development tech skills, such as controlling powerful emotions or
niques in their practice. Many skills develop improving refusal skills when around people
ment groups incorporate psychoeducational using alcohol or illicit drugs. Skills might also
elements into the group process, though skills be highly specific to certain clients, such as
development may remain the primary goal of relaxation training.
the group. Skills development groups usually run for a
Purpose. Coping skills training groups (the limited number of sessions. The size of the
most common type of skills development group) group needs to be limited, with an ideal range
attempt to cultivate the skills people need to of 8 to 10 participants (perhaps more, if a
achieve and maintain abstinence. These skills cofacilitator is present). The group has to be
may either be directly related to substance use small enough for members to practice the skills
(such as ways to refuse offers of drugs, avoid being taught.
triggers for use, or cope with urges to use) or While skills development groups often incorpo
may apply to broader areas relevant to a rate elements of psychoeducation and support,
client’s continued sobriety (such as ways to the primary goal is on building or strengthening
manage anger, solve problems, or relax). behavioral or cognitive resources to cope better
Skills development groups typically emerge in the environment. Psychoeducational groups
from a cognitive–behavioral theoretical tend to focus on developing an information base
approach that assumes that people with sub on which decisions can be made and action
stance use disorders lack needed life skills. taken. Support groups, to be discussed later in
Clients who rely on substances of abuse as a this chapter, focus on providing the internal and
method of coping with the world may never environmental supports to sustain change. All
have learned important skills that others have, are appropriate in substance abuse treatment.
or they may have lost these abilities as the While a specific group may incorporate elements
result of their substance abuse. Thus, the of two or more of these models, it is important to
capacity to build new skills or relearn old ones maintain focus on the overall goal of the group
is essential for recovery. and link methodology to that goal.
16 Types of Groups Commonly Used in Substance Abuse Treatment
grow and evolve, knowledge of the patterns Furthermore, many
that show how people relate to one another in behavioral changes
group, skills in fostering interaction among that seem straightfor
members, managing conflict that inevitably ward on the surface Skills development
arises among members in a group environment, have powerful effects
and helping clients take ownership for the at deeper levels of groups typically
group. psychological func
tioning. For instance,
In addition, group leaders should know and be assertiveness may
emerge from a cog
able to demonstrate the set of skills that the touch feelings of
participants are trying to develop. Leaders also shame and unworthi
nitive–behavioral
will need significant experience in modeling ness. Thus, new
ments of behavior. Other general skills, such as may be incompatible
sensitivity to what is going on in the room and with and over
cultural sensitivity to differences in the ways whelmed by deep feel
people approach issues like anger or assertive ings of inadequacy
ness, also will be important. Depending on the and low selfesteem. As a result, a client may
skill being taught, there may be certain educa learn a new behavior, but be unable to incor
tional or certification requirements. For exam porate it into a repertoire of positive action.
ple, a nurse might be needed to teach specific Counselors should not automatically assume,
health maintenance skills, or a trained facilita therefore, that a newly learned skill inevitably
tor may be needed to run certain meditation or will translate into action. Feedback from par
relaxation groups. ticipants on their progress since the last group
skills development group will vary greatly incorporation of skills.
depending on the skills being taught. (For more An often unstated and underrecognized diffi
information on the techniques used in cogni culty in leading skills groups is that a leader
tive–behavioral coping skills training see chap teaching the same material week after week can
ter 4 of TIP 34, Brief Interventions and Brief become bored with the content. In due course,
Therapies for Substance Abuse Treatment the boredom will creep into the teaching. To
[CSAT 1999a].) retain energy and teaching effectiveness, lead
It is useful to keep in mind that most skills, ers can switch topics, or one leader can teach
such as riding a bicycle or swimming, seem rel different topics over time. When feasible, it
atively simple, straightforward, and easy once also may help to provide feedback to leaders
incorporated into one’s repertoire of behavior. by making video or audio recordings of their
The process of learning and incorporating new presentations.
skills, however, may be difficult, especially if Other specific techniques for skills develop
the previous approach has been used for a long ment groups depend on the nature of the
time. For instance, individuals who have been group, topic, and approach of the group lead
passive and nonassertive throughout life may er. Before undertaking leadership of a skills
have to struggle mightily to learn to stand up development group, it is wise for the leader to
for themselves. As a consequence, it is crucial have previously participated in the specific
for leaders of skills development groups to be kind of skills development group to be led.
sensitive to the struggles of group participants, Often special training programs are available
hold positive expectations for change, and not for leaders of these kinds of groups.
demean or shame individuals who seem over
whelmed by the task.
Types of Groups Commonly Used in Substance Abuse Treatment 17
Cognitive–Behavioral Groups decisions, opinions, and assumptions. A num
ber of thoughts and beliefs are affected by an
Cognitive–behavioral groups are a well
individual’s substance abuse and addiction.
established part of the substance abuse treat
Some common errant beliefs of individuals
ment field and are particularly appropriate in
entering recovery are
early recovery. The term “cognitive–behavioral
therapy group” covers a wide range of formats • “I’m a failure.”
informed by a variety of theoretical frame • “I’m different.”
works, but the common thread is cognitive
restructuring as the basic methodology of • “I’m not strong enough to quit.”
change. • “I’m unlovable.”
• “I’m a (morally) bad person.” The word
Purpose. Cognitive–behavioral groups concep
“morally” carries the implication of a “shame
tualize dependency as a learned behavior that
script” and feeling defective as a person.
is subject to modification through various
“Bad” alone refers more to behavior, or
interventions, including identification of condi
doing “bad things.”
tioned stimuli associated with specific addictive
behaviors, avoidance of such stimuli, develop Changing such cognitions and beliefs may lead
ment of enhanced contingency management to greater opportunities to maintain sobriety
strategies, and responsedesensitization and live more productively.
(McAuliffe and Ch’ien 1986). The etiologies of
dependency include neurobehavioral factors Principal characteristics. In cognitive–
(Rawson et al. 1990), biopsychosocial (Nunes behavioral groups for people who abuse
Dinis and Barth 1993; Wallace 1990), and the substances, the group leader focuses on pro
disease model (Miller and Chappel 1991), in viding a structured environment within which
which the key etiological determinants of group members can examine the behaviors,
dependency are genetic and physiological fac thoughts, and beliefs that lead to their mal
tors, ones that the person with dependency adaptive behavior. Treatment manuals—
cannot control. providing specific protocols for intervention
techniques—may be helpful in some, though
Cognitive–behavioral therapy groups work to not all, cognitive–behavioral groups. In any
change learned behavior by changing thinking case, most cognitive–behavioral groups
patterns, beliefs, and perceptions. The groups emphasize structure, goal orientation, and a
also work to develop focus on immediate problems. Problem
social networks that solving groups often have a specific protocol
support continued that systematically builds problemsolving
abstinence so the skills and resources.
person with depen
Cognitive– dency becomes One example is a model cognitive–behavioral
aware of behaviors group for women with posttraumatic stress dis
behavioral groups that may lead to order (PTSD) and substance abuse designed to
relapse and develops
strategies to contin • Educate clients about the two disorders
are particularly
ue in recovery • Promote selfcontrol skills to manage over
(Matano et al. 1997). whelming emotions
appropriate in
• Teach functional behaviors that may have
Cognitive processes
early recovery. deteriorated as a result of the disorders
include a number of
different psychologi • Provide relapse prevention training (Najavits
cal elements, such as et al. 1996)
thoughts, beliefs,
18 Types of Groups Commonly Used in Substance Abuse Treatment
The group format is an important element of cognition (beliefs, judgments, and perceptions)
the model, given the importance of social sup and the behavior that flows from it. Some
port for PTSD and substance use disorders. In approaches focus more on behavior, others on
addition, group treatment is a wellestablished, core beliefs, still others on developing problem
relatively lowcost modality, so it can success solving capabilities. Regardless of the particu
fully reach a large number of clients. Some key lar focus, the group therapist conducting cogni
characteristics of this program are that it tive–behavioral groups should have a solid
grounding in the broader theory of
• Uses a model designed for 24 sessions, in cognitive–behavioral therapy. This basis is the
which 3–10 members meeting twice each week framework from which specific interventions
for 3 months in 90minute group meetings can be drawn and implemented. Training in
• Is earlyrecovery–oriented, with a strong cognitive–behavioral theory is available in
focus on coping skills to gain control over many workshops on counseling skills and in
symptoms many alcohol and drug training programs for
• Has homogeneous membership (for example, counselors. For instance, over a 2week period
all women) in 2002, the Rutgers Summer Schools of
Alcohol and Drug Studies offered seven week
• Includes a sixsession unit on relationships
long courses that concentrated specifically on
and themes, such as Safety and Self
cognitive counseling theory and methods. Many
protection and Reaching Out for Help
books are available on the theory of cogni
• Uses educational devices to promote rapid tive–behavioral therapy (Beck 1976; Ellis and
and sustained learning of material, such as MacLaren 1998; Glasser 2000; Leahy 1996) as
visual aids, role preparation, memory well as selfhelp manuals with a cognitive–
improvement techniques, written summaries, behavioral focus (Burns 1999; Greenberger
review sessions, homework, and audiotapes and Padesky 1995). See chapter 7 for more
of each session information about training sources.
• Focuses on both disorders, with instruction
on stages of recovery to motivate members to The level of interaction by the therapist in cog
achieve abstinence and control over PTSD nitive–behavioral groups can vary from very
symptoms (Najavits et al. 1996) directive and active to relatively nondirective
and inactive. It also can vary from highly con
Another cognitive–behavioral model was frontational with group members to relatively
employed to reduce the anger that can trigger nonconfrontational demeanor. Perhaps the
renewed use of cocaine among 59 men and 32 most common leadership style in cognitive–
women diagnosed with cocaine dependence. behavioral groups is active engagement and a
The model assumed that angry responses are consistently directive orientation.
learned behavior that can be changed. Clients
in the pilot program were taught to gauge their A cautionary note: In cognitive–behavioral
anger levels and to use anger management groups, the leader may be tempted to become
strategies like timeouts and conflict resolution. the expert in how to think, how to express that
During the 12 weeks of treatment, participants thinking behaviorally, and how to solve prob
were able to reduce and control their anger lems. It is important not to yield to such a
more effectively than they had in the past, and temptation, but instead to allow group mem
these gains held at the followup 3 months after bers to use the power of the group to develop
treatment. Violent behavior also decreased sig their own capabilities in these areas.
nificantly (Reilly and Shopshire 2000). Techniques. Specific techniques may vary
Leadership skills and styles. Cognitive–behav based on the particular orientation of the lead
ioral therapies encompass a variety of method er, but in general, techniques include those
ological approaches, all focused on changing which (1) teach group members about self
Types of Groups Commonly Used in Substance Abuse Treatment 19
destructive behavior and thinking that leads to cies sustain abstinence without necessarily
maladaptive behavior, (2) focus on problem understanding the determinants of their depen
solving and short and longterm goal setting, dence (Cooper 1987).
and (3) help clients monitor feelings and behav
ior, particularly those associated with drug use. The focus of support groups can range from
More experienced leaders will have a wider strong leaderdirected, problemfocused groups
range of specific techniques to engage partici in early recovery, which focus on achieving
pants and more comfort with a wider range of abstinence and managing daytoday living, to
client needs and expectations. groupdirected, emotionally and interpersonal
ly focused groups in middle and later stages of
An important element of conducting cognitive– recovery.
behavioral groups is recognizing that behav
ioral change and intellectual insight gained in Purpose. Support groups bolster members’
the group can be provocative and upsetting for efforts to develop and strengthen the ability to
clients with a poor sense of self, low self manage their thinking and emotions and to
esteem, and fear of emotional and interperson develop better interpersonal skills as they
al inadequacy. As a result, resistance to change recover from substance abuse. Support group
inevitably will occur as the group evolves and members also help each other with pragmatic
behavioral changes begin to become routine. concerns, such as maintaining abstinence and
Experienced leaders learn to recognize, managing daytoday living. These groups are
respect, and work with the resistance instead of also used to improve members’ general self
simply confronting it. Clinical supervision is esteem and selfconfidence. The group—or
quite beneficial in learning a variety of styles of more often, the group leader—provides specific
working with resistance generated by growth kinds of support, such as being sure to help
and change. clients avoid isolation and finding something
positive to say about each participant’s contri
Many specific approaches to cognitive–behav bution. In some programs, support groups
ioral therapy, including rational emotive thera might be considered process (therapy) groups,
py (Ellis 1997), reality therapy (Glasser 1965) but the main interest of support groups is
and the work of Aaron Beck and colleagues not in the intrapsychic world, and the goal
(1993), incorporate various techniques specific is not character change. Process issues may
to each approach. Substance abuse treatment be involved, but support groups are less
counselors may find it useful to explore these complex, more direct, and narrower in focus
approaches for techniques appropriate to their than process groups.
specific client populations.
Principal characteristics. Many people with
substance use disorders avoid treatment
Support Groups because the treatment itself threatens to
The widespread use of support groups in the increase their anxiety. Because of support
substance abuse treatment field originated in groups’ emphasis on emotional sustenance
the selfhelp tradition in the field. These groups providing a safe environment, these groups are
also have roots in the realization that signifi especially useful for apprehensive clients,
cant lifestyle change is the longterm goal in indeed, for any client new to abstinence. The
treatment and that support groups can play a adjective “support” itself may be a way of
major role in such life transitions. Selfhelp destigmatizing the activity. For this reason, a
groups share many of the tenets of support “support” group may be more attractive to
groups—unconditional acceptance, inward someone less committed to recovery than a
reflection, open and honest interpersonal inter “therapy” group.
action, and commitment to change. These Not all support groups, however, are intended
groups attempt to help people with dependen just for clients new to recovery. Support groups
20 Types of Groups Commonly Used in Substance Abuse Treatment
can be found for all stages of treatment in all this TIP is mainly concerned with groups led
sorts of settings (inpatient, outpatient, continu by a trained, professional group leader.
ing care, etc.). While a support group always Support group leaders need a solid grounding
will have a clearly stated purpose, the purpose in how groups grow and evolve and the ways
varies according to its members’ motivation in which people interact and change in groups.
and stage of recovery. Many of these groups are It is also critical that group leaders have a
openended, with a changing population of theoretical framework for counseling (such as
members. As new clients move into a particular cognitive–behavioral therapy) that informs
stage of recovery, they may join a support their approach to support group development,
group appropriate for that stage until they are the therapeutic goals for group members, the
ready to move on again. Groups may continue guidance of group members’ interactions, and
indefinitely, with new members coming in and the leader’s imple
old members leaving, and occasionally, return mentation of specific
ing. Program differences will also alter how this intervention methods.
type of group is used. A support group will be In a support
different in a 4 to 6week daily treatment pro Since the leader
gram from the way it is used in a 1year treat should help build con
ment community. nections between group, members
members and empha
In a support group, members typically talk size what they have in typically talk
about their current situation and recent prob common, it is useful
lems that have arisen. Discussion usually focus for the leader to have about their cur
es on the practical matters of staying abstinent; participated in a sup
for example, ways to deal with legal issues or port group and to rent situation and
avoid places that tempt people to use sub have been supervised
stances. Group members are encouraged to in support group
problems that
share and discuss their common experiences. work before under
taking leadership of
Issues that do not specifically relate to the such a group. have recently
focus of the group are often considered extra Training and supervi
neous, so discussion of them is limited. Support sion focused on how arisen.
groups provide guidance through peer feed individuals develop
back, and group members generally require psychologically, typi
accountability from each other. The group cal psychological con
leader, however, will try to minimize confronta flicts, and the way these conflicts may appear
tion within the group so as to keep anxiety lev in group therapy settings also may help the
els low. In cohesive, highly functioning support support group leader function more effectively,
groups, membertomember or leadertomem since such considerations help the leader
ber confrontation does occur. understand individual members’ behavior in
Support groups can work from a variety of the the group.
oretical positions. Many reflect the 12Step tra The leadership style for someone running a
dition in the substance abuse field, but other support group typically will be less directive
recovery tools, such as relapse prevention, can than for psychoeducational, skills develop
form the basis of a support group. Some sup ment, or cognitive–behavioral groups because
port groups are based on theoretical frame the support group is generally groupfocused
works such as cognitive therapies or spiritual rather than leaderfocused. The leader’s pri
paths. Programs may even design a support mary role is to facilitate group discussion, help
group by combining theories or philosophies. ing group members share their experiences,
Leadership skills and styles. Some support grapple with their problems, and overcome dif
groups may be peergenerated or peerled, but ficult challenges. The group leader also pro
vides positive reinforcement for group mem
Types of Groups Commonly Used in Substance Abuse Treatment 21
bers, models appropriate interactions between experience. Understanding some of the history
individuals in the group, respects individual of each person in the group, the leader also
and group boundaries, and fosters open and watches to see whether the group is providing
honest communication in the group setting. In each individual with emotional and interper
a most general way, the leader is active but not sonal experiences that build success and skills
directive. that apply to life arenas outside the group. In
addition to monitoring individuals in the
Techniques. The techniques of leading support group, the leader also monitors the progress of
groups vary with group goals and member the group as a whole, making sure that group
needs. In general, leaders need to actively development proceeds through its predictable
facilitate discussion among members, maintain stages and does not become blocked at any
appropriate group boundaries, help the group stage of its evolution.
work though obstacles and conflicts, and pro
vide acceptance of and regard for members. In Finally the leader is responsible for recognizing
a support group, the leader exercises the role interpersonal blocks or struggles between
of modeler of appropriate behaviors. In this group members. It is not necessarily the
way, the leader helps members grow and responsibility of the leader to resolve these
change. blocks, or even to point them out to group
members, but to ensure that such struggles
Specific group techniques may appear to be do not hinder the development of the group or
less important for the leader of a support any member of the group.
group, since the leader is usually less active in
group direction and leadership. The techniques
used in support groups, however, are simply Interpersonal Process Group
less obvious. Psychotherapy
Interventions, for example, are likely to be The interpersonal process group model for
more interpretive and observational and less substance abuse treatment is grounded in an
directive than in many other groups. The extensive body of theory (Brown 1985; Brown
observations are generally limited to support and Yalom 1977; Flores 1988; Flores and
for the progress of the group and facilitating Mahon 1993; Khantzian et al. 1990; Matano
supportive interac and Yalom 1991; Vannicelli 1992; Washton
tion among group 1992). Even this sharply defined area of pro
members. The goal cessoriented group therapies is widely diverse.
is not to provide Psychodynamic group therapies can be thought
Processoriented insight to group of as a generic name encompassing several ways
members, but to of looking at the dynamics that take place in
group therapy facilitate the evolu groups. Originally, these dynamics were consid
tion of support with ered in Freudian psychoanalytic terms that
in the group. placed a heavy emphasis on sexual and aggres
uses the process of sive drives, and conflicts and attachments
The support group between parents and children. Over the past
the group as the leader is also respon half century many researchers, such as Jung,
sible for monitoring Adler, Bion, Noreno, Rogers, Perls, Yalom,
primary change each individual’s and others, expanded or changed the Freudian
progress in group emphasis. As a result, current dynamic concep
mechanism. and ensuring that tualizations include heavy emphasis on the
individuals are par social nature of human attachment, rivalry and
ticipating (in their social hierarchies, and cultural and spiritual
own way) and bene concerns (i.e., existential issues and questions
fiting from the group
22 Types of Groups Commonly Used in Substance Abuse Treatment
of faith). This therapeutic approach focuses on • Sometimes perceptions distort reality. People
healing by changing basic intrapsychic (within often draw generalizations from their life
a person) or interpersonal (between people) experiences and apply the generalizations to
psychological dynamics. the current environment, even when doing so
is inappropriate or counterproductive. These
Thus, a student of processoriented group ther “cognitive distortions” may serve to maintain
apy, a group treatment approach that uses the habits people would otherwise like to change.
process of the group as the primary change
mechanism, soon learns that the way Bion • Psychological and cognitive processes outside
(1961) taught group therapy will be far differ awareness influence behavior. As clients
ent from the way other recognized authorities, become conscious of some formerly subcon
such as Wolf and Schwartz (1962), taught. scious processes supporting a behavior they
These theorists in turn differ from the process want to change, this information can be used
orientation exemplified by Durkin (1964) or to alter dysfunctional relationships.
Glatzer (1969). The many theoretical variants • Behaviors are chosen to adapt to situations
differ in what they pay most of their attention and protect people from harm. A specific
to as group members interact. behavior is a person’s best effort to adapt to
a particular situation given individual make
Purpose. Interpersonal process groups use up, environment, and personal history. In a
psychodynamics, or knowledge of the way peo sense, people come to therapy because of
ple function psychologically, to promote change their solutions, not their problems.
and healing. The psychodynamic approach rec
ognizes that conflicting forces in the mind, Within the interpersonal process model, the
some of which may be outside one’s awareness, objects of interest are the hereandnow inter
determine a person’s behavior, whether healthy actions among members. Of less importance is
or unhealthy. Attachment to others is one of what happens outside the group or in the past.
the contending forces. From a psychodynamic All therapists using a “processoriented group
point of view, starting in early childhood, therapy” model continually monitor three
developmental issues are a key concern, as are dynamics:
environmental influences, to which certain peo
• The psychological functioning of each group
ple are particularly vulnerable because of their
member (intrapsychic dynamics)
genetic and other biological characteristics. For
those people who have been drawn to substance • The way people are relating to one another in
abuse, the interpersonal process group raises the group setting (interpersonal dynamics)
and reexamines fundamental developmental • How the group as a whole is functioning
issues. As faulty relationship patterns are per (groupasawhole dynamics)
ceived and identified, the group participant
can begin to change dysfunctional, destructive A group leader conducting an interpersonal
patterns. The group member becomes increas process group, however, will tend to pay more
ingly able to form mutually satisfying relation attention to the interpersonal dynamics and
ships with other people, so alcohol and drugs concentrate less on each member’s individual
lose much of their power and appeal. psychological dynamics and the workings of the
group as a whole. The section that follows
Basic tenets of the psychodynamic approach includes illustrations (Figures 23 to 26) of how
include the following groups might differ according to their focus on
intrapsychic, interpersonal, and groupasa
• Early experience affects later experience. whole dynamics.
Individuals bring their histories—personal,
cultural, psychological, and spiritual—to The experienced group leader knows that the
therapy. intervention chosen at any moment in the group
will have an impact on all three dynamics and
Types of Groups Commonly Used in Substance Abuse Treatment 23
that a delicate balance must be struck in the or authoritarian leader. The IPGP model per
attention given to each. A toointense focus on mits a group experience that is neither leader
group members’ interaction, to the exclusion of dependent nor leadercentered. This general
attention to individual psychological needs or ly egalitarian setting helps to reduce resis
the needs of the group as a whole, blunts the tance.
effectiveness and relevance of group develop • Synergistic. IPGP and substance abuse treat
ment. ment complement each other, reciprocally
Principal characteristics. Interpersonal pro setting the scene for the establishment of the
cess group therapy delves into major develop crucial components of effective treatment.
mental issues, searching for patterns that con The combination of IPGP and substance
tribute to addiction or interfere with recovery. abuse treatment allows the client to experi
The group becomes a microcosm of the way ence treatment as emotionally supportive.
group members relate to people in their daily This sparing of the client’s selfimage enables
lives. the client to identify positively with treatment
and mutes any strong reactions to the coun
The Interpersonal Process Group Psychothe selor. Further, the combination of these two
rapy (IPGP) model links the abstinencebased treatment approaches can ease the client’s
treatment approach with current psychological handling of shame, the need to change
principles of treatment, while still remaining aspects of self, the uncomfortable newness of
compatible with 12Step theory and practice. the recovery period, and the therapeutic
IPGP and substance abuse treatment both rec experience itself. Recovery can proceed as
ognize that a person’s capacity for healthy clients experience and reexperience deep
interpersonal relationships supports solid attachment dynamics and use the experience
recovery from substance abuse. IPGP is easy to to craft major changes in character and
understand and adapt because it is behavior.
24 Types of Groups Commonly Used in Substance Abuse Treatment
bringing to the group as a whole, and how indi to be more or less
vidual resistances to change are interacting active in the group
with and influencing group functioning. The life. They might also
interventions of the leader are dependent on choose, based on the
his or her perceptions of this mix. needs of the group, to In interpersonal
make more or fewer
Since the group leader’s theoretical persuasion, interpretations of process groups,
training, experience, and personality determine individual and group
the level of intervention that takes priority at a dynamics to the group leaders focus on
particular time, it is rare to find two interper as a whole. Likewise
sonal process group leaders who will conduct a they might choose to the present.
group in exactly the same manner. Even so, show more warmth
leaders in this type of group are not fonts of and supportiveness
information, skill builders, problemsolving toward group mem
directors, or client boosters. In interpersonal bers or take a more
process group therapy, the leader’s job is to aloof position. For
promote and probe interactions that carry instance, in contrast to leading a support
a point. group, where the leader is likely to be uncondi
Most group leaders who apply a processorient tionally affirming, the process leader might
ed approach to group therapy with people who make a conscious decision to allow clients to
abuse substances recognize the theoretical struggle to affirm themselves, rather than
influence of the Interactional Model (Yalom essentially doing it for them.
1975). Yalom recommends an adaptable Such choices should be based on the needs of
approach to group treatment, one that allows group members and the needs of the group as a
easily applied modifications across the continu whole, rather than the style that is most com
um of the recovery needs of an individual who fortable for the group leader. Obviously such
abuses substances. His model can be tightened tactical decisions require a high degree of
(to have more structure) early in treatment and understanding and insight about group dynam
can subsequently be loosened (to relax struc ics and individual behavior. For this reason,
ture) as more abstinent time passes, recovery is almost all leaders of process groups will seek
solidified, and the danger of relapse decreases. supervision and consultation to guide them in
Techniques. In practice, group leaders may use making the best tactical decisions on behalf of
different models at various times, and may the group and its members.
simultaneously influence more than one focus
level at a time. For example, a group that Three group dynamics
focuses on changing the individual will also in practice
have an impact on the group’s interpersonal
relations and the groupasawhole. Groups When deciding on a model for a substance
will, however, have a general orientation that abuse treatment group, programs need to con
determines the focus the majority of the time. sider their resources, the training and theoreti
This focus is an entry point for the group lead cal orientation of group leaders, and the needs
er, helping to provide direction when working and desires of clients in order to determine
with the group. what approaches are feasible. While it is
beyond the scope of this TIP to provide
Specific techniques of the process group leader detailed instruction on how to run each of the
will vary, not only with the type of process different models of groups, the following figures
group, but also with the developmental stage of do illustrate the basic differences among the
the group. Early on in group development, psychodynamic emphases. Figure 23 describes
process group leaders might consciously decide an argument drawn from a problemfocused
Types of Groups Commonly Used in Substance Abuse Treatment 25
Figure 23
Group Vignette: Joe’s Argument With His Roommate
Before the first meeting of a new problemfocused group, Joe had been arguing
with his roommate because the roommate had forgotten to pay the phone bill the
previous month. Joe had told his roommate, Mike, that he might remember to
pay the bills on time if he were not smoking pot every day, and they began an
angry discussion about the roommate’s drug use. Joe tells the group that he wants
to talk about his distrust of his roommate. Joe is not currently using drugs, but
he is still struggling with attempts to control his drinking. Group members are
generally supportive of Joe in his argument with his roommate. They express
concern that he is living with someone who is actively using marijuana and other
drugs. One group member, Jane, voices strong objections, however, to Joe’s lack
of trust for his roommate. Jane is struggling with her own abuse of prescription
tranquilizers, and she is typically rather quiet and anxious in group.
Nonetheless, she attacks Joe verbally with uncharacteristic vehemence.
Source: Adapted from Flores 1997.
group, which assists people in resolving a spe and psychodrama as well as the glossary in
cific problem in their lives. (For additional appendix D).
information on this type of group, see the last
section in this chapter. The reader also may The group is conceived as an aggregate of indi
refer to appendix B of TIP 34, Brief viduals in which the group leader generally
Interventions and Brief Therapies for works sequentially with one group member at
Substance Abuse [CSAT 1999a], for a list of a time. While one individual’s issues are
resources that can provide further training and addressed, the other group members serve as
information about the theoretical orientations observers, contributors, alter egos, or signifi
that influence these groups.) cant others. Generally, however, more than
one group member will be involved in the con
versation at one time, and all group members
Individually focused groups will be encouraged to actively help each other
The individually focused group concentrates on and learn from each other’s experiences. This
individual members of the group and their dis model of group does not require a client to
tinctive internal cognitive and emotional pro have insight into a problem but does require
cesses. How the client interacts in the world at awareness of behavior and its immediate caus
large is not on the agenda. The group instead es and consequences. Some individually orient
strives to modify clients’ behavior. This model ed approaches will use group members in a
is used with a range of technical and theoretical structured/directive way, such as in a role
approaches to group therapy, including cogni playing exercise.
tive therapy, expressive therapies, psychodra
ma, transactional analysis, redecision therapy, In the more cognitively oriented approaches,
Gestalt, and reality therapy (see section below clients will focus on their behaviors in relation
for further discussion of expressive therapies to thoughts. The more expressive form of indi
vidually oriented groups is particularly bene
26 Types of Groups Commonly Used in Substance Abuse Treatment
ficial for clients who need a structured envi group include sensitivity training, or Tgroups
ronment or have so much contained, powerful (Bradford et al. 1964), and L. Ormont’s
emotion that they need some creative way of Modern Analytic Approach (Ormont 1992). In
releasing it. groups that follow this model, emphasis is
placed primarily on current interactions
Individually focused groups are useful to iden between and among group members. Clients
tify the first concrete steps in coping with sub are urged to explore how they behave, how this
stance abuse. They can help clients become behavior affects others, and how
more aware of behavior and its causes, and at others’ behavior affects them.
the same time, they increase the client’s range
of options as to how to behave. The ideal end In interpersonally focused groups, the group
result is the client’s freedom from an unpro leader serves as a role model, but does not
ductive or destructive behavior. explicitly assess the clients’ behavior. That task
is left to other group members, who evaluate
Figure 24 describes how an individually each other’s behavior. The group leader moni
focused group might respond to the conflict tors the way clients relate to one another, and
described in Figure 23. reinforces therapeutic group norms, such as
members responding to each other in an
Interpersonally focused emphatic way. The leader also steps in to
groups extinguish contratherapeutic norms that might
damage group cohesion or to point out behav
Interpersonally focused groups generally work ior that could inhibit empathic relationships
from a theory of interactional group therapy, within the group.
most often associated with the work of Irving
Yalom (1995). Other examples of this model of
Figure 24
Joe’s Case in an Individually Focused Group
The group leader in an individually focused group might work first with Joe and
then Jane (or vice versa, depending on who seemed to have the more pressing
issues). The group leader might ask Joe to tell the group more about his anger
and how he experiences it and might ask him to say why he has difficulty trust
ing his roommate. Joe could be urged to see how this situation might relate to
other circumstances and how his reaction to his roommate’s substance abuse
might help him understand his own problems with drinking. The leader might
use roleplaying techniques with Joe so that he can practice how he will interact
with his roommate and better understand his reaction to his roommate’s behav
ior. Jane might be asked why Joe’s reaction to his roommate made her so angry.
The group leader could try to help her see if Joe reminded her of anyone and
whether she identified with the roommate because she too had been judged. Her
fears of being judged might be related to her own substance abuse, and the
group could explore that possibility.
Source: Adapted from Flores 1997.
Types of Groups Commonly Used in Substance Abuse Treatment 27
Figure 25
Joe’s Case in an Interpersonally Focused Group
A group leader working from an interpersonally focused group model would
direct the group’s attention to what is going on between Joe and Jane. The lead
er might ask Jane if she can tell Joe directly how his statements have made her
feel, and then ask Joe to say how he feels about what she said. The group leader
might also ask Joe if he sees any parallel in his response to both his roommate
and Jane. The leader might ask him if Jane could have reported what she felt in
a way that would make him feel less defensive. Jane might tell Joe that she is
reacting to his judgmental behavior toward his roommate and his evasiveness
about his own drinking. This interaction confronts Joe’s denial. If Jane discloses
the reasons behind her response to Joe, namely that her husband distrusts her
in a similar manner, the group leader would turn the issue over to the group,
perhaps asking Jane how she thinks Joe feels about her. Another group member
who has worked on issues concerning trust may interpret what is really going on
between Joe and Jane. The goal is to help Joe and Jane deal authentically and
realistically with one another, and strengthen the attachment between them.
This analysis of relationships within the group may ultimately transfer to set
tings outside the group and improve Joe’s and Jane’s relationships with others
outside the group.
Source: Adapted from Flores 1997.
Figure 25 describes how an interpersonally as a single unit with its own ways of operating
focused group might respond to the conflict in the world.
described in Figure 23.
This model generally is inappropriate for
clients with substance use disorders—at least
Groupasawhole focused as the sole approach to treatment. It can be
groups harmful, especially to clients new to recovery,
The theoretical approaches most often associat and can add to their problems without helping
ed with the groupasawhole orientation are them manage their substance abuse. Certain
Tavistock’s GroupasaWhole (Bion 1961; Rice techniques taken from this approach, however,
1965), Agazarian SystemsCentered Therapy may be used productively in an eclectic treat
for Group (Agazarian 1992), Bion’s primary ment group. For example, when the entire
assumption groups (Bion 1961), and the focal group seems to be sharing a mood, behavior, or
conflict model (Whitaker and Lieberman viewpoint, a group leader may choose to use
1965). As the name suggests, in this model, the mass group process comments, such as “You all
group leader focuses on the group as a single seem quiet today” or “Almost everyone is gang
entity or system. While model variations may ing up on Jim.”
recognize the group as an aggregate of individ Figure 26 describes how a groupasawhole
uals (the SystemsCentered Therapy does, for focused group might handle Joe’s problem.
instance), the emphasis remains on the group
28 Types of Groups Commonly Used in Substance Abuse Treatment
Figure 26
Joe’s Case in a GroupAsAWhole Focused Group
A group leader with a Bion orientation would notice a lot of conflict swirling
around this incident and that the group is in a “fight mode.” The point of inter
est would be the source of the tension and how it interferes with the work of the
group, which is the recovery process. The leader might note that the group has
become very involved in this discussion as a way of evading issues of trust com
mon to the whole group. Is the group perhaps fleeing from dealing directly with
trust? Looking at Jane’s response, the group leader would consider whether
Jane’s response is carrying something for the group, that is, representing a
group concern about whether the group will judge members for what they have
to say. The discussion might be redirected toward how the group is coping with
feelings of uncertainty about continued substance use.
Source: Adapted from Flores 1997.
Three cautionary notes Specialized Groups in
These vignettes illustrate the different interven
tions available. No single approach necessarily
Substance Abuse
is more appropriate than any other. The Treatment
critical question is always, “Is this approach A variety of therapeutic groups that do not
the most likely to succeed with this particular fit in the alreadydescribed group models may
group in substance abuse treatment?” be employed in substance abuse treatment
In addition to making the right strategic choice settings. Some of these specialized groups are
of approach, the interventions should be done unique to substance abuse treatment (like
at the right time. Treatment as a timedepen relapse prevention), and others are unique in
dent process should be the guiding principle format, group membership, or structure (such
when working with people with addictions as culturally specific groups and expressive
in group. therapy groups). It would be impossible to
describe all of the types of special groups that
Finally, what works for the client without might be used in substance abuse treatment.
addictions will not always work with a client The three that follow represent a crosssection
with addictions. Consequently, the rest of this of special groups.
TIP will be dedicated to exploring the modifi
cations in group technique that need to be
made when treating people with substance Relapse Prevention
use disorders. Relapse prevention groups focus on helping a
client maintain abstinence or recover from
relapse. This kind of group is appropriate for
clients who have attained abstinence, but who
have not necessarily established a proven track
record indicating they have all the skills to
maintain a drugfree state. Relapse prevention
Types of Groups Commonly Used in Substance Abuse Treatment 29
also can be helpful for people in crisis or who skills development; other models tend to
are in some way susceptible to a return to sub emphasize support.
stance use.
These approaches share a number of basic ele
Purpose. Relapse prevention groups help ments, including teaching clients to recognize
clients maintain their sobriety by providing highrisk situations that may lead to relapse,
them with the skills and knowledge to “antici preparing them to meet those highrisk situa
pate, identify, and manage highrisk situations” tions, and helping them develop balance and
that lead to relapse into substance use “while alternative ways of coping with stressful situa
also making security preparations for their tions. Many of these approaches also increase
future by striving for broader life balance” group members’ feelings of self
(Dimeff and Marlatt 1995, p. 176). Thus, control, so they feel capable of resisting
relapse prevention is a doublelevel initiative. relapse. (More information on the techniques
It aims both to upgrade a client’s ability to of relapse prevention appears in TIP 34, Brief
manage risky situations and to stabilize a Interventions and Brief Therapies for
client’s lifestyle through changes in behavior Substance Abuse [CSAT 1999a].)
(Dimeff and Marlatt 1995).
Research has demonstrated that relapse is com
Principal characteristics. Relapse prevention mon and to be expected during the process of
groups focus on activities, problemsolving, and recovery (Project MATCH 1997). In a meta
skillsbuilding. They also may take the form of analysis of 24 controlled clinical trials evaluat
psychotherapy. For instance, Khantzian et al. ing relapse prevention programs delivered in
(1992) assert that, because the same traits in both group and individual formats, Carroll
personality and character predispose people (1996) found that relapse prevention groups
to use substances initially and to relapse dur were effective in comparison to notreatment
ing recovery, psychodynamic approaches can controls for many substances of abuse; the
mitigate psychological vulnerabilities. Because groups were most effective for smoking cessa
relapse prevention groups may use techniques tion. Carroll also notes that relapse prevention
drawn from all of these types of groups, they groups seem to reduce the intensity of relapse
are considered a special type of group in when it occurs. Groups also appear to be more
this TIP. effective than other approaches for clients who
have “more severe levels of substance use,
The different models greater levels of negative affect, and greater
for relapse preven perceived deficits in coping skills” (1996, p. 52).
tion groups
Relapse (Donovan and Research also suggests that relapse prevention
Chaney 1985) can be conducted in both group and oneon
include those devel one formats, with little measurable difference
prevention groups
oped by Annis and in outcomes. Schmitz and colleagues (1997)
Davis (1988), Daley compared relapse prevention for cocaine abuse
focus on activities, (1989), Gorski and delivered in group and individual formats.
Miller (1982), and Both demonstrated favorable outcomes; no
problemsolving, Marlatt (1982). All significant difference was detected in cocaine
of these models are use as measured by urine tests. Clients treated
and skills derived from princi in groups, however, reported fewer cocaine
ples of cognitive related problems than those treated in individ
building. therapy. Some, such ual sessions. Further, McKay et al. (1997)
as that of Marlatt, found that 6 months after intensive outpatient
classify relapse pre treatment for cocaine abuse, subjects treated
vention as a form of in a group setting displayed higher rates
30 Types of Groups Commonly Used in Substance Abuse Treatment
of sustained abstinence than those treated Techniques. Relapse prevention groups draw
individually. on techniques used in a variety of other types
of groups, especially the cognitive–behavioral,
Relapse prevention carried out in group set psychoeducational, skills development, and
tings enables clients to explore the problems of processoriented groups. Because the purpose
daily life and recovery together and to work of a relapse prevention group is to help mem
collaboratively to isolate and overcome prob bers develop new ways of living and relating to
lems. Because of these dual goals, relapse pre others, thereby undercutting the need to return
vention groups may improve clients’ quality of to substance use or abuse, potential group
life. However, as Schmitz and colleagues note, members need to achieve a period of abstinence
it may also be the case that the group experi before joining a relapse prevention group.
ence makes members less willing to report the
severity of their problems or cause them to feel
that their problems are less severe by compari Communal and Culturally
son to those of others (Schmitz et al. 1997). Specific Groups
Leadership skills and styles. Leaders of Restoring lost cultural ties or providing a sense
relapse prevention groups need to have a set of of cultural belonging can be a powerful thera
skills similar to those needed for a skills devel peutic force in substance abuse treatment, and
opment group. However, they also need experi in important ways, substance abuse is intimate
ence working in relapse prevention, which ly intertwined with the cultural context in
requires specialized training, perhaps in a par which it occurs. Cultural prohibitions against
ticular model of relapse prevention. Leaders substance use and cultural patterns of permis
also sible use define, in part, what is reasonable use
need a welldeveloped ability to work on group and what is abuse of substances (Westermeyer
process issues. 1995). Risk factors such as cultural displace
ment or discrimination cause substance abuse
Group leaders need to be able to monitor client rates to rise drastically for a given population.
participation to determine risk for relapse, to Problems that pervade particular cultures,
perceive signs of environmental stress, and to such as racism, poverty, and unemployment,
know when a client needs a particular interven have an impact on the incidence of substance
tion. Above all, group leaders should know how abuse and are appropriate focuses for inter
to handle relapse and help the group process vention in substance abuse treatment (Taylor
such an event in a nonjudgmental, nonpunitive and Jackson 1990; Thornton and Carter 1988).
way—clients, after all, need to feel safe in the
group and in their recovery. Leaders should Communal and culturally specific wellness
know how to help the group manage the absti activities and groups include a wide range of
nence violation effect, in which a single lapse activities that use a specific culture’s healing
leads to a major recurrence of the addiction. practices and adjust therapy to cultural values.
For instance, Hispanics/Latinos generally share
Additionally, the leader of a relapse prevention a value of personalismo, a preference for per
group should understand the range of conse sontoperson contact. Effective substance
quences a client faces because of relapse. These abuse treatment providers thus build personal
consequences can be culturally specific relationships with clients before turning to the
responses, criminal justice penalties, child tasks of treatment. Also, at the outset of treat
protective services actions, welfaretowork ment, personal relationships do not yet exist.
setbacks, and so on. The group leader, like any At this point, a client’s hesitation should not
counselor, should know the confidentiality be mistaken for resistance (Millan and Ivory
rules (42 C.F.R. Part 2) and the legal reporting 1994).
requirements relating to client relapse.
Types of Groups Commonly Used in Substance Abuse Treatment 31
Three common ways to integrate such their own background, cope with prejudice,
strengthsfocused activities into a substance and resolve other problems related to minori
abuse treatment program are ty status. Groups described in this TIP fall
into this category.
• Culturally specific group wellness activities
may be used in a treatment program to help Purpose. Groups and practices that accentuate
clients heal from substance abuse and prob cultural affinity help curtail substance abuse
lems related to it. by using a particular culture’s healing practices
• Culturally specific practices or concepts can and tapping into the healing power of a com
be integrated into a therapeutic group to munal and cultural heritage. Many have
instruct clients or assist them in some aspect commented on the usefulness of these types of
of recovery. For example, a psychoeducation groups (Trepper et al. 1997; Westermeyer
al group formed to help clients develop a bal 1995), and clinical experience supports their
ance in their lives might use an American utility. As this TIP is written, little research
Indian medicine wheel diagram or the seven based evidence has accumulated to confirm the
principles of Kwanzaa. The medicine wheel effectiveness of this approach. Research is
represents four dimensions of wellness: needed to evaluate the effectiveness of cultural
belonging, independence, mastery, and gen ly specific groups and ascertain the primary
erosity. These four concepts promote wellness indications for their use.
for the individual and collective good of the Principal characteristics. Different cultures
AmericanIndian tribal group and humani have developed their own views of what consti
ty/environments. Kwanzaa is based on a tutes a healthy and happy life. These ideas may
value system of seven principles called the prove more relevant and understandable to
Nguzo Saba. The Kwanzaa paradigm is a members of a minority culture than do the val
nonreligious, nonheroic ritual that has been ues of the dominant culture, which sometimes
widely embraced by the national African can alienate rather than heal. All cultures also
American community. The Nguzo Saba and have specific processes for promoting wellness
other Kwanzaa symbols and practices can be among their members.
used therapeutically in the regrounding and
reconnecting process for AfricanAmerican In using a culture’s healing practices or group
clients. activities, whether in heterogeneous or homoge
• Culturally or communityspecific treatment neous groups (that is, all one culture or a mix
groups may be developed within a services of cultures), treatment providers should be
program or in a substance abuse treatment careful to show respect for the culture and its
program serving a heterogeneous population healing practices. As long as respect and
with a significant minority population of a awareness are evident, the use of such prac
specific type. Examples might include a tices will not harm the members of a particular
group for people with cognitive disabilities, culture.
or a bilingual group for recent immigrants.
Leadership characteristics and style. Group
Such groups typically are process or sup
leaders always need to strive to be culturally
portoriented, though they also may have
competent with members of the various popula
psychoeducational components. The groups
tions who enter their programs.1 Substance
help minority group members understand
1 See chapter 3 of this TIP and the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment
(SAMHSA in development a) for more information on cultural competence. TIP 29, Substance Use Disorder Treatment
for People With Physical and Cognitive Disabilities (CSAT 1998b), contains information on being sensitive and respon
sive to the needs of people with disabilities, and A Provider’s Introduction to Substance Abuse Treatment for Lesbian,
Gay, Bisexual, and Transgender Individuals (CSAT 2001) has information on working with gay and lesbian populations.
32 Types of Groups Commonly Used in Substance Abuse Treatment
abuse treatment counselors first need to be and practices of the cultural group. The group
aware of the demographics in their program leader should pay attention to a number of fac
areas, and to be aware as well that there are tors, all of which should be considered in any
many people from mixed ethnic backgrounds group but which will be particularly important
who do not necessarily know or recognize their in culturally specific groups. Clinicians should
cultural heritage. Clinicians should actively
avoid stereotyping clients based on their looks, • Be aware of cultural attitudes and resistances
and instead allow them to selfidentify. Clients toward groups.
should be asked what it means to them to • Understand the dominant culture’s view of
belong to a particular group. Clinicians also the cultural group or community and how
should be sensitive to selfidentification issues that affects members of the group.
such as sexual orientation, gender identifica • Be able to validate and acknowledge past and
tion, and disability. When in doubt, clinicians current oppression, with a goal of helping to
should discuss the issue privately with the empower group members.
client.
• Be aware of a cultural group’s collective grief
A group leader for a culturally specific group and anger and how it can affect counter
will need to be sensitive and creative. How transference issues.
much authority leaders will exercise and how
interactive they will be depends on the values
Figure 27
The SageWind Model for Group Therapy
In programs that have the resources, the capacity to offer a variety of types of
groups addressing a range of client needs is preferred. SageWind in Reno,
Nevada, offers more than 100 groups each week.
To assess each client’s unique needs, SageWind’s comprehensive biopsychosocial
assessment evaluates the severity of a client’s substance abuse. In addition, the
clinical team, the client, and any others concerned (such as probation or parole
officers, parents or legal guardians, or social workers) determine the best course
of group therapy formats.
Group intervention ranges in intensity from one group per week to more than
20. The large number of weekly groups offered in SageWind’s menu of options
covers a continuum of treatment options from psychoeducational to skillsbuild
ing to experiential to processoriented. In a structured program similar to that
of a university, where fundamental courses are required before more advanced
ones may be taken, clients attend the groups they need, then change to others
and progress through the program. Clients complete groups, moving to more
advanced formats until they have met discharge criteria based on the American
Society of Addiction Medicine (ASAM) Patient Placement Criteria2R (PPC2R)
(ASAM 2001).
Types of Groups Commonly Used in Substance Abuse Treatment 33
• Focus on what is held in common among states that play therapy and art therapy are
members of the group, being sensitive to particularly useful for substance abuse treat
differences. ment clients who have been incest victims.
Play and art therapies enable these clients to
The SageWind Model for group therapy, work through their trauma and substance
discussed in Figure 27 (see p. 33), provides abuse issues using alternatives to verbal
individually tailored interventions for its communication (Glover 1999).
clients.
Although a number of articles have theorized
Techniques. Different cultures have specific about the usefulness of various types of expres
activities that can be used in a treatment sive therapy for clients with substance use dis
setting. Some common elements in treatment orders, little study on the subject has used rig
include storytelling, rituals and religious prac orous research methods. Clinical observation,
tices, holiday celebrations, retreats, and rites however, has suggested benefits for female
of passage practice (these may be particularly clients involved in dance therapy (Goodison
useful for adolescent clients). and Schafer 1999). Client selfreports suggest
Culturally specific groups work best if all mem the value of psychodrama for female clients in
bers of the population become involved in the treatment for alcoholism, particularly for high
activity, even the clients who are not familiar ly educated women and those who are inclined
with their cultural heritage. In fact, the reasons to be extroverted and verbally expressive
for that lack of familiarity can become a topic (Loughlin 1992).
of discussion. Helping clients understand what As Galanter and colleagues note, expressive
they have lost by being separated from their therapy groups—which they called “activity
cultural heritage, whether because of substance groups”—often can be “the source of valuable
abuse or societal forces, can provide one more insight into patients’ deficits and assets, both of
reason to continue in sobriety. which may go undetected by treatment staff
members concerned with more narrowly
Expressive Groups focused treatment interventions” (Galanter et
al. 1998, p. 528).
This category includes a range of therapeutic
activities that allow clients to express feelings Principal characteristics. The actual charac
and thoughts—conscious or unconscious—that teristics of an expressive therapy group will
they might have difficulty communicating with depend on the form of expression clients are
spoken words alone. asked to use. Expressive therapy may use art,
music, drama, psychodrama, Gestalt, bioener
Purpose. Expressive therapy groups generally getics, psychomotor, play (often with children)
foster social interaction among group members games, dance, free movement, or poetry.
as they engage either together or independently
in a creative activity. These groups therefore Leadership characteristics and style.
can improve socialization and the development Expressive group leaders generally will have a
of creative interests. Further, by enabling highly interactive style in group. They will need
clients to express themselves in ways they might to focus the group’s attention on creative activi
not be able to in traditional talking therapies, ties while remaining mindful of group process
expressive therapies can help clients explore issues. The leader of an expressive group will
their substance abuse, its origins, the effect it need to be trained in the particular modality to
has had on their lives, and new options for cop be used (for example, art therapy).
ing. These groups can also help clients resolve
trauma (like child abuse or domestic violence) Expressive therapies can require highly skilled
that may have been a progenitor of their sub staff, and, if a program does not have a trained
stance abuse. For example, Glover (1999) staff person, it may need to hire an outside
consultant to provide these services. Any con
34 Types of Groups Commonly Used in Substance Abuse Treatment
sultant working with the group should be in cific form of cogni
regular communication with other staff, since tive–behavioral group
expressive activities need to be integrated into used to eliminate or
the overall program, and group leaders need to modify a single par Expressive
know about each client if they are to under ticular problem, such
stand their work in the group. as shyness, loss of a therapy groups
loved one, or sub
Expressive therapies can stir up very powerful stance abuse. In
feelings and memories. The group leader foster social
sheer numbers, these
should be able to recognize the signs of reac groups are the most
tions to trauma and be able to contain clients’ interaction as
widespread.
emotional responses when necessary. Group Additionally, prob
leaders need to know as well how to help clients lemsolving groups are members engage
obtain the resources they need to work though directed from a cogni
their powerful emotions. tive–behavioral in a creative
Finally, it is important to be sensitive to a framework. They
client’s ability and willingness to participate in focus on problems of activity.
an activity. To protect participants who may be daily life for people in
in a vulnerable emotional state, the leader early and middle
should be able to set boundaries for group recovery, helping
members’ behavior. For example, in a move group members learn
ment therapy group, participants need to be problemsolving skills, cope with everyday diffi
aware of each other’s personal space and culties, and develop the ability to give and
understand what types of touching are not receive support in a group setting. As clients
permissible. discuss problems they face, these problems are
generalized to the experience of group mem
Techniques. The techniques used in expressive bers, who offer support and insight.
groups depend on the type of expressive thera
py being conducted. Generally, however, these Purpose. Problemfocused groups’ primary
groups set clients to work on an activity. purpose is to “change, alter, or eliminate a
Sometimes clients may work individually, as in group member’s selfdestructive or selfdefeat
the case of painting or drawing. At other times, ing target behavior. Such groups are
they may work as a group to perform music. usually shortterm and historically have been
After clients have spent some time working on used with addictive types of behavior (smoking,
this activity, the group comes together to dis eating, taking drugs) as well as when the focus
cuss the experience and receive feedback from is on symptom reduction…or behavioral
the group leader and each other. In all expres rehearsal” (Flores 1997, p. 40).
sive therapy groups, client participation is a Principal characteristics. Problemfocused
paramount goal. All clients need to be involved groups are short (commonly 10 or 12 weeks),
in the group activity if the therapy is to exert highly structured groups of people who share a
its full effect. specific problem. This type of group is not
intended to increase client insight, and little or
Groups Focused on Specific no emphasis is placed on selfexploration.
Instead, the group helps clients develop effec
Problems tive coping mechanisms to enable them to meet
In addition to the five models of therapeutic social obligations and to initiate recovery from
groups and three specialized types of groups substance abuse. The group’s focus, for the
discussed above, groups can be classified by most part, is on one symptom or behavior, and
purpose. The problemfocused group is a spe they use the cohesiveness among clients to
Types of Groups Commonly Used in Substance Abuse Treatment 35
increase the rate of treatment compliance and cific problem or loss (such as breast cancer or
change. A problemfocused group commonly is suicide in the family), help people alter a par
used in the early stages of recovery to help ticular behavior or trait (like overeating or shy
clients engage in treatment, learn new skills, ness), or learn a new skill or behavior (for
and commit to sobriety. This kind of group is instance, conflict resolution or assertiveness
helpful particularly for new clients; its homo training).
geneity and simple focus help to allay feelings
of vulnerability and In practice, group leaders may use different
anxiety. models at various times, and may simultane
ously influence more than one focus level at a
Leadership charac- time. For example, a group that focuses on
The leader in a teristics and styles. changing the individual will also have an
The group leader impact on the group’s interpersonal relations
problemfocused usually is active and and the groupasawhole. Groups will, however,
directive. have a general orientation that determines the
group usually Interaction within focus the majority of the time. This focus is an
the group is limited entry point for the group leader, helping to
is active and typically to provide direction when working with the group.
exchanges between
individual clients When deciding on a model for a substance
directive. and the group lead abuse treatment group, programs will need
er; the rest of the to consider their resources, the training and
group acts to theoretical orientation of group leaders, and
confront or support the needs and desires of clients in order to
the client according to the leader’s guidance. determine what approaches are feasible. The
reader may also refer to appendix B of TIP 34,
Techniques. Many traditional recovery groups Brief Interventions and Brief Therapies for
fall into the problemfocused category, which Substance Abuse (CSAT 1999a), for a list of
includes abstinence maintenance, relapse pre resources that can provide further training and
vention, support, behavior management, and information about the theoretical orientations
many continuing care groups. Other examples that influence these groups.
are groups that help support people with a spe
36 Types of Groups Commonly Used in Substance Abuse Treatment
3 Criteria for the
Placement of Clients
in Groups
Overview
In This
Before any client is placed in a group, readiness for particular groups
must be assessed. Techniques such as ecomaps and resources like
Chapter…
American Society of Addiction Medicine (ASAM) criteria (see the
“Primary Placement Considerations” section of this chapter) can be
Matching Clients
very helpful. The clinician must also determine the client’s current stage
With Groups
of recovery and stage of change.
Assessing Client
Culture and ethnicity considerations also are of primary importance.
Readiness for
This chapter explains ways to facilitate the placement of people from
Group
minority cultures and ease such clients into existing groups. From this
Primary Placement
discussion, clinicians can also assess their readiness to deal with other
Considerations
cultures and become aware of processes that occur in multiethnic
Stages of Recovery
groups.
Placing Clients
From Racial or
Ethnic Minorities
Matching Clients With Groups
Diversity in a Broad Sense
Therapy groups, designed to treat substance abuse by resolving persis
Leader SelfAssessment
tent life problems, are used frequently, but the individual success of this
Diversity and Placement
group experience depends in important respects on appropriate place
Ethnic and Cultural
ment. Matching each individual with the right group is critical for suc
Matching
cess. Before placing a client in a particular group, the provider should
Other Considerations for
consider
Practice
• The client’s characteristics, needs, preferences, and stage of recovery
• The program’s resources
• The nature of the group or groups available
The placement choice, moreover, should be considered as constantly
subject to change. Recovery from substance abuse is an ongoing process
and, if resources permit, treatment may continue in various forms for
some time. Clients may need to move to different groups as they progress
through treatment, encounter setbacks, and become more or less com
mitted to recovery. A client may move, for example, from a psychoedu
cational group to a relapse prevention group to an interpersonal process
group. The client also may participate in more than one group at the
same time.
37
ecomap (sometimes called a sociogram) is a
Assessing Client graphic representation that depicts interper
Readiness for Group sonal relationships (Garvin and Seabury 1997;
Placement should begin with a thorough assess Hartman 1978). The client occupies the center
ment of the client’s ability to participate in the of the page. Then, circles are added to show
group and the client’s needs and desires regard each significant relationship. The closer the
ing treatment. This assessment can begin as relationship, the closer it is to the center circle.
part of a general assessment of clients entering A solid line between circles indicates a strong,
the program, but the evaluation process should nurturing relationship, while a dotted line
continue after the initial interview and through depicts a conflicted connection. Arrows drawn
as long as the first 4 to 6 weeks of group. on the lines can represent the direction of the
relationship. An arrow from the center out
Assessment should inquire about all drugs used means “I care about this person.” An incoming
and look for crossaddictions. It also is impor arrow means “This person cares about me.”
tant to match groups to clients’ current needs.
In addition to these and other assessment con Clients who are inarticulate or withdrawn may
siderations, clients should be asked about the welcome the opportunity to present informa
composition of their social networks, types of tion visually, and clinicians can gather useful
groups they have been in, their experience in information from these diagrams. If the dia
those groups, and the roles they typically have gram indicates few, distant, and conflicted rela
played in those groups (Yalom 1995). tionships, the client may require a group that is
very structured.
To help assess clients’ relationships and their
ability to participate productively in a group, The ecomap is indicative, but not comprehen
the clinician can have the client draw an sive. It only provides the client’s viewpoint.
ecomap (see an example in Figure 31). An Though it is a useful tool, leaders should be
Figure 31
EcoMap
Father
Client Wife
Drinking
Brother Buddy Joe
Sister
#2 Exwife
Source: Adapted from Garvin and Seabury 1997; Hartman 1978.
Used with permission.
38 Criteria for the Placement of Clients in Groups
wary of basing placement decisions on this or months. A group usually can be heterogeneous
any other single source of information. Clinical in demographic composition, including men
observation and judgments, information from and women, younger and older clients, and
collateral resources, and other assessment people of different races and ethnicities, but
instruments all should contribute to a decision clients should be placed in groups with people
on a client’s readiness and appropriateness for with similar needs.
group treatment. Either the group leader or
another trained staff person should meet with a People with significant character pathology (for
client before assignment to a group. In this example, a personality disorder) placed in a
interview, it is important to evaluate how the group of people who do not have a similar dis
client reacts to the group leader and to assess order almost certainly would violate the bound
current and past interpersonal relationships. aries of the group and of individuals in the
The group leader also may hold an orientation group. As a result, both the clients who have
group (perhaps educational in nature) to and who lack the character disorder would
observe how the client relates to others. The have a negative group experience and limited
client also may be observed in a waiting room opportunity for growth. Clients with a person
with other clients or in a similar social situation ality disorder generally need a group that can
to gain insight into how each person relates place significant limits on their behavior both
to others. in and beyond the group setting. In groups
treating clients with active psychoses, special
The clinician pays such careful attention to the adaptations would need to be made for possible
relationships clients can manage at their cur psychotic symptoms, delusions, and paranoia.
rent stage of recovery because this capacity has Once such adaptations in technique are made
everything to do with how able the client is to to fit the special circumstances of the popula
participate in a group. Whatever their diagno tion being treated, group therapy—in the
sis, clients in groups—especially interpersonal hands of a skilled group leader—can be an
process groups—need to be able to engage with effective, appropriate form of treatment.
other people. They need motivation to change,
creativity, and dogged perseverance (Brown Other types of clients who may be inappropri
1991). Furthermore, the group leader should ate for group therapy include
continue to assess clients as treatment progress • Clients who refuse to participate. No one
es. The clients’ needs and abilities are apt to should be forced to participate in group
change––change is part of successful treat therapy.
ment––and the appropriate type of group or
the suitability for group in general may shift • People who can’t honor group agreements.
dramatically. Sometimes, as noted, these clients may have a
disqualifying pathology. In other instances,
Not all clients are equally suited for all kinds of they cannot attend for logistical reasons,
groups, nor is any group approach necessary such as a work schedule that conflicts with
or suitable for all clients with a history of sub that of regular group meetings.
stance abuse. For instance, a person who • Clients who, for some reason, are unsuitable
relapses frequently probably would be inap for group therapy. Such people might be
propriate in a support group of individuals prone to dropping out, getting and remaining
who have attained significant abstinence and stuck, or acting in ways contrary to the inter
who have moved on to resolving practical life ests of the group.
problems. It would be equally disadvantageous
• People in the throes of a life crisis. Such
to place a person in the throes of acute with
clients require more concentrated attention
drawal from crack cocaine in a group of people
than groups can provide.
with alcoholism who have been abstinent for 3
Criteria for the Placement of Clients in Groups 39
• People who can’t control impulses. Such Women. Recent studies have shown that
clients, however, may be suitable for women do better in womenonly groups than in
homogeneous groups. mixed gender groups. When women have single
• People whose defenses would clash with the gender group therapy, retention is improved
dynamics of a group. People who can’t toler (Stevens et al. 1989). They also are more likely
ate strong emotions or get along with others to complete their treatment programs (Grella
are examples. 1999), use more services during the course of
their treatment, and are more likely to feel they
• People who experience severe internal
are doing well in treatment (NelsonZlupko et
discomfort in groups.
al. 1996).
The primary reason samesex groups are more
Primary Placement effective for women is that women have distinct
Considerations treatment needs that are different from those
of men. Women are more likely than men to
A formal selection process is essential if clini have experienced traumatic events, which often
cians are to match clients with the groups best lead to depression, anxiety, and posttraumatic
suited to their needs and wants. For each stress disorder. About threequarters of the
group, different filters are appropriate. Some women in treatment have been child or adult
groups may require only that members be par victims of sexual, physical, or emotional abuse
ticipants in a particular program. Others may (Roberts 1998). Statistically, women with sub
require a multidisciplinary panel review of the stance use disorders also have experienced
client’s case history. For many groups, espe more severe types of abuse (such as incest),
cially interpersonal process groups, pregroup and perpetrators have abused them for longer
interviews and client preparation are essential. periods of time in comparison to women with
Client evaluators should not rely solely on the out substance use disorders. The perpetrators
review of forms, but should meet with each are most often male partners, male family
candidate for group placement. The interview members, or male acquaintances. Women
er should listen carefully to the client’s hopes, are less willing to disclose and discuss their
fears, and preferences. Ideally, clients should victimization in mixedgender groups (Hodgins
be offered a menu of appropriate options, since et al. 1997).
people will be more likely to remain committed Women further are more likely to be caretakers
to courses of treatment that they have chosen. for minor children or elderly parents and need
Client choice also may strengthen the therapeu to balance these family responsibilities with
tic alliance and thereby increase the likelihood their own treatment needs. They face greater
of a positive treatment outcome (Emrick 1974, challenges in securing employment, are more
1975; Miller and Rollnick 1991). Naturally, likely to have cooccurring mental illness, and
appropriate clinical guidance should also play encounter greater stigma for their substance
a part in placement decisions. use disorders than men.
After specifying the appropriate treatment Because women are relational by nature and
level, a therapist meets with the client to identi develop a sense of self and selfworth in rela
fy options consistent with this level of care. tion to others (Miller 1986), groups specifically
More specific screens are needed to determine for women are advisable, particularly in early
whether, within the appropriate level of care, treatment. Genderspecific treatment groups
the client is appropriate for treatment in a provide both the safety women often need to
group modality. If so, further screens are need resolve the problems that fuel their substance
ed to determine the most helpful type of group. use disorders and the healing environment they
Considerations include the following.
40 Criteria for the Placement of Clients in Groups
need to develop a healthier development of self (Lawson and Lawson
and connections to other women. 1992), especially the
chapter on group psy
It is important to help female clients make the chotherapy with ado
transition from an environment supportive of lescents by Shaw.
their specific needs to one that is less sensitive In placement,
Last, a journal article
to them. Following treatment, they will need an (Pressman et al. 2001)
effective support network in their communities relates the special dif both the client’s
to help them sustain the gains of treatment. ficulties group psy
(See the forthcoming TIP Substance Abuse chotherapy presents and the group’s
Treatment: Addressing the Specific Needs of for adolescents with
Women [Center for Substance Abuse both psychiatric best interests need
Treatment (SAMHSA) in development b].) and substance abuse
Adolescents. Planning, designing, and operat problems—another to be considered.
ing group therapy services for adolescent common complexity
clients is a complex undertaking. Adolescents of providing group
are strikingly different from adults, both psy therapy for adoles
chosocially and developmentally, and require cents with substance
decidedly different services. Local, State, and abuse disorders.
Federal laws related to confidentiality; infec The client’s level of interpersonal function-
tious disease control; parental permissions and ing, including impulse control. Does the client
notifications; child abuse, neglect, and endan pose a threat to others? Is the client prepared
germent; and statutory rape all can come into to engage in the give and take of group dynam
play when substance abuse treatment services ics? The client’s “level of psychological func
are delivered to minors. Add the complications tioning and integration” should be considered,
related to scheduling around school and the as should “the kinds of defenses [used] to
need to include family in the treatment process, maintain abstinence, and the rigidity of [those]
and it is no surprise that most group therapy defenses” (Vannicelli 1992, p. 31). A client who
for teens occurs in the context of an overall has not moved beyond sloganism, including
treatment program or as part of highly special “avoid strong feelings,” may not do well in a
ized, targeted programs (e.g., see the discussion group that has evolved more sophisticated ways
of Cognitive Behavioral Therapy group sessions to maintain abstinence (Vannicelli 1992).
in Sampl and Kadden 2001). Indeed, to serve
as a substance abuse counselor or clinician in Motivation to abstain. Clients with low levels
the delivery of group therapy to adolescents of motivation to abstain should be placed in
typically requires prior training and experience psychoeducational groups. They can help the
with the particular age group to be served. client make the transition into the recovery
ready stage.
The complexities related to adolescents and
group therapy lie outside the scope of the TIP. Stability. In placement, both the client’s and
Suggested reading for those interested in the group’s best interests need to be considered.
rationale for group therapy with adolescents For example, bringing a new member who is in
includes, but is not limited to, Sampl and crisis into treatment may tax the group beyond
Kadden 2001 or textbooks such as Group its ability to function effectively, yet the group
Therapy with Children and Adolescents might easily manage a person in similar crisis
(Kymissis and Halperin 1996), including the who already is part of the group (Vannicelli
chapter by Spitz and Spitz on adolescents who 1992). Group stability counts as well. An ongo
abuse substances, or Adolescent Substance ing group of clients who have gained insight
Abuse: Etiology, Treatment, and Prevention into the management of their feelings can sup
Criteria for the Placement of Clients in Groups 41
port a new member, mary factor to consider regarding continued
helping that person participation in group should be a client’s abili
solve problems with ty to get something out of the experience, it is
Every effort out getting caught also important to determine how each person’s
up in feelings of cri participation affects the group as a whole. A
should be made to sis themselves. client who, for whatever reason, cannot partici
pate may have a profoundly adverse effect on
Stage of recovery. the group’s ability to coalesce and function
place the client in The five stages of cohesively. If a client does not interfere with
Prochaska and group progress, however, sometimes it is appro
a group in which DiClemente’s trans priate to keep a nonparticipant in the group
theoretical model of and simply allow that person to sit and listen.
the client can change (discussed
briefly in chapter 2 A number of different assessment models can be
succeed. and in greater detail used to allow meaningful dialog between client
in TIP 35, and program representatives during the screen
Enhancing ing and placement phase, even when resources
Motivation for are limited. The ASAM PPC2R treatment cri
Change in teria (ASAM 2001) commonly are used for client
Substance Abuse placement. The criteria are arranged in two
Treatment [CSAT 1999b]) map the route that a sets, one for adults and one for adolescents.
person abusing substances must travel during Each set covers five levels of service:
the transition from abuse to recovery. The
stages of change are best conceived as a cycle, • Level 0.5 Early Intervention
but movement through the cycle is not always a • Level I Outpatient Treatment
tidy, forward progression. Clients can––and • Level II Intensive Outpatient Treatment/
often do––move backward as they struggle with Partial Hospitalization
dependence. Varying types of groups will be
• Level III Residential/Inpatient
appropriate for clients at different stages of
Treatment
recovery. For example, an interpersonal pro
cess group might be overstimulating for some • Level IV Medically Managed Intensive
clients in early stages of recovery, particularly Inpatient Treatment
those undergoing detoxification. They would
On each level of care ASAM’s criteria
benefit most from a group with a strong prima
describe appropriate treatment settings, staff
ry focus on achieving and maintaining absti
and services, admission, continued service, and
nence. Once abstinence and attachment to the
discharge criteria for six “dimensions”:
recovery process are established, the client is
ready to work on such issues as awareness and • Potential for acute intoxication or withdrawal
communication of feelings, conflict resolution,
• Biomedical conditions and complications
healthy interdependence, and intimacy.
• Emotional and behavioral conditions or
Expectation of success. Every effort should be complications
made to place the client in a group in which the • Treatment acceptance or resistance
client, and therefore, the program, can succeed.
• Relapse and continued use potential
A poor match between group and client is not • Recovery environment
always apparent at the outset. Monitoring can
ensure that clients are in groups in which they On the five levels of care, ASAM also provides
can learn and grow without interfering with the a brief overview of the services available for
learning and growth of others. Although the pri particular severities of addiction and related
42 Criteria for the Placement of Clients in Groups
problems. Another commonly used assessment judgment. Actual client placement should take
tool, the Addiction Severity Index, can be into account characteristics such as substances
found in appendix D of TIP 38, Integrating abused, duration of use, treatment setting, and
Substance Abuse Treatment and Vocational the client’s stage of change. For example, a
Services (CSAT 2000). client in a maintenance stage may need to
acquire social skills to interact in new ways,
Some States require providers to use the ASAM may need to address emotional difficulties, or
PPC2R for patient placement, continuing stay, may need to be reintegrated into a community
and discharge decisions. For placement in and culture of origin. Only an additional level
group therapy, a provider can also consider of assessment will determine which of these
• A client’s stage of recovery (see next section) groups (or combination of groups) is best for
the client.
• The progression of the disease
• The client’s stage of readiness for change
Stages of Recovery
Although no single set of criteria is sufficient to
evaluate a client’s proper placement, this docu A number of classification systems have been
ment presents a chart (see Figure 32) that applied to the stages of recovery from sub
summarizes the types of group treatment most stance abuse. The most common, however,
appropriate for clients at different stages of classifies clients as being in an early, middle, or
recovery. Clinicians can use the chart as a late stage of recovery:
guide to determine the type of group most • Early recovery. The client has moved into
appropriate for a client. treatment, focusing on becoming abstinent
When different dimensions of evaluation con and then on staying sober. Clients in this
flict in their placement indications, the clini stage are fragile and particularly vulnerable
cian will need to break the impasse with clinical to relapse. This stage generally will last from
1 month to 1 year.
Figure 32
Client Placement by Stage of Recovery
Psycho- Skills- Cognitive– Support Inter- Relapse Ex- Culture-
educa- Building Behavioral personal Preven- pressive Specific
tion Process tion
Early +++ ++ + +++ + + *
Middle + ++ ++ ++ +++ +++ + *
Late and ++ + +++ *
Maintenance
Key:
Blank Generally not appropriate
+ Sometimes necessary
++ Usually necessary
+++ Necessary and most important
Source: Consensus Panel.
Criteria for the Placement of Clients in Groups 43
Figure 33
Client Placement Based on Readiness for Change
Psycho- Skills- Cognitive– Support Inter- Relapse Ex- Culture-
educa- Building Behavioral personal Preven- pressive Specific
tion Process tion
Precontem + + + +
plation
Contem + + + + + + +
plation
Preparation + + + + + + +
Action + + + + + + + +
Maintenance + + + + + + +
Recurrence + + + + + + +
Source: Consensus Panel; Prochaska and DiClemente 1984.
• Middle recovery. The client feels fairly secure
in abstinence. Cravings occur but can be
Placing Clients From
recognized. Nonetheless, the risk of relapse Racial or Ethnic
remains. The client will begin to make signifi
cant lifestyle changes and will begin to change
Minorities
personality traits. This stage generally will
take at least a year to complete, but can last Diversity in a Broad Sense
indefinitely. Some clients never progress to In all aspects of group work for substance abuse
the late recovery/maintenance stage. Some treatment, clinicians need to be especially mind
times they relapse and revert to an early ful of diversity issues. Such considerations are
stage of recovery. key in any form of substance abuse treatment,
• Late recovery/maintenance. Clients work to but in a therapeutic group composed of many
maintain abstinence while continuing to make different kinds of people, diversity considera
changes unrelated to substance abuse in their tions can take on added importance. As group
attitudes and responsive behavior. The client therapy proceeds, feelings of belonging to an
also may prepare to work on psychological ethnic group can be intensified more than in
issues unrelated to substance abuse that have individual therapy because, in the group pro
surfaced in abstinence. Since recovery is an cess, the individual may engage many peers who
ongoing process, this phase has no end. are different, not just a single therapist who is
different (Salvendy 1999).
Figure 33 uses Prochaska and DiClemente’s
stages of change model to relate group While the word “diversity” often is used to
placements to the client’s level of motivation refer to cultural differences, it is used here in a
for change. broader sense. It is taken to mean any differ
ences that distinguish an individual from others
and that affect how an individual identifies
himself and how others identify him.
Considerations such as age, gender, cultural
44 Criteria for the Placement of Clients in Groups
background, sexual orientation, and ability It is important for clinicians to realize that
level are all extremely important, as are less diversity issues affect everyone. All individuals
apparent factors such as social class, education have unique characteristics. Further, how
level, religious background, parental status, people view themselves and how the dominant
and justice system involvement. Figure 34 culture may view them are frequently different.
provides several definitions around culture. In any event, no one should be reduced to a sin
gle characteristic in an attempt to understand
To help clinicians understand the range of diver that person’s identity. All people have multiple
sity issues and the importance of these issues, characteristics that define who they are.
this volume adapts a diversity wheel from Loden
and Rosener (1991) (see Figure 35 on p. 46). While ideas of difference are social construc
The wheel depicts two kinds of characteristics tions, they do have a realworld effect. For
that can play an important role in understand example, members of groups tend to act in dif
ing client diversity: The inner wheel includes ferent ways when with members of their own
permanent characteristics such as age or race; group than they would in a heterogeneous
the outer wheel lists a number of secondary group. Further, the dominant culture’s atti
characteristics that can be altered. Note that tudes and beliefs about people (based on age,
primary characteristics are not necessarily race, sexual preference, and so on) influence
more important than secondary ones and that everyone.
this figure does not include a comprehensive
list of secondary characteristics. A culturally homogeneous group quite natural
ly will tend to adopt roles and values from its
Figure 34
What Is Culture?
Culture: Integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions
of a racial, ethnic, religious, or social group.
Cultural knowledge: Familiarity with selected cultural characteristics, history,
values, belief systems, and behaviors of the members of another ethnic group.
Cultural awareness: Developing sensitivity to and understanding of another
ethnic group. This usually involves internal changes of attitudes and values.
Awareness and sensitivity also refer to the qualities of openness and flexibility
that people develop in relation to others. Cultural awareness should be
supplemented with cultural knowledge.
Cultural competence: A set of congruent behaviors, attitudes, and policies that
come together in a system, agency, or among professionals that enable them to
work effectively in crosscultural situations.
Source: Giachello 1995; Office of Minority Health 2001.
Criteria for the Placement of Clients in Groups 45
Figure 35
Diversity Wheel
SECONDARY
CHARACTERISTICS
PRIMARY level of accultaration,
religion,
CHARACTERISTICS learning style,
socioeconomic
language,
class,
race, gender, ethnicity, age, accent,
education
sexual orientation, criminal justice
physical/mental system involvement
ability
geographic location, time orientation,
appearance, marital status,
parental status, military status,
immigrant status
Source: Adapted from Loden and Rosener 1991. Used with permission.
46 Criteria for the Placement of Clients in Groups
culture of origin (Tylim 1982). These ways ethnicity, and gender identity mean to that
should be understood, accepted, respected, person. If a leader believes that cultural tradi
and used to promote healing and recovery. tions might be a factor in a client’s participation
However, group leaders should also be aware in group or in misunderstandings among group
of the possibility that these group roles and val members, the leader should check the accuracy
ues might conflict with treatment requirements, of that perception with the client involved.
and therefore clinicians need to be prepared to Therapists should be aware, however, that indi
provide more direction to group members when viduals may not always be able to perceive or
required (Salvendy 1999). For example, a articulate their cultural assumptions.
group composed of Southeast Asian refugees
might give authority to older men in the group, Group leaders should be able to anticipate a
who may never be challenged, contradicted, or particular group’s characteristics without auto
disagreed with because to do so would show matically assigning them to all individuals in
disrespect (Kinzie et al. 1988). These older, that group. It would be a mistake, for instance,
adult males can assist in group leadership. if an institution assigned all immigrants or peo
However, the opinions of female group mem ple of color to a single group, assuming they
bers, particularly younger ones, might be would be more comfortable together. Members
ignored, and a group leader should be able to of such groups may not have anything in com
compensate for this tendency. As another mon. An AsianAmerican woman assigned to
example, many Hispanics/Latinos may be sus the only AsianAmerican therapist in the insti
picious of rules and the people who enforce tution might resent her placement and protest
them. Consequently, group leaders regarded as in strong terms. She would want the best thera
authority figures (that is, not compadres) pist for her, not an automatic matchmaking
unwittingly may represent discrimination and based on ethnicity.
encroachments on freedom (TorresRivera et Clinicians working primarily with other cultur
al. 1999). al or ethnic groups should be open and ready
Cultural practices also affect communication to learn all they can about their clients’ cul
among group members. Many traditionally ture. For example, a therapist working with
raised Asians, for example, will be reluctant to Salvadoran immigrants should be prepared to
disagree openly with their elders or even voice learn not only about the country and culture of
a personal opinion in their presence (Chang El Salvador, but also about all the events and
2000). Genderspecific cultural roles, too, may influences that have shaped this population’s
be played out in groups. For example, women experience, including social conditions in El
may hold emotional energy for men or nurture Salvador and the experience of immigration.
them. Therapists should be alert to assump Accommodating cultural and ethnic character
tions and roles that may inhibit the develop istics is not a simple matter. These adaptations
ment of individuals or the group as a whole. should be made, however, because ethnicity
Unfortunately, little research reveals how and culture can have a profound effect on
group therapy should be adapted to meet such many aspects of treatment. For instance,
differences, and many of the findings that do pressures to conform to the dominant culture
exist are contradictory. Further, any general represented in the group can be intense. The
izations about cultural groups may not apply to norms of the group may also be in painful
individuals because of variance in levels of conflict with an individual’s traditional cultural
acculturation and other experiential factors. A values. An example is shown in Figure 36 (see
particular Latino youth, for example, may p. 48). Figure 37 (see p. 48) provides three
identify with the dominant culture and not suggested resources on culture and ethnicity;
think of himself as Latino. The client is always however, this list is by no means exhaustive.
to be considered the expert on what culture,
Criteria for the Placement of Clients in Groups 47
Figure 36
When Group Norms and Cultural Values Conflict
A middleaged, single professional woman of Philippine background who, in one
group session, recounted death wishes toward an elder sister whom she perceived
as domineering, remained silent the following week in the group. When other
members tried to engage her, wanting her to follow up, she complained of debili
tating migraines and refused to talk. Months later, she was able to share with the
group that she felt ashamed and disloyal to her sister, a great transgression in
her culture. The client believed she was punished for her “naughtiness” with
crippling headaches.
Source: Adapted from Salvendy 1999, p. 441.
Figure 37
Three Resources on Culture and Ethnicity
Culture and Psychotherapy: A Guide to Clinical Practice is a resource for men
tal health professionals treating people of widely varying cultural backgrounds.
Case studies include the story of an AmericanIndian woman who could not
escape her “spirit song,” a Latina who feared “losing her soul,” and an Arab
woman whose psychological conflicts were related to cultural changes in her soci
ety that involved the social status of women. Other chapters describe treatment
techniques for various racial and ethnic groups and models of therapy (Tseng
and Streltzer 2001).
Ethnic Sensitivity in Social Work provides a section on crosscultural orientation
and one on specific cultures, including AfricanAmerican, Hispanic/Latino,
AmericanIndian, and Asian and Pacific Island cultures. The second part of the
book is a psychocultural overview of several major ethnic groups in the United
States. For each group, the authors discuss work and economic systems, family
life and kinships, political structures and stratification, intergroup relations and
ideological structures, identity, social interaction rules, and health behaviors
(Winkelman 1995).
Readings in Ethnic Psychology contains several chapters on substance abuse and
treatment among several ethnic and racial groups and describes culturally
appropriate interventions used in therapy, including group therapy (Organista
et al. 1998).
48 Criteria for the Placement of Clients in Groups
Leader SelfAssessment all members equally, regardless of gender.
Clinicians also need to evaluate how competent
Group leaders should be aware that their own
they are managing issues of cultural diversity.
ethnicities and standpoints can affect their
In cases where cultural or language barriers are
interpretation of group members’ behavior.
very strong, a group leader may need to refer a
The group leader brings to the group a sense of
client to another group or make special accom
identity, as well as feelings, assumptions,
modations to allow the client to participate.
thoughts, and reactions. Leaders should be
conscious of how their own backgrounds affect Reed and her colleagues (1997) have developed
their ability to work with particular popula a list of principles for group leaders to evalu
tions. For example, a female therapist who has ate their own attitudes about diversity (see
survived domestic violence may have severe Figure 38). Figure 39 (see pp. 50–52) is a self
difficulties working with spouse abusers. assessment guide for group counselors working
Another example is that male group leaders with diverse populations.
may be inclined to call on male members more
often than female members of the group. If so,
they need to make a conscious effort to call on
Figure 38
Guidelines for Clinicians on Evaluating Bias and Prejudice
• The processes of gaining knowledge about the workings of discrimination and
oppression and for guarding against bias should be ongoing and lifelong.
• Clinicians should learn about their own culturally shaped assumptions so as to
refrain from unconsciously imposing them on others and should exhibit a pro
fessional’s values, standards, and actions.
• Clinicians should work harder to recognize institutionalized racism than they
do to perceive individual prejudice; that is, they should recognize how bias is
structured into policies, practices, and norms in program relations.
• Clinicians should question the knowledge base and theories that underlie their
practice in order to eliminate prejudice and bias in that practice.
• Clinicians should look at their own feelings and reactions and listen to the feed
back of others to recognize how their own ideas have been unconsciously
shaped by discriminatory social dynamics.
• Clinicians can use their knowledge of how their personal characteristics are
likely to affect a range of others to reduce communication problems and dis
putes between group members.
Source: Adapted from Reed et al. 1997. Used with permission.
Criteria for the Placement of Clients in Groups 49
Figure 39
SelfAssessment Guide
The questions that follow can serve as a guide and selfassessment for group
leaders working with clients of diverse cultures.
Are you familiar with a broad range of special populations, particularly those in
your community?
• What cultural customs and health beliefs, practices, and attitudes of
ethnic/racial groups would affect treatment in a group situation?
• Would tensions within any broad cultural group––say one that includes
Cubans, Mexicans, and Puerto Ricans––pose problems in therapy?
• What languages are spoken within the community?
• What are the typical communication styles, including body language, of various
racial/ethnic groups? Are clients likely to speak in a group setting? Would they
speak only with others of their same culture? Would they speak in an ethnically
mixed group?
• How do clients think about the cultures of the world? Do they have pronounced
prejudices? How do they understand the major and minor cultural subgroups
that make up the community?
• How do language, social class, race/ethnicity, and gender affect the outward
signs and symptoms of substance abuse, emotional distress, and mental illness?
• In any local cultures, do specific social stresses, such as homelessness or uncer
tain immigration status, complicate the problem of coping with substance abuse
and psychiatric disorders?
• What are community views about different kinds of substances? Is alcohol more
acceptable than marijuana? Marijuana more acceptable than cocaine? Are
males with addictions tolerated more than females?
• How do various cultural subgroups perceive women in the community? The
elderly? Lesbian, gay, and bisexual persons?
Do you understand your own thoughts, feelings, and experiences regarding other
cultures?
• With what cultural groups other than your own do you have frequent contact?
• With what ethnic groups do you have contact? How frequently?
• What are some of the key characteristics of these groups?
• What do you know about the principal cultural groups in the country? In your
community?
• What are the main ethnic groups in the United States?
• What are the important characteristics of your own culture?
• How does your culture affect the way you interact with others? What is your
culture’s style of interaction?
50 Criteria for the Placement of Clients in Groups
Figure 39
SelfAssessment Guide (continued)
• Do you have a personal style that differs from your culture’s norms?
• Toward which cultural groups do you feel positive?
Which groups make you feel uneasy or uncomfortable?
• Are you comfortable counseling persons with sexual orientations different
from yours?
• Have you worked with a variety of age groups?
• Do you have substantial knowledge of any particular population’s key
attributes and values regarding child rearing, marriage, financial matters,
and other major matters of life?
• Do you know any other group’s social and political history well enough to
predict its impact on group dynamics around a given issue?
What resources in the community are available to meet the needs of special
populations?
• Are cofacilitators with special expertise, such as fluency in other languages,
available to assist with groups?
• Are services available in other languages? Have support groups been designed
for racial/ethnic groups? Lesbians and gay men? Women? Elderly people?
• What State and communitybased organizations provide social services for
people from nonmainstream cultures?
What systemic barriers and staff attitudes and beliefs inhibit cultural sensitivity
and competence in your programs?
• Is crosscultural training available to group leaders?
• Are any staff members fluent in languages spoken by potential clients in group?
• Is there someone in your agency or organization who assists clients with social
services support, including Medicaid?
What are the characteristics of the person about to be placed?
• Are the client’s language skills adequate to permit participation in this group?
• To what degree is the client acculturated? For example, how long has a
Salvadoran been in this country?
• Is the client discriminated against?
• Does this client share traits (for example, educational attainment, socioeconom
ic status, motivation level) with others in the group who are not from the same
population?
• How familiar is the client with the goals of therapy? With group therapy?
Criteria for the Placement of Clients in Groups 51
Figure 39
SelfAssessment Guide (continued)
• How does the client currently relate to the therapist? To treatment in general?
• How would the client fit into an existing group? Would the client be the only
representative of that culture in the group? What is the current makeup of the
group with respect to cultural diversity? What views do current members hold
toward the prospective member’s culture?
• How long has the person been a resident of your community? Is the client trav
eling from another community for therapy? How long has the person been a
resident of this geographical area?
• Would the client fit in better with a homogeneous group; for example, a single
sex group for a woman who has been a victim of sexual abuse or incest?
• How does the client’s family handle issues of power and control? Independence
and autonomy? Trust? Communication of feelings?
• Does the culture of origin provide traditional healing practices that could be
used in the group?
• Might specific cultural issues affect the recovery process?
• To what extent will the new client adapt to an existing group’s norms?
• Will changes that satisfy the group’s norms alienate the client from the culture
of origin?
• What are the alternatives to placing the person in a specific group? What
accommodations may have to be made?
Source: Adapted from Winkelman 1995. Used with permission.
Diversity and Placement ings, or attitudes. Rather, group members are
encouraged to share these feelings and beliefs
In many groups, the composition of members verbally and overtly, even if this may be upset
will be heterogeneous; for example, a majority ting to some or all of the group’s members”
of Caucasians placed with a minority of ethni (Brook et al. 1998, p. 77). Although therapists
cally or racially different members. The may be uncomfortable when group members
greater the mix of ethnicities, the more likely
talk about subjects like racism and discrimina
that biases will emerge and require mediation tion, such expression sometimes is an impor
(Brook et al. 1998). Whatever a client’s belief tant part of an individual’s recovery process.
system or origin, “neither the therapist nor the
group should ask any group member to give up Firstgeneration immigrants who speak little or
or renounce any ethnic/cultural beliefs, feel no English usually are underrepresented in
52 Criteria for the Placement of Clients in Groups
group therapy because of their limited fluency. Assess the behaviors
While an immigrant may be able to communi and attitudes of cur
cate adequately in individual therapy with a rent group members Understanding the
single healthcare professional, that newcomer to ascertain whether
may be unable to follow a fastflowing group the new client would cultural character
discussion. match the group.
From the start of a istics of major
As previously mentioned, before placing a multicultural therapy
client in a particular group, the therapist needs group, members
to understand the influence of culture, family racial and ethnic
should feel that race is
structure, language, identity processes, health a safe topic to discuss
beliefs and attitudes, political issues, and the populations will
(Salvendy 1999).
stigma associated with minority status for each Because group mem
client who is a potential candidate for a group. bers are less restricted permit better
In addition, the therapist will need to do the to their usual social
following: circles and customary informed decisions
Address the substance abuse problem in a man ethnic and cultural
ner that is congruent with the client’s culture. boundaries, the group about placement.
Each culture incorporates beliefs and values is potentially a social
that guide the behavior of everyone identified microcosm within
with the culture and that govern experiences which members may
related to the use of substances. Some cultures, safely try out new ways of relating (Matsukawa
for instance, use chemical substances as part of 2001). Even so, potential problems between a
rituals, some of them religious. This entwine candidate and existing group members should
ment of substance use and culture does not be identified and counteracted to prevent
mean that the therapist cannot discuss the issue dropout and promote engagement cohesion
of this substance use with a client. Some among members.
clients, of their own volition, will reduce or Understand personal biases and prejudices
eliminate the use of substances once they exam about specific cultural groups. A group leader
ine their beliefs and experiences. should be conscious of personal biases to be
Appreciate that particular cultures use sub aware of countertransference issues, to serve as
stances, usually in moderation, at specified a role model for the group, and to create group
types of social occasions. For many people, norms that permit discussion of prejudice and
occasional, moderate use of substances might other topics relevant to a multicultural setting.
be part of a meaningful social/cultural ritual, Understanding the cultural characteristics of
but for people with substance use disorders major racial and ethnic populations—particu
such use, even when culturally accepted, is larly their history, acculturation level, family
contraindicated because it might provoke and community roles and relationships, health
relapse, binges, or other destructive reactions. beliefs, and attitudes toward substance abuse—
Again, a culturally sensitive discussion of this will permit betterinformed decisions about the
issue with clients may result in individual deci placement of individuals from these popula
sions to abstain on these occasions, despite con tions into existing therapy groups. Naturally,
siderable cultural pressure to use substances of no group leader can know everything about
abuse. In contrast, some cultures have beliefs every culture, but a good counselor can be
in direct opposition to the client’s use of sub aware of major characteristics of cultural
stances. Helping the client redirect behavior to groups. This knowledge can guide the place
come into accord with these beliefs may be an ment of clients into appropriate groups and
important treatment approach.
Criteria for the Placement of Clients in Groups 53
Figure 310
Preparing the Group for a New Member
From a Racial/Ethnic Minority
To promote cohesion, a positive group quality stemming from a sense of
solidarity within the group, the group leader should
• Inform the group members in advance that people from a variety of back
grounds and racial and ethnic groups will be in the group.
• Discuss the differences at appropriate times in a sensitive way to provide an
atmosphere of openness and tolerance.
• Set the tone for an open discussion of differences in beliefs and feelings.
• Help clients adapt to and cope with prejudice in effective ways, while maintain
ing their selfesteem.
• Integrate new clients into the group slowly, letting them set their own pace.
• When new members start to make comments about others or to accept feed
back, encourage more participation.
help a leader anticipate relationships and ten woman who showed her craft work without
sions that may arise within a group. comment) are used to communicate indirect
ly and acceptably. In such a situation,
Figure 310 provides tools to prepare both the Matsukawa says, the therapeutic approach
group and the minority client for the client’s is modified to perceive and permit a
entry and integration into an established thera JapaneseAmerican woman to present
peutic group. herself tacitly without pressing for verbal
One researcher cites four major dynamic pro elaboration. Therapists also should
cesses that occur within a multiethnic group intervene if nonverbal communications are
(Matsukawa 2001). Identifying these processes misinterpreted.
as they function in a group may help a thera 2. Cultural transference of traits from one per
pist predict whether a possible placement will son of a certain culture to another person of
support a cohesive social microcosm or create a that culture. If a group member has had
threatening and disruptive environment. experiences (usually negative) with people of
the same ethnicity as the therapist, the
1. Symbolism and nonverbal communication. group member may transfer to the therapist
In some cultural groups, direct expression the feelings and reactions developed with
of thoughts and feelings is considered others of the therapist’s ethnicity. In short,
unseemly. Matsukawa (2001) points out that Matsukawa (2001) says, the group member
among the Japanese, a highly valued trait is jumps to conclusions and assigns traits to
the ability to sense what another person the therapist based on ethnicity alone. The
wants without explicitly stated cues. In such therapist first should detect these miscon
a culture, symbolic gestures (a gift, perhaps)
or nonverbal signals (the author describes a
54 Criteria for the Placement of Clients in Groups
ceptions and then reveal them for what they treated may have some merit, the reality is that
are to dispel them. such a course seldom is feasible. Health care
3. Cultural countertransference, the thera providers from culturally and linguistically
pist’s (often subconscious) emotional reac diverse groups are underrepresented in the
tion to a client. Therapists also can jump to current service delivery system, so it is likely
conclusions. Countertransference of culture that a group leader will be from the main
occurs when a therapist’s response to a cur stream culture (Cohen and Goode 1999). While
rent group member is based on experience it might be ideal to match all participants by
with a former group member of the same ethnicity in a therapeutic group, the most
ethnicity as the new client. Matsukawa important determinants of success are the val
(2001) cautions therapists to exercise ues and attitudes shared by the therapist and
restraint when in the middle of a “counter group members (Brook et al. 1998).
transference storm.” It should be noted that recent research suggests
4. Ethnic prejudice. “Stereotypes become prej that an ethnic match between therapist and
udice,” Matsukawa (2001, p. 256) writes, client does not “consistently improve out
“when they are hard to modify and when comes” (Salvendy 1999, p. 437). Other
one’s interactions, or lack thereof, with research (Atkinson and Lowe 1995) suggests
another person are based on preconceived that, while the ethnicity of the therapist is a
feelings and judgments about the person’s factor that can influence treatment, it is by no
race, without enough knowledge, under means the most important factor. Culturally
standing, or experience.” In multiethnic specific homogeneous groups should be used
groups, it is vital to develop an environment only when someone’s “cultural, religious, or
in which it is safe to talk about race. Not to political beliefs are very different from the
do so will result in scapegoating or division mainstream and they are not open to adjust
along racial lines (Matsukawa 2001). ments,” as, for example, with recent immi
grants or refugees (Brook et al. 1998; Ivey et
In practice, people connect and diverge in ways
al. 1993; Salvendy 1999, p. 457; Silverstein
that cannot be predicted solely on the basis of
1995; Takeuchi et al. 1995; Yeh et al. 1994).
ethnic or cultural identity. Two people from
different ethnic backgrounds may share many If less acculturated people with limited lan
other common experiences that provide a basis guage skills are treated in groups, the program
for identification and mutual support. All the should provide bilingual clinicians who are sen
same, it is possible to rule out some combina sitive to gender and culture. Therapists should
tions. For example, two elderly men, one focus on problemoriented, shortterm treat
Korean and the other Japanese, may not blend ment; should consider employing a proactive
well since their cultures have clashed in the therapeutic style; and should be aware that
past many times. Similarly, a single 17yearold clients may view them as authority figures
girl would not mix well with a group made up (Brook et al. 1998).
primarily of middleaged males. Potentially
undesirable and distracting group dynamics In culturally specific groups, a member of the
could easily be foreseen. Leaders are responsi focus culture usually runs the group, although
ble for considering carefully the positions of this ideal situation is not always possible. If a
people who are different in some way, especial trained clinician who also belongs to the group
ly when planning fixedmembership groups. is not available, it may be advantageous to add
a cofacilitator who belongs to the population,
understands the population’s specific problems
Ethnic and Cultural Matching and strengths, and can serve as a role model to
Although arguments for matching the ethnicity assist the clinician. Of course, if the program is
of the therapist with that of the group members not specifically focused on cultural or communi
Criteria for the Placement of Clients in Groups 55
ty issues and is simply incorporating some cul Americans look to leaders as problemsolvers. In
tural elements, the staffing requirements are Hispanic/Latino culture, people are equals until
not as stringent. In such cases, the presence of a proven otherwise––roles do not automatically
member of the culture that developed the prac constitute a supervisor/subordinate relationship
tice or knowledge is desirable, but not vital. (Wilbur and RobertsWilbur 1994).
“Children often accompany their parents to Differences that may influence an individual’s
therapeutic encounters to translate and provide perception of a leader’s role should be explored
support” for immigrant parents, but relying on in the pregroup interview. The interviewer can
“the children in this way actually perpetuates explain how the leader’s role may differ from
isolation and decreases pressure to build a net what the client might expect. Later, in group,
work of supports. Finding an interpreter who leaders need to be alert to unexpected differ
not only speaks the language but also who may ences in interpretation of their actions. For
share the values and the migration experience is example, a group member who expects the
crucial to further the acculturation and therapy leader to exercise authority might view a lead
process” (Nakkab and Hernandez 1998, p. 98). er’s attempt to empower the group as shirking
responsibility. The leader can help by being
explicit about his or her role and responsibili
Other Considerations for ties in the group.
Practice
Group leaders also should be aware that people
Groups may include people who have varying manage conflict in culturally diverse ways. A
• Expectations of leaders native New Yorker might have an inyourface
approach to conflict, while some Asian
• Experience in decisionmaking and conflict Americans may find a raised voice offensive.
resolution Cultural factors may frame a client’s percep
• Understanding of gender roles, families, and tion of conflict in a way not readily apparent to
community the group. For an example, see Figure 311.
• Values
For more detailed information on cultural
All these differences, and many others, will diversity in client placement, see the forth
affect individual and group experiences. Group coming TIP Improving Cultural Competence
leaders should be keenly aware of ways in in Substance Abuse Treatment (SAMHSA in
which ethnicity and culture can affect participa development a).
tion in interactive therapy. One of the most pro
Once placement decisions are completed, group
found ways that different cultural backgrounds
development begins. Chapter 4 explains this
may affect individuals in groups is in expecta
process.
tions of the leader. For example, many African
56 Criteria for the Placement of Clients in Groups
Figure 311
Culture and the Perception of Conflict
A 33yearold single, secondgeneration ChineseCanadian woman joined a group
after proper preparation. She was one of two nonCaucasians in this longterm,
interpersonally focused, slowturnover group. Unfortunately, in her first session,
the group forcefully confronted an elderly man, who was emotionally abusive to
his spouse and shirked responsibility for it. The new member froze throughout
the session and was clearly very anxious. The therapist acknowledged her dis
comfort and the stressfulness of the situation for her. Nevertheless, the following
day this client wanted to discontinue group, feeling very threatened by the
directness of the confrontation and its target, the elderly father figure. Her anxi
ety was accepted as genuine and not seen as resistance by the therapist, who pro
vided several individual sessions parallel to the group to clarify that this was not
an attack on all fathers (including her own) in the group, and that it was done to
help the elderly group member. This ChineseCanadian client also was reassured
that the other group members would be informed about the sociocultural reasons
for her being upset, and that they would be empathic to her feelings on this mat
ter. This intervention facilitated her integration in the group and her perception
of the therapist as culturally credible and competent.
Source: Adapted from Salvendy 1999, p. 451.
Criteria for the Placement of Clients in Groups 57
4 Group Development
and PhaseSpecific Tasks
Overview
In This
This chapter begins by discussing the varying uses of fixed or revolving
groups. Fixed groups generally stay together for a long time, while
Chapter…
members in revolving groups remain only until they accomplish their
goals. Each is used for different purposes, and each requires different
Fixed and
leadership.
Revolving
Membership
As treatment and recovery have stages, group development also changes
Groups
over time. The first phase pays attention to orientation and establishing
Fixed Membership Groups
safe, effective working relationships. In the middle (and longest) phase,
Revolving Membership
the actual work of the group is done. The end phase is a deliberate,
Groups
positive termination of group business. Each phase requires attention to
specific tasks.
Preparing for
Client Participation
in Groups Fixed and Revolving Membership
Pregroup Interviews
Increasing Retention
Groups
Identifying the Need for
The way groups are developed varies by the type of group. A wide range
Wraparound Services
of therapeutic groups may be used with people who have substance use
Group Agreements
problems. For the purpose of this discussion, however, groups have been
classified into two broad categories, each with the same two
PhaseSpecific
subcategories:
Group Tasks
Beginning Phase—
1. Fixed membership groups
Preparing the Group To
Begin
A. Timelimited
Middle Phase—Working
B. Ongoing
Toward Productive
Change
2. Revolving membership groups
End Phase—Reaching
A. Timelimited
Closure
B. Ongoing
59
Fixed Membership Groups training in group dynamics (such as individu
als’ boundaries and the roles different mem
Fixed membership groups are relatively small
bers assume) and leadership along with excel
(not more than 15 members); membership is
lent supervisory skills. Examples in this catego
relatively stable. Typically, the therapist
ry include interpersonal process groups and
screens prospective members, who then receive
some psychoeducational therapy groups.
formal preparation for participation. Any
departure from the group occurs through a Fixed groups are rare because they demand a
welldefined process. Two variations of this longterm commitment of resources. Most out
category are patient programs provide only 8–20 sessions,
and most inpatient programs are limited to
• A timelimited group, in which the same
2–4 weeks.
group of people attend a specified number of
sessions, generally starting and finishing
together Revolving Membership
• An ongoing group, in which new members fill Groups
vacancies in a group that continues over a
New members enter a revolving membership
long period of time
group when they become ready for the service
In timelimited groups with fixed membership, it provides. Revolving membership groups fre
learning builds on what has taken place in quently are found in inpatient treatment pro
prior meetings. Thus, members need to be in grams. As clients are admitted and discharged,
the group from its start. New members are people come and go in the group. Conse
admitted only in the earliest stages of group quently, revolving groups must adjust to fre
development (for example, only during the first quent, unpredictable membership changes.
week for a daily group or during the first The two variations of revolving membership
month for a group that meets weekly). Ongoing groups are
fixed membership groups may be used for
• A timelimited group that members generally
shortterm therapy, skill building, psychoedu
join for a set number of sessions
cation, and relapse prevention.
• An ongoing group that clients join until they
In ongoing groups accomplish their goals
with fixed member
ship, the size of the Revolving membership groups can be larger
group is set; new than fixed membership groups. The temptation
members enter only to have many members often is strong due to
New members when there is a insufficiently trained staff and shortages of
vacancy. The leader funding. While revolving membership groups
enter a revolving generally is less have no absolute limit on the number of mem
active than is the bers, it is prudent to keep the group small
membership group leader of a timelim enough (about 15 or fewer) for participants to
ited group, since the feel heard and understood, for the leader to
interaction among know each of them, and for members to feel a
when they become
group members is sense of connection and belonging to the group.
more important than If a group becomes too large (more than 20),
ready for the ser group interaction breaks down and the clients
leadertomember
interactions. To con become a class made up of individuals, rather
vice it provides. duct this type of than a single, cohesive, therapeutic body.
group, the leader
Revolving membership groups generally are
needs substantial
more structured and require more active lead
60 Group Development and PhaseSpecific Tasks
ership than fixed mem Several possible varieties of ongoing groups
bership groups. have revolving membership. Such groups may
Participation and be (1) openended, with clients staying for as
learning are not highly many sessions as they wish; (2) repeating sets of
One advantage to dependent on atten topics, with clients staying only until they have
dance at previous ses completed all of the topics; or (3) a duration
revolving member sions. In some settings, specific format, with clients attending for a set
new members may be number of weeks (either consecutively or non
ship groups is the brought in at fixed
consecutively). An interpersonal process group
intervals. In a daily
as part of an intensive outpatient program is an
stimulation that group, for instance,
example of an ongoing group with revolving
new members might membership. Clients enter this treatment group
enter once a week. and attend until the work specified in the treat
new members Members who have ment plan has been completed.
been in the group for a
provide. substantial number of Other examples of revolving membership
meetings often help to groups include inpatient unit groups, continu
orient newer members. ing care dropin groups, transition groups for
inpatients leaving and moving to outpatient
One advantage to care, psychoeducational groups, expressive
revolving membership therapy groups, and longterm support groups,
groups is the stimulation that new members such as ongoing continuing care groups and
provide. A potential problem is that new group maintenance groups. Figure 41 (see p. 62) pro
members may dread joining a group, feeling vides the characteristics of fixed and revolving
themselves to be at a disadvantage because membership groups.
existing members already know each other,
how the group operates, and what has been dis
cussed in previous sessions. For its part, the Preparing for Client
group itself may be apprehensive about the new
member (Rasmussen 1999).
Participation in Groups
A related possible problem is the adverse effect Pregroup Interviews
that membership changes can have on group
Research shows a strong tendency toward
cohesion. For these reasons, preparation for
relapse early in the substance abuse treatment
revolving groups is of paramount importance:
process. A person early in recovery is at
Group leaders need to pay special attention to
greater risk for returning to use than someone
helping new members become acclimated to the
with 3, 6, or even 18 months of abstinence
group, and clients chosen to fill a group vacan
(Johnson 1973; Project MATCH 1997). The
cy should have the capacity to observe and
better clients are prepared for treatment, how
adjust to the dynamics of the group
ever, the longer they stay in treatment. If clini
(Rasmussen 1999).
cians ensure that clients come to the group with
In timelimited groups, each member generally appropriate expectations, both clinicians and
is expected to attend a certain number of ses clients can expect a greater degree of success.
sions for a certain number of weeks or months.
Group leaders should conduct initial individual
A psychodrama group (one kind of expressive
sessions with the candidate for group to form a
therapy group), for example, might be offered
therapeutic alliance, to reach consensus on
every spring. Other common examples include
what is to be accomplished in therapy, to edu
psychoeducational groups and some skills
cate the client about group therapy, to allay
building groups.
anxiety related to joining a group, and to
Group Development and PhaseSpecific Tasks 61
Figure 41
Characteristics of Fixed and Revolving Membership Groups
Entry Group Development Examples
Fixed Membership Groups
Time- • New members admitted • Learning built on what • Shortterm therapy groups
limited only in earliest stages of has happened in prior • Skillsbuilding and
group development meetings psychoeducational groups
• Groups begin and end with • Relapse prevention groups
same membership
62 Group Development and PhaseSpecific Tasks
explain the group agreement. These activities Explain how group interactions compare to
may take as little as one meeting or as long as those in selfhelp groups, such as Alcoholics
several weeks (Rutan and Stone 2001). Anonymous (AA). Clients should be informed
Normally, the longer the expected duration of that group therapy differs from 12Step or
the group, the longer the preparation phase. other similar recovery groups. In particular,
Clients should have an opportunity to air any the membertomember “crosstalk” discour
concerns, especially if they are apprehensive aged in 12Step groups is an essential part of
about their cultural status within the group. interactive therapy (Margolis and Zweben
During this time, the group facilitator should 1998). Although clients sometimes perceive a
learn how the client handles interpersonal conflict between their AA or AlAnon experi
functions on a daytoday basis, how the ence and group therapy due to these different
client’s family functions, and how the client’s formats, the therapist should know with cer
culture perceives the substance abuse problem. tainty that the two are not mutually exclusive,
but that they serve different functions and pro
The process of preparing the client for partici vide support in distinct, complementary ways
pation in group therapy begins as early as the (Vannicelli 1992). Therapists also should be
initial contact between the client and the pro careful to distinguish treatment groups from
gram. Clients’ preconceptions about the group, AA’s selfhelp approach, which, having no for
their expectation of how the group will benefit mal leadership, cannot provide meaningful
them, their understanding of how they are accountability (Vannicelli 1992; Zweben 1995).
expected to participate, and whether they have
experienced a motivational session prior to the Emphasize that treatment is a longterm pro
group will all influence members’ participation. cess. Participants should know in advance that
in group therapy, each person’s attendance at
Preparation meetings serve a dual purpose. each session is vital. They should also recognize
First, they ensure that clients understand that while the first 3 months of treatment after
expectations and are willing and able to meet detoxification are critical, fully effective treat
them. Second, these meetings help clients ment takes much longer.
become familiar with group therapy processes.
Where indepth, oneonone meetings are Let new members know they may be tempted to
impractical because of group size or other con leave the group at times. It should be empha
siderations, at least some form of orientation sized that although the work is difficult and
should be provided, perhaps in the form of even upsetting at times, clients gain a great deal
readings, videotape, group preparation meet from persistent commitment to the process and
ing, or discussion with the primary counselor should resist any temptation to leave the group.
prior to attending a group. Clients also should be encouraged to discuss
thoughts about leaving the group when they
Pregroup interviews are widely used to gather arise so that the antecedents of these thoughts
useful information about clients and prepare can be examined and resolved.
them for what they can expect from a group.
The pregroup interview should cover clients’ Give prospective and novice members an
goals for treatment, the group contract, client opportunity to express anxiety about group
behaviors that might present an obstacle to work, and help allay their fears with informa
group work, and any other information that tion. For some prospective members, group
clients feel may be pertinent (Vannicelli 1992). process work may need to be demythologized.
Clients should be thoroughly informed about Misperceptions should be countered to keep
what group therapy will be like. In addition, them from interfering with group participation.
client preparation should address the follow Some providers conduct a shortterm group to
ing: prepare clients for upcoming participation in
other kinds of groups. This approach enables
Group Development and PhaseSpecific Tasks 63
leaders to assess clients’ suitability for various It is important to explore issues of difference in
types of group work. advance of group placement. It similarly is
important to acknowledge cultural or ethnic
Recognize and address clients’ therapeutic backgrounds and to emphasize that differences
hopes. With help, clients can explain how they can be strengths that can contribute to the
think group work can help them, identify their group. If a client believes that a particular
preferences, and articulate realistic goals. group situation would be uncomfortable, how
Leaders can use this information to be sure ever, the counselor may offer the client other
that clients are placed in groups most likely to treatment options.
fulfill their aspirations.
The counselor also is responsible for raising the
For a sample dialog that takes place in a prepa level of group members’ sensitivity and empa
ration interview, see “Preparing the Patient for thy. It is important at times, for instance, to
Group Psychotherapy” (Hoffman 1999). prepare group members for situations in which
In preparing prospective members for a group others have symptoms that could offend or
experience, it is important to be sensitive to repel them. The therapist can initiate discus
people who are different from the majority of sion by asking questions such as, “What would
the other participants in some way. Such a per it be like for you to be with people who some
son may be much older or younger than the times cut themselves?”
rest of the group, the lone woman, the only While group leaders have many responsibilities
member with a particular disorder, or the per to prepare clients for participation in groups,
son from a distinctive ethnic or cultural minori the clients have obligations, too. Their respon
ty. The leader should consult privately with sibilities are specified in group agreements, dis
people who stand out in the group to determine cussed later in this chapter.
from their unique perspective how they are
experiencing the group. They should always be
allowed to be the experts on their own situa Increasing Retention
tion. Further, clients should be encouraged to Throughout the initial sessions of therapy,
define the extent of their identification with the clients are particularly vulnerable to return to
groups to which they belong and to determine substance use and to discontinue treatment.
what that identification implies. The first month appears to be especially critical
The fixed membership format provides more (Margolis and Zweben 1998). Yalom (1995)
time to discuss issues of difference prior to writes that premature termination usually
joining a group. A person unlike the rest of “stems from problems caused by deviancy, sub
the group may be asked by the other group grouping, conflicts in intimacy and disclosure,
members: the role of the early provocateur, external
stress, complications of concurrent individual
• How do you think you would feel in a and group therapy, inability to share the lead
group in which you differ from other group er, inadequate preparation, and emotional con
members? tagion” (p. 315) (a concept discussed later in
• What would it be like to be in a group where chapter 6).
everyone else is a strong believer in some Retention rates are affected positively by client
thing, such as AA, and you are not? preparation, maximum client involvement dur
Such questions might be coupled with positive ing the early stages of treatment, the use of
comments that stress the benefits that a unique feedback, prompts to encourage attendance,
perspective may bring to the group. and the provision of wraparound services (such
as child care and transportation) to make it
possible or easier for clients to attend regularly.
64 Group Development and PhaseSpecific Tasks
Consideration needs to be given to the timing sobriety and the use of a continuing care
and length of groups, too, because these factors participation contract.
affect retention. • An appointment card and an automated
To achieve maximum involvement in group telephone message reminder of each upcom
therapy during this period, motivational ing group session.
techniques, such as psychoeducation and • A note from the therapist following the first
attendance prompts, may be used to engage the session saying that he was glad the client
client. Evidence suggests that if people are self chose to attend the group and was looking
motivated, they will persist longer in behaviors forward to seeing the client at upcoming
consistent with recovery, and will attach more sessions.
value to their quest than they would in • At least two followup phone calls after
response to external pressure. Incorporating missed sessions (Lash and Blosser 1999).
motivational elements in pregroup preparation
or offering groups that focus on motivation is Yalom (1995) notes that it is common practice
likely to increase compliance with continuing for therapists to try to forestall premature ter
care requirements (Foote et al. 1999). mination by persuading clients who plan to
leave group to attend just one more session.
Some pretreatment techniques that appear to The hope is that other group members will
reduce the incidence of dropping out include persuade the restless member not to drop out.
the following: This tactic rarely works, however. Instead,
during the preparation of clients for group,
• Role induction uses formats such as inter
Yalom suggests emphasizing that periods of dis
views, lectures, and films to educate clients
couragement are likely to occur during therapy.
about the reasons for therapy, setting realistic
goals for therapy, expected client behaviors, Another effective way to retain clients can be
and so on. used in groups that have a few veteran mem
• Vicarious pretraining using interviews, lec bers. When new members join, the old mem
tures, films, or other settings demonstrates bers are asked to predict which new member
what takes place during therapy so the client will be the first to drop out. This prediction
can experience the process vicariously. paradoxically increases the probability that it
• Experiential pretraining uses group exercises will not be fulfilled (Yalom 1995).
to teach client behaviors like selfdisclosure Researchers note that
and examination of emotions. these simple initia
• Motivational interviews use specific listening tives, which make so
and questioning strategies to help the client much difference in To achieve maxi
overcome doubt about making changes continuing care
(Walitzer et al. 1999). engagement, and the
mum involvement
outcomes of treat
sessions are another important way to engage mal clinical and cleri
treatment (Lash and Blosser 1999). One suc (Lash and Blosser
cessful strategy increased the number of clients 1999, p. 58).
who began continuing care group therapy and
motivational
However, while auto
nearly doubled the attendance at group sessions mated phone
(Lash and Blosser 1999). The plan included: techniques may
reminders might be
• An explanation to each client of the impor useful for highly
structured skills
be used.
tance of continuing care in maintaining
building groups early
Group Development and PhaseSpecific Tasks 65
in recovery or for groups of lowfunctioning they provide wraparound services to meet these
clients, in interpersonal process groups with and other practical needs, they retain clients in
higher functioning clients, the prompts might therapy longer. As a result, clients are more
set up norms that place too much responsibility likely to develop new behaviors and thought
on the leader and too little on group members. processes that enable them to remain abstinent.
Two examples of programs that provide such
services are described in Figures 42 and 43.
Identifying the Need for
Wraparound Services The first step toward wraparound services is to
document the need for them. The next step is
Practical problems, such as a lack of suitable to recognize that wraparound services seldom
childcare or transportation, deter many clients flourish in isolation. A thorough search of
from participation in substance abuse counsel existing community resources may identify ser
ing services. Many programs find that when vices already in place that could meet some
Figure 42
The Family Care Program of the Duke Addictions Program
The Family Care Program (FCP) at Duke University in Durham, North
Carolina, is a substance abuse program for women who abuse substances and
are pregnant and/or mothers of young children. Transportation is a major diffi
culty for many of the women and should be provided if their group experience is
to be consistent. Using vans supplied by the county and the State, FCP uses
Medicaid funding to provide transportation to and from approved medical inter
ventions. The program schedules appropriate transportation for the mother and
her children on days that therapy is provided at the Duke Addictions Program.
Viewing the mother and child dyad as the client, FCP provides wraparound ser
vices to support the involvement of the woman and her children in treatment.
FCP works closely with the Department of Social Services, the Child Protection
Team at Duke University Medical Center, Head Start, and Vocational Rehab
ilitation, thus providing a wide range of services, all coordinated through FCP.
Because women are encouraged to bring their infants to group, changing tables
and diapers are available within the group space. For the physical comfort of
pregnant women, particularly those in the later stages of pregnancy, rooms are
furnished with chairs that move into a variety of positions.
Older children who are not yet in school are also included in the treatment pro
gram. Because these children could be upset by the subject matter that can arise
in the group, they are not present when women are discussing sensitive issues.
Instead, they have their own treatment programs, supported by a specially trained
child treatment and intervention specialist, who works with the children on issues
of selfesteem, life skills, overall adjustment, and academic performance.
Source: Jeffrey M. Georgi, Senior Clinician, Duke Addictions Program.
66 Group Development and PhaseSpecific Tasks
Figure 43
SageWind
SageWind in Reno, Nevada, provides a variety of wraparound services to sup
port clients in recovery. First, it has a working agreement with the local school
district’s alternative high school education program, under which two teachers
help clients acquire high school credits that can be transferred to other schools
in the district. SageWind pays the salary of one teacher and the district pays the
other. SageWind also hires two summer school teachers in order to offer clients
yearround schooling. Throughout the year, college students and other adult
volunteers provide tutoring.
SageWind has a fulltime wellness coordinator who is a licensed substance abuse
counselor. The wellness program includes a wide range of recreational activities
designed to teach clients to enjoy alcohol and drugfree experiences. Clients
participate in such activities as woodshop projects, along with basketball, pool,
bowling, baseball, and volleyball games.
Through a Qualified Service Organization Agreement with the county health
department, SageWind offers onsite mandatory tuberculosis testing and counsel
ing and voluntary HIV and pregnancy testing and counseling. A registered nurse
teaches a weekly health class on issues ranging from communicable diseases to
nutrition. Treatment technicians can provide transportation, picking up clients
for treatment and returning them to work or home. When necessary, SageWind
also offers bus passes.
An onsite mental health and family clinic at SageWind addresses cooccurring
disorders and strengthens the family unit. Multifamily group counseling, family
support groups, couples counseling, and family therapy help develop skills need
ed for the survival and growth of the family.
All of SageWind’s primary counselors also function as case managers. If a client
or the client’s family needs housing, food, clothing, or medical care, counselors
will provide referral information and assistance. SageWind receives donated
returned items from two of the area’s largest retailers. The agency maintains a
clothes closet and can also help clients obtain household furnishings and similar
necessities. Any remaining items are donated to other nonprofit organizations in
nearby areas.
Finally, a fulltime career counselor at SageWind facilitates a career track. The
counselor provides individual and group services, as well as onsite monitoring of
clients’ job performance. The goal is to assist clients not only to gain employ
ment, but to perform well consistently in their jobs.
Source: A Consensus Panel member.
Group Development and PhaseSpecific Tasks 67
needs. Services still needed can be provided by agreement as the basis for group activities,
initiating cooperative ventures with organiza group members can be asked to recall specific
tions that have similar interests and comple agreements during the first session. To an
mentary capabilities. Note all the cooperation appropriate response, the leader can reply,
between and among organizations described in “Yes, that’s an important one.” Responses that
Figures 42 and 43. are distorted may be referred to the group to
determine how others recall the agreement
(Vannicelli 1992).
Group Agreements
A group agreement establishes the expectations The agreement provides for “a mutual under
that group members have of each other, the standing of the common task and the conditions
leader, and the group itself. For example, under which it will be pursued. It is through
many leaders require that group members the contract that the leader derives his authori
entering longterm fixed membership groups ty to work: to propose activities, to confront a
commit to remain in the group for a set period. member, to make interpretations. And it is by
Another common provision of group contracts virtue of the contract that certain other activi
stipulates that sessions will start and end at ties can be declared ‘out of bounds’ by either
specific times. The leader should make sure leader or member” (Singer et al. 1975, p. 147).
that these time boundaries are observed, both Sometimes, obtaining compliance to the group
by clients and the leader. Group members can agreement requires flexibility and ingenuity. In
not be expected to abide by the group agree some cultures, for example, time is a process,
ment if the leader does not. not a concept represented by a number. Of
A group member’s acceptance of the contract course, it remains important to maintain time
before entering a group has been described as boundaries. However, when many group mem
the single most important factor contributing to bers share a culture or ethnicity with a marked
the success of outpatient therapy groups ly relaxed attitude toward time, it may be
(Flores 1997). Consequently, it is important to appropriate to design and adhere to a structure
present the contract appropriate for that group. For example,
in a way that causes SageWind accommodates its Hispanic/Latino
clients to view it as a clients’ flexible view of time and traditions of
true commitment sociability. One model moves clients from a
It is important to and not a mere for shared lunch to group. By the time group starts,
mality. Particularly all its members have arrived and are ready to
begin group work. Another tactic is to schedule
present the con with people referred
to treatment through longer group times that enable members to move
the criminal justice into group work from a socializing phase, usual
tract in a way that ly including rituals of food or music.
system, it is impor
causes clients to tant to make thera The group agreement is intended to inspire
peutic contracts that clients to accept the basic rules and premises of
are explicit and the group and to increase their determination
view it as a true clear, and that carry and ability to succeed. These agreements are
a firm expectation not meant to provide a basis for excluding or
commitment and that the agreement is punishing anyone. On the contrary, the leader
to be honored by all should understand that few group members are
not a mere members of the able to meet all stipulations in the agreement
group. throughout their recovery. When provisions of
formality. the group agreement are violated, the leader
To reinforce the
importance of the should avoid assuming an authoritarian role
68 Group Development and PhaseSpecific Tasks
Figure 44
Examples of Agreements About Time and Attendance
Regular and timely attendance at all Attendance. Regular attendance and
sessions is expected. As a member, it is punctuality increase the value of the
your responsibility to notify the group group for each member. Such cohe
in advance when you know that you siveness creates a climate of work,
will be away or late for group. support, and success. In the event of a
member’s inability or decision not to
To emphasize the importance of each attend a session, a telephone call to
person to the group, members are also this effect is expected. Group will
required to notify the leader when begin and end promptly at the desig
they are unable to attend. nated times. Group members will
Members joining longterm groups agree to be in group at the time it
remain as long as they find the group starts and stay until it finishes.
useful in working on important issues Commitment. Members are allowed to
in their lives. We recommend at least 1 join the group only if they are willing
year’s participation. to make a 6month commitment.
Members are required to make an ini This agreement ensures that the group
tial 3month commitment in order to process will not be disrupted by mem
determine the usefulness of this partic bers “dropping in” for one or two ses
ular group for them. sions and then dropping out of the
In the event of an unexpected absence, group. The agreement also ensures
group members are expected to notify that any person who joins the group
the group at least 24 hours in advance will be making enough of a commit
to avoid being charged for the missed ment to benefit from the group.
session.
and instead ask questions that refer infractions Communicating grounds for
to the group. The violation becomes important
and useful material for group members to dis
exclusion
cuss as part of the group process. The errant The terms under which clients will be excluded
behavior should be understood as a meaningful from the group should be made explicit in the
deviation and approached with interest and group agreement, so exclusion does not come as
curiosity, not with an air of reproach. See a surprise. Some stipulations in the group
Figures 44 and 45 (see p. 71) for examples of agreement might have to incorporate legal
group agreement stipulations. requirements since courtmandated treatment
groups may have attendance criteria set by the
State. If so, the State will set forth the conse
quences for failure to attend the requisite num
ber of sessions.
Group Development and PhaseSpecific Tasks 69
Confidentiality betrayed when someone outside the group
knows about something said within the group.
Group members should be asked not to discuss
anything outside the group that could reveal Except in situations specified in Federal law,
the identity of other members. The leader programs may not disclose information about
should emphasize that confidentiality is critical the services a client receives without the client’s
and should strongly encourage group members written consent. The law is explained in detail
to honor their pledge of confidentiality. The in Confidentiality of Patient Records for
principle that “what is said in the group stays Alcohol and Other Drug Treatment (Lopez
in the group” is a way of delineating group 1994).
boundaries and increasing trust in the group.
This atmosphere of trust is essential for group The leader should emphasize how to structure
members to feel safe enough to disclose their consent and disclosure, especially through dis
feelings and problems. cussion of the minimum necessary principle.
Only specific information can be disclosed.
Though group members are precluded from Legal requirements commonly require, for
identifying other members of the group or dis example, that the therapist report instances of
cussing anything they say, members can discuss elder or child abuse and take action when
the themes of the group and what they person clients threaten to harm themselves or others.
ally have said. In fact, talking about the group Actions might include the hospitalization of the
with a significant other or therapist in a way prospective perpetrator and/or a warning to
that does not violate the confidentiality of oth the intended victim. Group leaders need to be
ers can be important to a client’s growth. familiar with confidentiality requirements in
their programs and their States. See chapter 6
Under some circumstances, as defined by the for a discussion of confidentiality.
Federal confidentiality regulation or by more
stringent State regulation, certain information
may be shared. Physical contact
However, the infor Touch in a group is never neutral. People have
mation shared with different personal histories and cultural back
out consent is grounds that lead to different interpretations of
restricted by the what touch means. Consequently, the leader
minimum necessary should evaluate carefully any circumstance in
clause. Refer to 42 which physical contact occurs, even when it is
Group leaders C.F.R., Part 2, intended to be positive. In most groups, touch
Confidentiality of (handholding or hugs) as part of group rituals
need to be familiar Alcohol and Drug is not recommended, though in others (such as
Abuse Patient an expressive therapy or dance group), touch
with confidenti Records to identify may be acceptable and normative. Naturally,
the specific circum group agreements always should include a
ality requirements stances under which clause prohibiting physical violence.
these exceptions
apply. Group mem
in their programs
bers should know
Use of moodaltering
what information substances
and their States. about them might be Some programs, especially ones connected to
shared and why, the judicial system, have policies that require
how, and when this expulsion of group members who are using
sharing occurs, so drugs of abuse. Counselors are required to
they do not feel report these violations. Part of client prepara
70 Group Development and PhaseSpecific Tasks
tion and orientation is to explain all legally viding that group rules permit and encourage
mandated provisions and consequences for such disclosures).
failure to comply with group and treatment
guidelines. Contact outside the group
Many in the substance abuse treatment field Generally speaking, the group agreement
believe that such rules lead to withholding of should discourage personal contact outside the
information (Vannicelli 1992). They reason that group. The reality is, however, that clients who
clients cannot be open and honest about sub have bonded in group are likely to communi
stance use if their candor is punished. A rea cate outside the group and may encounter each
sonable requirement, many believe, is that other on occasions like AA meetings. Under
clients “must be in an appropriate condition to some circumstances, it may even be desirable
participate in order to be at the group. This to encourage individuals who support each
allows the therapist to make a clinical judgment other’s efforts to abstain from substance abuse.
on a casebycase basis, as to whether or not a The group members need to be told and
client who has slipped may benefit from being reminded that new intimate relationships are
in the group that night” (Vannicelli 1992, pp. hazardous to early recovery and are therefore
59–60). Members also should pledge to discuss discouraged. Further, any contacts outside the
a return to use promptly after it occurs (pro group should be discussed openly in the group.
Figure 45
Examples of Agreements About Group Participation
Members will have a commitment to To help you benefit most from your
talk about important issues in their group experience, you will agree to:
lives that cause difficulty in relating to
others or in living life fully. Talk about the issues and problems
that prompted you to join the group.
Members will have a commitment to
talk about what is going on in the Tell the emotionally meaningful stories
group itself as a way of better under of your life.
standing their own interpersonal Verbally communicate your immediate
dynamics. thoughts and feelings about yourself,
the group leaders, and the group
members.
Take an equal share of the total talk
ing time.
Not leave the group before you com
plete or resolve what you came to the
group to address.
Group Development and PhaseSpecific Tasks 71
Participation in the life of
should emphasize the need to involve the group
in termination decisions. Ultimately, however,
the group
the group members should make their own
The group agreement should specify what choice about discontinuing treatment.
group members are expected to divulge. For
example, group members should be willing to Premature termination (dropping out) may
discuss, in an honest way, the issues that have serious consequences for some clients.
brought them to the group. Instructions to par Courtreferred clients (those on parole, proba
ticipants should emphasize that they are tion, and so on) must be reported if they drop
responsible for maintaining their personal out of treatment. The group agreement should
boundaries, and they should participate at the clearly state all requirements for reporting and
pace and level they find comfortable. They all consequences established by the referring
should not be required to share personal infor agency. Members of the group should all clear
mation until they feel safe enough to do so. ly understand what behaviors might lead to a
premature termination.
Financial responsibility
In the group agreement, members agree to pay PhaseSpecific Group
their bills at a specified time. The agreement
also may specify (1) a commitment to discuss
Tasks
any problems that occur in making payments Every group has a beginning, middle, and end.
(Vannicelli 1992) and (2) the circumstances These phases occur at different times for differ
under which a group member will be held ent types of groups. One or two sessions of a
responsible for payments. For example, group particular revolving membership group may
members should know ahead of time that they cover all three stages of group therapy for a
will be financially responsible for missed ses particular client, while for a longterm fixed
sions if that is the agency policy. membership group, several sessions may be
only part of the beginning phase. Whatever the
type or length of a group, the group leader is
Termination
responsible for attending to certain key ele
Group agreements should specify how group ments at each of these points. (Note that this
members should handle termination or occa discussion focuses on phases of group develop
sions when they are ment, not phases of treatment.)
considering termina
tion. Sometimes, a
group member close Beginning Phase––Preparing
Premature to an emotionally the Group To Begin
charged issue may
During the beginning phase of group therapy,
decide to terminate
termination issues arise around topics such as orientation,
rather than to con
beginners’ anxiety, and the role of the leader.
front the uncomfort
(dropping out) able feelings.
The purpose of the group is articulated, work
ing conditions of the group are established,
Because group mem
may have serious members are introduced, a positive tone is set
bers often are tempt
for the group, and group work begins. This
ed to leave the group
consequences for phase may last from 10 minutes to a number
prematurely instead
of months. In a revolving group, this orienta
of working toward
tion will happen each time a new member joins
some clients. the necessary
the group.
changes in their
lives, the agreement
72 Group Development and PhaseSpecific Tasks
Introductions members will need to enter to ensure survival
of the group. In contrast, revolving member
Even in shortterm revolving membership
ship groups may have frequent changes
groups, it is important for the leader to connect
because of the demands of treatment payment
with each member. This joining can be as sim
guidelines or admission and discharge proce
ple as a friendly smile and a oneword wel
dures. Careful thought should be given to the
come. At this time, all members, at the very
pace and timing of membership changes for
least, should have an opportunity to give their
particular group types.
names and say something about themselves.
Some leaders ask members to introduce them
selves. Others let the group figure out how to Group agreement review
get acquainted. One cautionary note, however, The group agreement should be reviewed in an
is that many clients treated for substance abuse interactive way, involving the group members in
also have histories of emotional and physical discussion of the
abuse. Merely directing attention toward them terms. The
can trigger feelings of shame. Thus, while it is group leader
extremely important to make connections should ask
between and among group members and to members if they Ideally, member
involve them in the process, the sensitive leader are aware of
will not insist on recitations. Emotional safety concerns that
always should be foremost in the group
ship changes
might require
leader’s mind. additional group
agreement pro
should be held to
At the first meeting of a fixed membership
visions to make
group, group members also may be asked if a minimum,
the group a safe
they know anyone else in the group. If there
place to share
are connections that might cause difficulties, especially in fixed
and grow.
they will be discovered at the start.
Group members
Each new member who joins the group is enter should have an membership
ing the beginning phase of the group—for that opportunity to
individual. It is not easy to find one’s place in suggest and dis groups.
an already established group. The leader can cuss further
help build bridges between old and new mem stipulations. In
bers by pointing out that it is difficult to be the addition, the
new member and by encouraging old members group agree
to help the new one join the group. In long ment should be reviewed periodically.
term fixed membership groups, the group will
require careful preparation to receive a new Providing a safe, cohesive
member graciously. Even in revolving member environment
ship groups, which provide less opportunity for
preparation, the leader should let members During the beginning phase of the group, all
know when to expect membership changes, members should feel that they have a part to
introduce new members, and help build play in the group and have something in com
bridges—for example, by inviting existing mon with other members. This cohesion, both
members to say something about the group and among clients and between the clients and the
how it works. group leader, will affect the productivity of
work throughout the therapeutic process.
Ideally, membership changes should be held to Among the many components of group cohesion
a minimum, especially in fixed membership are “connectedness of the group demonstrated
groups, though as members graduate, new by working toward a common therapeutic goal;
Group Development and PhaseSpecific Tasks 73
acceptance, support, and identification with begin to withdraw. Care always should be
the group; affiliation, acceptance, and attrac taken not to shame group members or to allow
tiveness of the group; and engagement” others in the group to engage in shaming
(Marziali et al. 1997, p. 476). behaviors.
In the beginning phase, the leader ordinarily The leader also should bear in mind that in the
needs to be more supportive and active than beginning phase, the group is unable to with
will be necessary once the group gets under stand much conflict. Before the group develops
way. If particular members have spoken very trust and cohesion, conflict is likely to disrupt
little, it helps to let them know that their con proceedings or even to threaten a group’s exis
tributions are welcome. The leader might say tence, so it is unwise to permit confrontation.
something like, “We haven’t heard much from Instead the group leader should encourage
you tonight, Jane, but perhaps next week the interaction that minimizes aggression and hos
group will have a chance to get to know you a tility. Later, when the group is more stable,
little bit more” (Vannicelli 1992, p. 48). group members may be urged to risk more
provocative positions (Flores 1997).
To help group members bond with each other,
the leader should encourage the connections
members begin to make on their own and Establishing norms
should point out similarities. The leader might It is up to the leader to make sure that healthy
say, for instance, “It seems that Sue and Bob, group norms are established and that counter
and perhaps others in here as well, are strug productive norms are precluded, ignored, or
gling with very similar problems with their extinguished. The leader shapes norms not only
anger” (Vannicelli 1992, pp. 48–49). through responses to events in the group, but
also by modeling the behavior expected of oth
The leader also is responsible for ensuring that ers. For example, norms to be encouraged in a
early in the group, emotional expression stays process group include honesty, spontaneity, a
at a manageable level. Otherwise, members high level of attentive involvement, appropriate
quickly may feel emotionally overloaded and
Figure 46
Reminders for Each Group Session
Open.
Announcements: Who will be late? Absent? Does the leader plan any absences?
If there are new members, welcome them. Then explain the goals of the group.
Encourage new members to express their goals.
Track process.
To refocus the direction of the group, ask:
• How are things going (or feeling) in the group?
• What is happening right now?
• Does it feel as if we are on track?
74 Group Development and PhaseSpecific Tasks
Figure 46
Reminders for Each Group Session (continued)
Don’t fight what is hard––use it!
Capitalize on the energy of resistance (the client’s defense against the pain of
selfexamination) by
• Noticing it
• Validating it by welcoming honesty
• Linking it to group goals
Connect before tackling. Ally before confronting or stopping behavior.
Note the speaker’s positive intentions or efforts. Then ask the speaker to exam
ine his behavior or change course.
Encourage mutual connections among members.
Underscore resonating responses, either verbal or nonverbal. Ask how others
are reacting to what is being shared.
Share the work.
Use the group to help you when the going gets rough:
• Share your conflict and ask the group to help with it.
• When a problem occurs, ask the group members to share their thoughts
about how to proceed. For example, “Max clearly has a lot on his mind. Do
we go with that issue or stick to where we were headed a few minutes ago?”
Close.
Note that the time is up, or soon will be.
As you state the end boundary, ask if it is a hard time to end.
Source: Vannicelli, unpublished manuscript.
selfdisclosure, the desire for insight into one’s hostile to new members (Flores 1997). The
own behavior, nonjudgmental acceptance of leader should respond quickly and clearly to
others, and the determination to change habits that impede group work and that threat
unhealthy practices (Flores 1997). Unhealthy en to become normative.
norms that could hamper a process group
include a tendency to become leadercentered,
onedimensional (that is, allloving or all
attacking), or so tightly knit that the group is
Group Development and PhaseSpecific Tasks 75
Initiating actively, but even in more contentoriented
groups, nonverbal cues are indicative and
the work should not be ignored.
Termination is of the
The group, then, is a forum where clients inter
group
a particularly act with others. In this give and take of thera
The leader py, clients receive feedback that helps them
facilitates the rethink their behaviors and move toward pro
important work of the ductive changes. The leader helps group mem
group, bers by allocating time to address the issues
opportunity for whether by that arise, by paying attention to relations
providing among group members, and by modeling a
members to honor information in healthy interactional style that combines hon
a psychoedu esty with compassion. Figure 46 (p. 74) sug
the work they cational group gests some ways in which a group leader can
or by encour help the group accomplish its middlephase
have done. aging honest tasks.
exchanges
among mem
bers in other End Phase––Reaching Closure
types of Termination is a particularly important oppor
groups. Most leaders strive to keep the focus on tunity for members to honor the work they
the here and now as much as possible. The have done, to grieve the loss of associations and
leader also may need to prompt a new group friendships, and to look forward to a positive
with questions such as, “You seem to be future. Group members should learn and prac
responding to what Jane was sharing. Can you tice saying “goodbye,” understanding that it is
tell us something about what was going on for necessary to make room in their lives for the
you as she was talking?” (Vannicelli 1992, p. 50). next “hello.”
“Termination,” Yalom (1995, pp. 361–362)
Middle Phase––Working observes, “is more than the end of therapy; it is
Toward Productive Change … an important force in the process of change
The group in its middle phase encounters and … a stage in the individual’s career of growth.”
accomplishes most of the actual work of thera The group begins this work of termination
py. During this phase, the leader balances con when the group as a whole reaches its agreed
tent, which is the information and feelings upon termination point or a member deter
overtly expressed in the group, and process, mines that it is time to leave the group. In
which is how members interact in the group. either case, termination is a time for
The therapy is in both the content and process. • Putting closure on the experience
Both contribute to the connections between and
• Examining the impact of the group on each
among group members, and it is those connec
person
tions that are therapeutic.
• Acknowledging the feelings triggered by
Many new leaders focus strongly on content, departure
but thoughtful attention to group process is • Giving and receiving feedback about the
extremely important. Even in an educational group experience and each member’s role
group, tension in the room, rolling eyes, or side in it
conversations can interfere with messages that
need attention. In a process group, these cues • Completing any unfinished business
are part of the work and need to be explored
76 Group Development and PhaseSpecific Tasks
• Exploring ways to carry on the learning the ample advance notice (perhaps 4 weeks) to give
group has offered the group time to process the feelings associated
with the leavetaking (Flores 1997). Group
Departing clients have been classified into three members should be given permission to exam
groups. Completers have finished the work ine existential issues like loss, growth, death,
they came into group to do. Plateauers are not the shortness of time, the unfairness of life, and
really finished, but their progress has slowed or other thoughts that can prey on the mind
stopped for the time being. Fleers feel an irre (Yalom 1995). So often, clients who used drugs
sistible need to escape as rapidly as possible, or alcohol to anesthetize their grief over losses
often because they have encountered an upset come to confront their grief in early sobriety.
ting reality in the group or in their lives outside Every group facilitator working with substance
the group (Vannicelli 1992). abuse therefore should understand the grief
The group may be invited to explore the pro process and should be prepared to deal with
posal that a member leave the group. In addi grieving clients.
tion, the leader might ask clients about to ter It is natural for individuals and groups to try
minate to classify themselves as completers, to hold onto each other. “Some isolated
plateauers, or fleers. If the client is a fleer, that patients may postpone termination because
person might be asked a hypothetical question: they have been using the therapy group for
If you remained in group, what do you think social reasons rather than as a means for devel
you might work on? Such a query might bring oping the skills to create a social life for them
to light the issue the fleer wants very much to selves in their home environment. The thera
avoid. To dissuade a person departing prema pist should help these members focus on trans
turely, it may also help to comment, “One of fer of learning and encourage risk taking out
the characteristics of a good decision is that it side the group” (Yalom 1995, p. 363).
remains a good decision even after considera Alternatively, groups
tion a few weeks later” (Vannicelli 1992, p. (and therapists) may
179). Then ask the client if, by that standard, subtly pressure a par
his decision to leave will be a good one. ticular group member
Whatever attempts are made to dissuade pre to remain because
they value the depart In general, the
mature termination, some people with sub
stance abuse problems inevitably will leave ing member’s contri
butions and will miss longer members
groups abruptly, for a variety of reasons.
Groups should be forewarned that sudden him or her. When a
changes may take place, and leaders should be senior member leaves, have been with the
prepared to help group members cope with however, another
these changes. ordinarily will assume group, the longer
the role just vacated
Completing a group successfully can be an (Yalom 1995). they may need
important event for group members, when they
see the conclusion of a difficult but successful Some client feelings
may concern parting to spend on termi
endeavor (Flores 1997). The termination of a
group also is an opportunity for clients to prac from the therapist.
Some clients who are nation.
tice parting, with the understanding that a
departure leads to the next opportunity for exquisitely sensitive to
connection. abandonment, for
example, may deny
Even positive, celebrated departures, however, the gains they have
can raise strong feelings, so soontodepart made. They need reassurance that, once they
members of an ongoing group should give improve, they no longer will need the therapist.
Group Development and PhaseSpecific Tasks 77
In other reluctant clients, symptoms may In general, the longer members have been with
recur. These people need help seeing the the group, the longer they may need to spend
apparent setback for what it really is: fear of on termination. The group leader plays an
termination (Yalom 1995). important role in termination, either facilitat
ing an individual’s goodbye to the group or the
Under no circumstances should the therapist group’s goodbye to itself (if the group is end
“collude in the denial of termination” (Yalom ing). Although group leaders cannot say good
1995, p. 365). The client has to come to grips bye for the group, they can encourage the
with the reality of leaving and not routinely group to fashion its own farewell.
returning. The departing client and the balance
of the group should face the fact that “the
group will be irreversibly altered; replacements
will enter the group; the present cannot be
frozen; time flows on cruelly and inexorably”
(Yalom 1995, p. 365).
78 Group Development and PhaseSpecific Tasks
5 Stages of Treatment
Overview
This chapter describes the characteristics of the early, middle, and
In This
late stages of treatment. Each stage differs in the condition of clients,
Chapter…
effective therapeutic strategies, and optimal leadership characteristics.
Adjustments To
For example, in early treatment, clients can be emotionally fragile,
Make Treatment
ambivalent about relinquishing chemicals, and resistant to treatment.
Appropriate
Thus, treatment strategies focus on immediate concerns: achieving absti
nence, preventing relapse, and managing cravings. Also, to establish a
The Early Stage of
stable working group, a relatively active leader emphasizes therapeutic
Treatment
factors like hope, group cohesion, and universality. Emotionally charged
Condition of Clients in
factors, such as catharsis and reenactment of family of origin issues, are
Early Treatment
deferred until later in treatment.
Therapeutic Strategies in
Early Treatment
In the middle, or action, stage of treatment, clients need the group’s
Leadership in Early
assistance in recognizing that their substance abuse causes many of their
Treatment
problems and blocks them from getting things they want. As clients
reluctantly sever their ties with substances, they need help managing
The Middle Stage of
their loss and finding healthy substitutes. Often, they need guidance in
Treatment
understanding and managing their emotional lives.
Condition of Clients in
MiddleStage Treatment
Latestage treatment spends less time on substance abuse per se and
Therapeutic Strategies in
turns toward identifying the treatment gains to be maintained and risks
MiddleStage Treatment
that remain. During this stage, members may focus on the issues of liv
Leadership in Middle
Stage Treatment
ing, resolving guilt, reducing shame, and adopting a more introspective,
relational view of themselves.
The Late Stage of
Treatment
Condition of Clients in
Adjustments To Make Treatment
LateStage Treatment
Therapeutic Strategies in
Appropriate
LateStage Treatment
As clients move through different stages of recovery, treatment must
Leadership in LateStage
move with them, changing therapeutic strategies and leadership roles
Treatment
with the condition of the clients. These changes are vital since interven
tions that work well early in treatment may be ineffective, and even
harmful, if applied in the same way later in treatment (Flores 2001).
79
Any discussion of resolve the issues that arise at any stage of
intervention adjust recovery. The result is that different group
ments to make treat members may achieve and be at different stages
ment appropriate at of recovery at the same time in the lifecycle of
With guidance,
each stage, however, the group. The group leader, therefore, should
necessarily must be use interventions that take the group as a
clients can learn
oversimplified for whole into account.
three reasons. First,
to recognize
the stages of recov Third, therapeutic interventions, meaning the
ery and stages of acts of a clinician intended to promote healing,
the events and
treatment will not may not account for all (or any) of the change
correspond perfectly in a particular individual. Some people give up
situations that
for all people. drugs or alcohol without undergoing treatment.
Clients move in and Thus, it is an error to assume that an individu
out of recovery al is moving through stages of treatment
trigger renewed
because of assistance at every point from insti
stages in a nonlinear
process. A client tutions and selfhelp groups. To stand the best
substance use.
chance for meaningful intervention, a leader
may fall back, but
not necessarily back should determine where the individual best fits
to the beginning. in his level of function, stance toward absti
“After a return to nence, and motivation to change. In short,
substance use, generalizations about stages of treatment may
clients usually revert to an earlier change not apply to every client in every group.
stage—not always to maintenance or action,
but more often to some level of contemplation.
They may even become precontemplators The Early Stage of
again, temporarily unwilling or unable to try to Treatment
change . . . [but] a recurrence of symptoms
does not necessarily mean that a client has
abandoned a commitment to change” (Center
Condition of Clients in Early
for Substance Abuse Treatment 1999b, p. 19). Treatment
See chapters 2 and 3 for a discussion of the In the early stage of treatment, clients may be
stages of change. in the precontemplation, contemplation, prepa
ration, or early action stage of change, depend
A return to drug use, properly handled, can
ing on the nature of the group. Regardless of
even be instructive. With guidance, clients can
their stage in early recovery, clients tend to be
learn to recognize the events and situations that
ambivalent about ending substance use. Even
trigger renewed substance use and regression to
those who sincerely intend to remain abstinent
earlier stages of recovery. This knowledge
may have a tenuous commitment to recovery.
becomes helpful in subsequent attempts leading
Further, cognitive impairment from substances
to eventual recovery. Client progressregress
is at its most severe in these early stages of
progress waves, however, require the counselor
recovery, so clients tend to be rigid in their
to constantly reevaluate where the client is in
thinking and limited in their ability to solve
the recovery process, irrespective of the stage
problems. To some scientists, it appears that
of treatment.
the “addicted brain is abnormally conditioned,
Second, adjustments in treatment are needed so that environmental cues surrounding drug
because progress through the stages of recovery use have become part of the addiction”
is not timebound. There is no way to calculate (Leshner 1996, p. 47).
how long any individual should require to
80 Stages of Treatment
Typically, people who abuse substances do not connected to a dysfunctional subculture
enter treatment on their own. Some enter treat but socially isolated from healthy con
ment due to health problems, others because tacts (Milgram and Rubin 1992, p. 96).
they are referred or mandated by the legal sys
tem, employers, or family members (Milgram Emphasis therefore is placed on acculturating
and Rubin 1992). Group members commonly clients into a new culture, the culture of recov
are in extreme emotional turmoil, grappling ery (Kemker et al. 1993).
with intense emotions such as guilt, shame,
depression, and anger about entering treatment. Therapeutic Strategies in Early
Even if clients have entered treatment volun Treatment
tarily, they often harbor a desire for substances In 1975, Irvin Yalom elaborated on earlier
and a belief that they can return to recreation work and distinguished 11 therapeutic factors
al use once the present crisis subsides. At first, that contribute to healing as group therapy
most clients comply with treatment expecta unfolds:
tions more from fear of consequences than
from a sincere desire to stop drinking or using • Instilling hope—some group members exem
illicit drugs (Flores 1997; Johnson 1973). plify progress toward recovery and support
others in their efforts, thereby helping to
Consequently, the group leader faces the chal retain clients in therapy.
lenge of treating resistant clients. In general,
resistance presents in one of two ways. Some • Universality—groups enable clients to
clients actively resist treatment. Others passive see that they are not alone, that others have
ly resist. They are outwardly cooperative and similar problems.
go to great lengths to give the impression of • Imparting information—leaders shed light on
willing engagement in the treatment process, the nature of addiction via direct instruction.
but their primary motivation is a desire to be • Altruism—group members gain greater self
free from external pressure. The group leader esteem by helping each other.
has the delicate task of exposing the motives
• Corrective recapitulation of the primary
behind the outward compliance.
family group—groups provide a familylike
The art of treating addiction in early treatment context in which longstanding unresolved
is in the defeat of denial and resistance, which conflicts can be revisited and constructively
almost all clients with addictions carry into resolved.
treatment. Group therapy is considered an • Developing socializing techniques—groups
effective modality for give feedback; others’ impressions reveal how
a client’s ineffective social habits might
…overcoming the resistance that char undermine relationships.
acterizes addicts. A skilled group leader
can facilitate members’ confronting • Imitative behavior—groups permit clients to
each other about their resistance. Such try out new behavior of others.
confrontation is useful because it is dif • Interpersonal learning—groups correct the
ficult for one addict to deceive another. distorted perceptions of others.
Because addicts usually have a history • Group cohesiveness—groups provide a safe
of adversarial relationships with author holding environment within which people feel
ity figures, they are more likely to free to be honest and open with each other.
accept information from their peers
• Catharsis—groups liberate clients as they
than a group leader. A group can also
learn how to express feelings and reveal what
provide addicts with the opportunity for
is bothering them.
mutual aid and support; addicts who
present for treatment are usually well
Stages of Treatment 81
• Existential factors—groups aid clients in are ready for such highly charged work.
coming to terms with hard truths, such as Attention to group cohesiveness is important
(1) life can be unfair; (2) life can be painful early in treatment because only when group
and death is inevitable; (3) no matter how members feel safety and belonging within the
close one is to others, life is faced alone; (4) it group will they be able to form an attachment to
is important to live honestly and not get the group and fully experience the effects of new
caught up in trivial matters; (5) each of us is knowledge, universality, and hope.
responsible for the ways in which we live.
Therapeutic factors such as catharsis, existen
In different stages of treatment, some of these tial factors, or recapitulation of family groups
therapeutic factors receive more attention than generally receive little attention in early treat
others. For example, in the beginning of the ment. These factors often are highly charged
recovery process, it is extremely important for with emotional energy and are better left until
group members to experience the therapeutic the group is well established.
factor of universality. Group members should
come to recognize that although they differ in During the initial stage of treatment, the thera
some ways, they also share profound connec pist helps clients acknowledge and understand
tions and similarities, and they are not alone in how substance abuse has dominated and dam
their struggles. aged their lives. Drugs or alcohol, in various
ways, can provide a substitute for the giveand
The therapeutic factor of hope also is particu take of relationships and a means of surviving
larly important in this stage. For instance, a without a healthy adjustment to life. As sub
new member facing the first day without drugs stances are withdrawn or abandoned, clients
may come into a revolving membership group give up a major source of support without hav
that includes people who have been abstinent ing anything to put in its place (Brown 1985;
for 2 or 3 weeks. The mere presence of people Straussner 1997).
able to sustain abstinence for days––even
weeks––provides the new member with hope In this frightening time, counselors need to
that life can be lived without alcohol or illicit ensure that the client has a sense of safety. The
drugs. It becomes possible to believe that absti group leader’s task is to help group members
nence is feasible because others are obviously recognize that while alcohol or illicit drugs may
succeeding. have provided a temporary way to cope with
problems in the past, the consequences were
Imparting informa not worth the price, and new, healthier ways
tion often is needed can be found to handle life’s problems.
to help clients learn
what needs to be In earlystage treatment, strong challenges to a
done to get through client’s fragile mental and emotional condition
a day without chemi can be very harmful. Out of touch with unmed
Attention to group icated feelings, clients already are susceptible
cals. Psychoedu
cation also allows to wild emotional fluctuations and are prone to
cohesiveness is group members to unpredictable responses. Interpersonal rela
learn about addic tionships are disturbed, and the effects of sub
important early in tion, to judge their stances leave the client prone to use “primitive
practices against this defensive operations such as denial, splitting,
treatment. factual information, projective identification, and grandiosity”
and to postpone (Straussner 1997, p. 68).
intense interaction This vulnerable time, however, is also one of
with other group opportunity. In times of crisis, “an individual’s
members until they attachment system opens up” and the therapist
82 Stages of Treatment
A Note on Attachment Theory and
Substance Abuse Treatment
Attachment theory provides a comprehensive metatheory of addiction that
not only integrates diverse mental health models with the diseaseconcept, but
also furnishes guidelines for clinical practice that are compatible with existing
addiction treatment strategies including an abstinence basis and alignment with
12Step treatment philosophy.
Attachment theory (Bowlby 1979) and self psychology (Kohut 1977b) provided
the first compelling theories that offered a practical alternative rationale for the
addiction cycle that is not only compatible with the disease concept, but expands
it by providing a more complete and intellectually satisfying theoretical explana
tion why Alcoholic Anonymous (AA) works as it does.
According to the theory, attachment is recognized as a primary motivational
force with its own dynamics, and these dynamics have farreaching and complex
consequences (Bowlby 1979). In clients with substance use disorders there is an
inverse relation between their substance abuse and healthy interpersonal attach
ments. A person who is actively abusing substances can rarely negotiate the
demands of healthy interpersonal relationships successfully.
Using this theoretical model, substance abuse can be viewed as an attachment
disorder. Individuals who have difficulty establishing intimate attachments will
be more inclined to substitute substances for their deficiency in intimacy.
Because of their difficulty maintaining emotional closeness with others, they
are more likely to substitute various behaviors (including substance abuse) to
distract them from their lack of intimate interpersonal relations.
The use of substances may initially serve a compensatory function, helping those
who feel uncomfortable in social situations because of inadequate interpersonal
skills. However, substances of abuse will gradually compromise neurophysiologi
cal functioning and erode existing interpersonal skills. Managing relationships
tends to become increasingly difficult, leading to a heightened reliance on sub
stances, which accelerates deterioration and increases abuse and dependence.
Eventually, the individual’s relationship with substances of abuse becomes both
an obstacle to and a substitute for interpersonal attachments. If problems in
attachment are a primary cause of substance abuse, then a therapeutic process
that addresses the client’s interpersonal relations will be effective for longterm
recovery (Flores 2001; Straussner 1993). Treatment concentrates on removing
stressinducing stimuli, teaching ways to recognize and quell environmental cues
that trigger inappropriate behaviors, providing positive reinforcement and sup
port, cultivating positive habits that endure, and developing secure and positive
attachments.
Stages of Treatment 83
has a chance to change the client’s internal gests changes that might enable the client to
dynamics (Flores 2001, p. 72). Support net manage cravings better or avoid exposure to
works that can provide feedback and structure strong cues.
are especially helpful at this stage. Clients also
need reliable information to strengthen their For some clients, chiefly those mandated into
motivation. treatment by courts or employers, grave conse
quences inevitably ensue as a result of relapse.
At this time, clients are solidifying their “new As Vannicelli (1992) points out, however, clini
identity as an alcoholic with the corresponding cians should view relapse not as failure, but as
belief in loss of control.” They develop “a new a clinical opportunity for both group leader
logical structure” with which to assail their and clients to learn from the event, integrate
“former logic and behavior.” They also can the new knowledge, and strengthen levels of
develop a “new story . . . the Alcoholics motivation. Discussion of the relapse in group
Anonymous drunkalogue,” which recalls their not only helps the individual who relapsed
experiences and compares previous events with learn how to avoid future use, but it also gives
what life is like now (Brown 1985). other group members a chance to learn from
the mistakes of others and to avoid making the
Whether information is offered through skills same mistakes themselves.
groups, psychoeducational groups, supportive
therapy groups, spiritually oriented support
groups, or process groups, clients are most Leadership in Early Treatment
likely to use the information and tools provided Clients usually come to the first session of
in an environment alive with supportive human group in an anxious, apprehensive state of
connections. All possible sources of positive mind, which is intensified by the knowledge
forces in a client’s life should be marshaled to that they will soon be revealing personal infor
help the client manage life’s challenges instead mation and secrets about themselves. The ther
of turning to substances or other addictive apist begins by making it clear that clients have
behaviors. some things in common. All have met with the
Painful feelings, therapist, have acceded to identical agree
which clients are not ments, and have set out to resolve important
yet prepared to face, personal issues. Usually, the therapist then sug
can sometimes trig gests that members get to know each other. One
ger relapse. If technique is to allow the members to decide
During early treat relapses occur in an exactly how they will introduce themselves. The
outpatient therapist observes silently—but not impassive
ment, a relatively setting––as they ly—watching how interaction develops (Rutan
often do, because and Stone 2001).
active leader seeks relapses occur in all During early treatment, a relatively active lead
chronic illnesses, er seeks to engage clients in the treatment pro
to engage clients in including addic cess. Clients early on “usually respond more
tion––the group favorably to the group leader who is sponta
the treatment member should be neous, ‘alive,’ and engaging than they do to the
guided through the group leader who adopts the more reserved
regression. The lead stance of technical neutrality associated with
process. er encourages the the more classic approaches to group therapy”
client to attend self (Flores 2001, p. 72). The leader should not be
help groups, overly charismatic, but should be a strong
explores the enough presence to meet clients’ dependency
sequence of events needs during the early stage of treatment.
leading to relapse,
determines what cues led to relapse, and sug
84 Stages of Treatment
During early treatment, the effective leader will subjects who abused
focus on immediate, primary concerns: achiev stimulants (cocaine
ing abstinence, preventing relapse, and learning and methaphetamine).
ways to manage cravings. The leader should The studies also found
create an environment that enables clients to that deficits persisted Cognitive capacity
acknowledge that (1) their use of addictive sub for at least 3 to 6
stances was harmful and (2) some things they months after cessation usually begins to
want cannot be obtained while their pattern of of drug use. Whether
substance use continues. As clients take their these deficits predated return to normal
first steps toward a life centered on healthy substance abuse or
sources of satisfaction, they need strong sup not, treatment per in the middle stage
port, a high degree of structure, positive sonnel should expect
human connections, and active leadership. to see clients with of treatment.
impaired decision
In process groups, the leader pays particular making and impulse
attention to feelings in the early stage of treat control manifested by
ment. Many people with addiction histories are difficulties in attend
not sure what they feel and have great difficul ing, concentrating,
ty communicating their feelings to others. learning new material, remembering things
Leaders begin to help group members move heard or seen, producing words, and integrat
toward affect regulation by labeling and mir ing visual and motor cues. For the clinician,
roring feelings as they arise in group work. this finding means that clients may not have the
The leader’s subtle instruction and empathy mental structures in place to enable them to
enables clients to begin to recognize and own make the difficult decisions faced during the
their feelings. This essential step toward man action stage of treatment. If clients draw and
aging feelings also leads clients toward empathy use support from the group, however, the
with the feelings of others. client’s affect will reemerge, combine with new
behaviors and beliefs, and produce an increas
ingly stable and internalized structure (Brown
The Middle Stage of 1985).
Treatment Cognitive capacity usually begins to return to
normal in the middle stage of treatment. The
Condition of Clients in frontal lobe activity in a person addicted to
MiddleStage Treatment cocaine, for example, is dramatically different
after approximately 4–6 months of nonuse.
Often, in as little as a few months, institutional
Still, the mind can play tricks. Clients distinctly
and reimbursement constraints limit access to
may remember the comfort of their substance
ongoing care. People with addiction histories,
past, yet forget just how bad the rest of their
however, remain vulnerable for much longer
lives were and the seriousness of the conse
and continue to struggle with dependency.
quences that loomed before they came into
They need vigorous assistance maintaining
treatment. As a result, the temptation to
behavioral changes throughout the middle, or
relapse remains a concern.
action, stage of treatment.
Several studies (Committee on Opportunities in
Drug Abuse Research 1996; London et al.
Therapeutic Strategies in
1999; Majewska 1996; Paulus et al. 2002; MiddleStage Treatment
Strickland et al. 1993; Volkow et al. 1988, In middlestage recovery, as the client experi
1992) have observed decreased blood flow ences some stability, the therapeutic factors
and metabolic changes rates in the brains of
Stages of Treatment 85
of selfknowledge and altruism can be As the recovering client’s mental, physical, and
emphasized. Universality, identification, emotional capacities grow stronger, anger, sad
cohesion, and hope remain important as well. ness, terror, and grief may be expressed more
appropriately. Clients need to use the group as
Practitioners have stressed the need to work in a means of exploring their emotional and inter
alliance with the client’s motivation for change. personal world. They learn to differentiate,
The therapist uses whatever leverage identify, name, tolerate, and communicate feel
exists––such as current job or marriage con ings. Cognitive–behavioral interventions can
cerns––to power movement toward change. provide clients with specific tools to help modu
The goal is to help clients perceive the causal late feelings and to become more confident in
relationship between substance abuse and expressing and exploring them. Interpersonal
current problems process groups are particularly helpful in the
in their lives. middle stage of treatment, because the authentic
Counselors should relationships within the group enable clients to
recognize and experience and integrate a wide range of emo
The goal is to help
respect the client’s tions in a safe environment.
position and the
clients perceive the difficulty of change. When strong emotions are expressed and dis
The leader who cussed in group, the leader needs to modulate
causal relationship leaves group mem the expression of emerging feelings, delicately
bers feeling that they balancing a tolerable degree of expression and
between substance are understood is a level so overwhelming that it inhibits positive
more likely to be in a change or leads to a desire to return to sub
abuse and current position to influence stance use to manage the intensity. It also is
change, while sharp very important for the group leader to “sew the
problems in confrontations that client up” by the end of the session. Clients
arouse strong emo should not leave feeling as if they are “bleed
their lives. tions and appear ing” emotions that they cannot cope with or
judgmental may dispel. A plan for the rest of the day should be
trigger relapse developed, and the increased likelihood of
(Flores 1997). relapse should be acknowledged so group mem
bers see the importance of following the plan.
Therapeutic strategies also should take into
account the important role substance abuse has
played in the lives of people with addictions. Leadership in MiddleStage
Often, from the client’s perspective, drugs of Treatment
abuse have become their best friends. They fill
hours of boredom and help them cope with dif Historically, denial has been the target of most
ficulties and disappointments. As clients move treatment concepts. The role of the leader was
away from their relationship with their best primarily to confront the client in denial,
friend, they may feel vulnerable or emotionally thereby presumably provoking change. More
naked, because they have not yet developed recently, clinicians have stressed the fact that
coping mechanisms to negotiate life’s inevitable “confrontation, if done too punitively or if moti
problems. It is crucial that clients recognize vated by a group leader’s countertransference
these feelings as transient and understand that issues, can severely damage the therapeutic
the feeling that something vital is missing can alliance” (Flores 1997, p. 340). Inappropriate
have a positive effect. It may be the impetus confrontation may even strengthen the client’s
that clients need to adopt new behaviors that resistance to change, thereby increasing the
are adaptive, safe, legal, and rewarding. rigidity of defenses.
86 Stages of Treatment
When it is necessary to point out contradictions immediate gratification over longrange goals,
in clients’ statements and interpretations of so benefits achieved and sought after should be
reality, such confrontations should be well real, tangible, and quickly attainable.
timed, specific, and indisputably true. For
example, author Wojciech Falkowski had a The benefits of recovery yield little satisfaction
client whose medical records distinctly showed to some clients, and for them, the task of stay
abnormal liver functions. When the client ing on course can be difficult. Their lives in
maintained that he had no drinking problem, recovery seem worse, not better. Many experi
Falkowski gently suggested that he “convince ence depression, lassitude, agitation, or anhe
his liver of this fact.” The reply created a rip donia (that is, a condition in which formerly
ple of amusement in the group, and “the client satisfying activities are no longer pleasurable).
immediately changed his attitude in the desired Eventually, their lives seem devoid of any
direction” (Falkowski 1996, p. 212). Such car meaningful purpose, and they stop caring
ing confrontations made at the right time and about recovery.
in the right way are helpful, whether they come These clients may move quickly from “I don’t
from group members or the leader. care” to relapse, so the group leader should be
Another way of understanding confrontation is vigilant and prepared to intervene when a
to see it as an outcome rather than as a style. client is doing all that should be done in the
From this point of view, the leader helps group recovery process, yet continues to feel bleak.
members see how their continued use of drugs Such clients need attention and accurate
or alcohol interferes with what they want to get diagnosis. Do they have an undiagnosed co
out of life. This recognition, supported by the occurring disorder? Do they need antidepres
group, motivates individuals to change. It sants? Do they need more intensive, frequent,
seems that people who abuse substances need adjuncts to therapy, such as more Alcoholics
someone to tell it like it is “in a realistic fashion Anonymous or Narcotics Anonymous meetings
without adopting a punitive, moralistic, or and additional contacts with a sponsor?
superior attitude” (Flores 1997, p. 340). Leaders need to help group members under
In the middle stage of treatment, the leader stand and accept that many forms of therapy
helps clients join a culture of recovery in which outside the group can promote recovery. Group
they grow and learn. The leader’s task is to members should be
engage members actively in the treatment and encouraged to sup
recovery process. To prevent relapse, clients port each other’s
need to learn to monitor their thoughts and efforts to recover,
In the middle stage
feelings, paying special attention to internal however much their
cues. Both negative and positive dimensions needs and treatment
options may differ. of treatment, the
may be motivational. New or relapsed group
members can remind others of how bad their The leader helps leader helps clients
former lives really were, while the group’s individuals assess the
vision of improvements in the quality of life is a degree of structure
distinct and immediate beam of hope. join a culture of
and connection they
The leader can support the process of change need as recovery recovery in which
by drawing attention to new and positive devel progresses. Some
opments, pointing out how far clients have group members find
that participation in
they grow
traveled, and affirming the possibility of
increased connection and new sources of satis religious or faith
groups meets their and learn.
faction. Leaders should bear in mind, however,
that people with addictions typically choose needs for affiliation
and support. For
Stages of Treatment 87
longterm, chronically impaired people with ing issues often emerge, such as poor self
addictive histories, highly intensive participa image, relationship problems, the experience of
tion in 12Step groups is usually essential for shame, or past trauma. For example, an
an extended period of time. unusually high percentage of substance and
alcohol abuse occurs among men and women
who have survived sexual or emotional abuse.
The Late Stage of
Many such cases warrant an exploration of dis
sociative defenses and evaluation by a knowl
Treatment
edgeable mental health professional.
Condition of Clients in
When the internalized pain of the past is
LateStage Treatment
resolved, the client will begin to understand
and experience healthy mutuality, resolving
During the late (also referred to as ongoing or conflicts without the maladaptive influence of
maintenance) stage of treatment, clients work alcohol or drugs. If the underlying conflicts are
to sustain the attainments of the action stage, left unresolved, however, clients are at
but also learn to anticipate and avoid tempting increased risk of other compulsive behavior,
situations and triggers that set off renewed sub such as excessive exercise, overeating, gam
stance use. To deter relapse, the systems that bling, or excessive sexual activity.
once promoted drinking and drug use are
sought out and severed.
Therapeutic Strategies in Late
Despite efforts to forestall relapse, many
clients, even those who have reached the late
Stage Treatment
stage of treatment, do return to substance use In the early and middle stages of treatment,
and an earlier stage of change. In these cases, clients necessarily are so focused on maintain
the efforts to guard against relapse were not all ing abstinence that they have little or no capac
in vain. Clients who return to substance abuse ity to notice or solve other kinds of problems.
do so with new information. With it, they may In latestage treatment, however, the focus of
be able to discover and acknowledge that some group interaction broadens. It attends less to
of the goals they set are unrealistic, certain the symptoms of drug and alcohol abuse and
strategies attempted more to the psychology of relational interaction.
are ineffective, and
In latestage treatment, clients begin to learn to
environments
engage in life. As they begin to manage their
deemed safe are not
emotional states and cognitive processes more
at all conducive to
During the late successful recovery.
effectively, they can face situations that involve
conflict or cause emotion. A processoriented
With greater insight
stage of treatment, into the dynamics of
group may become appropriate for some clients
who are finally able to confront painful reali
their substance
clients work to ties, such as being an abused child or abusive
abuse, clients are
parent. Other clients may need groups to help
better equipped to
sustain the attain them build a healthier marriage, communicate
make another
more effectively, or become a better parent.
attempt at recovery,
Some may want to develop new job skills to
ments of the and ultimately, to
increase employability.
succeed.
action stage. As the substance
Some clients may need to explore existential
concerns or issues stemming from their family
abuse problem fades
of origin. These emphases do not deny the con
into the background,
tinued importance of universality, hope, group
significant underly
88 Stages of Treatment
cohesion and other therapeutic factors. Instead premature termina
it implies that as group members become more tion. While early and
and more stable, they can begin to probe deep middlestage interven
er into the relational past. The group can be tions strive to reduce
used in the here and now to settle difficult and or modulate affect, As group members
painful old business. latestage interven
tions permit more become more and
intense exchanges.
Leadership in LateStage Thus, in late treat
Treatment ment, clients no
more stable, they
The leader plays a very different role in late longer are cautioned
against feeling too can begin to probe
stage treatment, which refocuses on helping
group members expose and eliminate personal much. The leader no
longer urges them to deeper into the
deficits that endanger recovery. Gradually, the
leader shifts toward interventions that call apply slogans like
upon people who are chemically dependent to “Turn it over” and relational past.
take a cold, hard look at their inner world and “One day at a time.”
system of defenses, which have prevented them Clients finally should
from accurately perceiving their selfdefeating manage the conflicts
behavioral patterns. To become adequately that dominate their
resistant to substance abuse, clients should lives, predispose them
learn to cope with conflict without using chemi to maladaptive behaviors, and endanger their
cals to escape reality, selfsoothe, or regulate hardwon abstinence. The leader allows clients
emotions (Flores 1997). to experience enough anxiety and frustration to
bring out destructive and maladaptive charac
As in the early and middle stages, the leader terological patterns and coping styles. These
helps group members sustain abstinence and characteristics provide abundant grist for the
makes sure the group provides enough support group mill.
and gratification to prevent acting out and
Stages of Treatment 89
6 Group Leadership,
Concepts, and Techniques
Overview
This chapter describes desirable leader traits and behaviors, along with
In This
the concepts and techniques vital to process groups––though many of the
Chapter…
ideas can apply in other types of groups. Most of the ideas seem perfect
ly logical, too, once they are brought to mind.
The Group Leader
Personal Qualities
For instance, consistency in manner and procedure helps to provide a
Leading Groups
safe and stable environment for the newly recovering person with a sub
stance use disorder. When the upheaval in the lives of people recovering
Concepts,
from addictions is considered, it becomes clear how important it is to
Techniques, and
keep as many factors as possible both constant and predictable.
Considerations
The pages that follow discuss issues such as
Interventions
Transference and
• How to convert conflict and resistance into positive energy that powers
Countertransference
the group
Resistance in Group
• How to deal with disruptive group members, such as clients who talk
Confidentiality
incessantly or bolt from a session
Biopsychosocial and
Spiritual Framework—
• How to cool down runaway affect or turn a crisis into an opportunity
Treating the Whole Person
Integrating Care
People who abuse substances are a broad and diverse population, one
Management of the Group
that spans all ages and ethnic groups and encompasses people with a
Managing Other Common
wide variety of cooccurring conditions and personal histories. In work
Problems
ing with people who have substance use disorders, an effective leader
uses the same skills, qualities, styles, and approaches needed in any
kind of therapeutic group. The adjustments needed to treat substance
abuse are simply that—adjustments within the bounds of good practice.
The particular personal and cultural characteristics of the clients in
group also will influence the therapist’s tailoring of therapeutic strategies
to fit the particular needs of the group.
91
to exercise, how to structure the group, when to
The Group Leader intervene, how to effect a successful interven
tion, how to manage the group’s collective anxi
Personal Qualities ety, and the means of resolving numerous other
Although the attributes of an effective interper issues. It is essential for any group leader to be
sonal process group leader treating substance aware of the choices made and to remember
abuse are not strikingly different from traits that all choices concerning the group’s struc
needed to work successfully with other client ture and her leadership will have consequences
populations, some of the variations in (Pollack and Slan 1995).
approach make a big difference. Clients, for
example, will respond to a warm, empathic, Constancy
and lifeaffirming manner. Flores (1997) states
An environment with small, infrequent changes
that “many therapists do not fully appreciate
is helpful to clients living in the emotionally
the impact of their personalities or values on
turbulent world of recovery. Group facilitators
addicts or alcoholics who are struggling to iden
can emphasize the reality of constancy and
tify some viable alternative lifestyle that will
security through a variety of specific behaviors.
allow them to fill up the emptiness or deadness
For example, group leaders always should sit in
within them” (p. 456). For this reason, it is
the same place in the group. Leaders also need
important for group leaders to communicate
to respond consistently to particular behaviors.
and share the joy of being alive. This life
They should maintain clear and consistent
affirming attitude carries the unspoken mes
boundaries, such as specific start and end
sage that a full and vibrant life is possible with
times, standards for comportment, and ground
out alcohol or drugs.
rules for speaking. Even dress matters. The
In addition, because many clients with sub setting and type of group will help determine
stance abuse histories have grown up in homes appropriate dress, but whatever the group
that provided little protection, safety, and leader chooses to wear, some predictability is
support, the leader should be responsive and desirable throughout the group experience.
affirming, rather than distant or judgmental. The group leader should not come dressed in a
The leader should recognize that group mem suit and tie one day and in blue jeans the next.
bers have a high
level of vulnerability Active listening
and are in need of
Excellent listening skills are the keystone of any
support, particularly
effective therapy. Therapeutic interventions
in the early stage of
require the clinician to perceive and to under
treatment. A discus
stand both verbal and nonverbal cues to mean
sion of other essen
Excellent listening ing and metaphorical levels of meaning. In
tial characteristics
addition, leaders need to pay attention to the
for a group leader
skills are the follows. Above all, it
context from which meanings come. Does it
pertain to the hereandnow of what is occur
is important for the
keystone of any ring in the group or the thenandthere history
leader of any group
of the specific client?
to understand that
effective therapy. he or she is responsi
ble for making a Firm identity
series of choices as A firm sense of their own identities, together
the group progresses. with clear reflection on experiences in group,
The leader chooses enables leaders to understand and manage
how much leadership their own emotional lives. For example,
92 Group Leadership, Concepts, and Techniques
therapists who are aware of their own capaci Integrity
ties and tendencies can recognize their own
defenses as they come into play in the group. Largely due to the
They might need to ask questions such as: “Am nature of the material
I cutting off discussions that could lead to ver group members are
bal expression of anger because I am uncom sharing in process Good leaders are
fortable with anger? Have I blamed clients for groups, it is all but
the group’s failure to make progress?” inevitable that ethical creative and
issues will arise.
Group work can be extremely intense emotion Leaders should be flexible.
ally. Leaders who are not in control of their familiar with their
own emotional reactions can do significant institution’s policies
harm—particularly if they are unable to admit and with pertinent
a mistake and apologize for it. The leader also laws and regulations.
should monitor the process and avoid being Leaders also need to
seduced by content issues that arouse anger be anchored by clear
and could result in a loss of the required pro internalized standards
fessional stance or distance. A group leader of conduct and able to
also should be emotionally healthy and keenly maintain the ethical
aware of personal emotional problems, lest parameters of their profession.
they become confused with the urgent issues
faced by the group as a whole. The leader Trust
should be aware of the boundary between per
sonal and group issues (Pollack and Slan 1995). Group leaders should be able to trust others.
Without this capacity, it is difficult to accom
plish a key aim of the group: restoration of
Confidence group members’ faith and trust in themselves
Effective group leaders operate between the and their fellow human beings (Flores 1997).
certain and the uncertain. In that zone, they
cannot rely on formulas or supply easy answers Humor
to clients’ complex problems. Instead, leaders
have to model the consistency that comes from The therapist needs to be able to use humor
selfknowledge and clarity of intent, while appropriately, which means that it is used only
remaining attentive to each client’s experience in support of therapeutic goals and never is
and the unpredictable unfolding of each ses used to disguise hostility or wound anyone.
sion’s work. This secure grounding enables the
leader to model stability for the group. Empathy
Empathy, one of the cornerstones of successful
Spontaneity group treatment for substance abuse, is the
Good leaders are creative and flexible. For ability to identify someone else’s feelings while
instance, they know when and how to admit a remaining aware that the feelings of others are
mistake, instead of trying to preserve an image distinct from one’s own. Through these “tran
of perfection. When a leader admits error sient identifications” we make with others, we
appropriately, group members learn that no feel less alone. “Identification is the antidote to
one has to be perfect, that they––and loneliness, to the feeling of estrangement that
others––can make and admit mistakes, yet seems inherent in the human condition”
retain positive relationships with others. (Ormont 1992, p. 147).
For the counselor, the ability to project empa
thy is an essential skill. Without it, little can be
Group Leadership, Concepts, and Techniques 93
accomplished. Empathic listening requires ing out cues that indicate what another person
close attention to everything a client says and may be feeling.
the formation of hypotheses about the underly
ing meaning of statements (Miller and Rollnick One of the feelings that the group leader needs
1991). An empathic substance abuse counselor to be able to empathize with is shame, which is
common among people with substance abuse
• Communicates respect for and acceptance of histories. Shame is so powerful that it should
clients and their feelings be addressed whenever it becomes an issue.
• Encourages a nonjudgmental, collaborative
When shame is felt, the group leader should
relationship
look for it and recognize it (Gans and Weber
2000). The leader also should be able to
• Is supportive and knowledgeable
empathize with it, avoid arousing more shame,
• Sincerely compliments rather than denigrates and help group members identify and process
or diminishes another person this painful feeling. Figure 61 discusses shame
• Tells less and listens more and group therapy.
• Gently persuades, while understanding that
the decision to change is the client’s Leading Groups
• Provides support throughout the recovery
Group therapy with clients who have histories
process (Center for Substance Abuse
of substance abuse or dependence requires
Treatment [CSAT] 1999b, p. 41)
active, responsive leaders who keep the group
One of the great benefits of group therapy is lively and on task, and ensure that members
that as clients interact, they learn from one are engaged continuously and meaningfully
another. For interpersonal interaction to be with each other. Leaders, however, should not
beneficial, it should be guided, for the most make themselves the center of attention. The
part, by empathy. The group leader should be leader should be aware of the differing person
able to model empathic interaction for group alities of the group members, while always
members, especially since people with sub searching for common themes in the group.
stance use disorders Themes to focus on, for example, might include
often cannot identify loss, abandonment, and selfvalue (Pollack and
and communicate Slan 1995).
their feelings, let
alone appreciate the Leaders vary therapeutic
emotive world of styles with the needs of
others. The group
The group leader leader teaches group clients
members to under As explained in chapter 5, group leaders
should be able to stand one another’s should modify their styles to meet clients’ needs
subjective world, at different times. During the early and middle
model empathic enabling clients to stages of treatment, the therapist is more
develop empathy for active, becoming less so in the late stage.
interaction for each other (Shapiro Moreover, during the late stage of treatment,
1991). The therapist the therapist should offer less support and
promotes growth in gratification. This keeps the group at an “opti
group members.
this area simply by mal level of anxiety,” one that would be intoler
asking group mem able and counterproductive in the early or
bers to say what they middle stages of treatment (Flores 1997).
think someone else is
feeling and by point To determine the type of leadership required to
support a client in treatment, the clinician
94 Group Leadership, Concepts, and Techniques
Figure 61
Shame
Often failed attachments in childhood and failed relationships thereafter result
in shame, an internalized sense of being inferior, not good enough, or worthless.
Shame flares whenever clients encounter the discrepancy between their drug
affected behavior and personal or social values. In group therapy, feelings of
shame may be intensified because feelings of selfconsciousness are elevated and
other group members are present. The presence of other group members “often
stimulates regressive longings” (Gans and Weber 2000, p. 385). Furthermore,
group members have a marked tendency to compare themselves with one anoth
er (Gans and Weber 2000). In the past, when group facilitators used highly con
frontational efforts to break through denial and resistance, an undesirable side
effect was intensified shame, which increased the likelihood that group members
would relapse or leave treatment. Shame interferes dramatically with attempts
to heighten a client’s selfesteem, which in turn is important to recovery (Alonso
and Rutan 1988).
Clients with addictions often are exquisitely sensitive and prone to project their
shame onto relationships within the group. Often, at an unconscious level, they
anticipate disapproval or hostility when none was intended. In this way, clients
may demote themselves to the role of secondary player in the group.
One way to neutralize unintentionally shameprovoking comments is to reframe
membertomember communications. For example, if a group member asks,
“Sally, where were you last week? You didn’t come to group.” Sally may inter
pret the question as a criticism or even an implication that she has returned to
active use. The group facilitator may choose to reframe this membertomember
communication by speaking to the concern that the questioner really has for
Sally’s wellbeing.
This reframing would begin with the group leader asking why the group member
wanted to know where Sally had been, adding something like, “I suspect your
question reflects the feeling that you missed Sally last week and find group more
enjoyable when she is here.”
By focusing on positive interactions that reveal competency, the group facilitator
helps move clients from shame to an affirmative image of themselves. The group
leader should pay attention to membertomember interaction, looking for
instances of relational competence and support. The leader’s supportive interac
tions eventually develop into group norms that combat the shame attached to
addictive illness.
Source: Consensus Panel.
Group Leadership, Concepts, and Techniques 95
should consider the client’s capacity to manage including disclosure of a therapist’s past expe
affect, level of functioning, social supports, and riences with substance abuse or addiction. Too
stability, since these factors have some bearing often, selfdisclosure occurs to meet the thera
upon alcohol or illicit drug use. These consider pist’s own needs (for example, for affiliation
ations are essential to determine the type of and approval) or to gratify clients. When per
group best suited to meet the client’s needs. For sonal questions are asked, group leaders need
example, a client at the beginning stage of to consider the motivation behind the question.
treatment who is Often clients are simply seeking assurance that
high functioning and the therapist is able to understand and assist
used to working in them (Flores 1997).
groups generally will
require a less active Leaders can be cotherapists
therapist and less
structure. On the Cotherapy is an effective way to blend the
other hand, a lower diverse skills, resources, and therapeutic
Cotherapy is
functioning client perspectives that two therapists can bring to
who has little or no a group. In addition, cotherapy is beneficial
extremely power because, if properly carried out, it can provide
group experience
and is just beginning
ful when carried • The opportunity to watch “functional,
treatment would best adaptive behavior in the coleader pair”
be placed in a struc
out skillfully. tured, taskoriented • Additional opportunities for family
group. Such a per transferences when the leaders are of
son also would bene different genders
fit from a clinician • An opportunity for “two sets of eyes to view
who more actively the situation” (Vannicelli 1992, p. 238)
expresses warmth
and acceptance, thus Cotherapy, also called coleadership, is extremely
helping to engage the client. powerful when carried out skillfully. A male–
female cotherapy team may be especially
helpful, for a number of reasons. It allows
Leaders model behavior clients to explore their conscious and subcon
It is more useful for the therapist to model scious reactions to the presence of a parental
groupappropriate behaviors than to assume dyad, or pair. It shows people of opposite sexes
the role of mentor, showing how to “do recov engaging in a healthy, nonexploitative relation
ery.” For example, the therapist can model the ship. It presents two different gender role
way to listen actively, give accurate feedback, models. It demonstrates role flexibility, as
and display curiosity about apparent discrep clients observe the variety of roles possible for
ancies in behavior and intent. a male or a female in a relationship. It provides
an opportunity for clients to discover and work
Therapists should be aware that selfdisclosure through their gender distortions (Kahn 1996).
is always going on, whether consciously or
unconsciously. They intentionally should use Frequently, however, cotherapy is not done
selfdisclosure only to meet the taskrelated well, and the result is destructive. At times, a
needs of the group, and then only after supervisor and a subordinate act as cothera
thoughtful consideration, perhaps including a pists, and power differentials result. Alter
discussion with a supervisor. natively, cotherapists are put together out of
convenience, rather than their potential to
Both therapists and their institutions should work well together and improve and facilitate
have a thoughtful policy about selfdisclosure, group process. True cotherapy takes place
96 Group Leadership, Concepts, and Techniques
between clinicians of equal authority and Beck 1997, p. 2). The development of a healthy
mutual regard. (Naturally, the foregoing does relationship between cotherapists will have a
not apply to training opportunities in which a positive effect on their relationship to the
trainee sits in with a seasoned group therapist. group, relationships among members of the
In such a setting, the trainee functions as an group, and on individuals within the group as
observer, not a cotherapist.) they experience the continuous changes and
growth of the group (Dugo and Beck 1997).
Problems also may arise because institutions
and leaders fail to allow enough time for
cotherapists to prepare for group together and Leaders are sensitive to
to process what has happened after the group ethical issues
has met. Some suggest that cotherapists confer Group therapy by nature is a powerful type of
for as much time outside the group as the intervention. As the group process unfolds, the
length of the group itself, that is, 45 minutes of group leader needs to be alert, always ready to
consultation for each 45minute group session. perceive and resolve issues with ethical dimen
While this amount of time may be ideal, the sions. Some typical situations with ethical con
realities of most organizations do not make this cerns follow.
level of commitment feasible. At the least, how
ever, cotherapists should have a minimum of 15 Overriding group agreements
minutes before and after each group meets. Group agreements give the group definition
Personal conflict or professional disagreements and clarity, and are essential for group safety.
can be a third source of negative effects on the In rare situations, however, it would be unethi
group. Thus, cotherapists should carefully cal not to bend the rules to meet the needs of
work out their own conflicts and develop a an individual. For example, group rules may
leadership style suitable for the group before say that failure to call in before an absence
engaging in the therapeutic process. Cothera from group is cause for reporting the infraction
pists also should work out important theoreti to a referring agency. If the client can demon
cal differences before taking on a group, reach strate that an unavoidable emergency prevent
ing full agreement on their view of the group ed calling in, the group leader may agree that
and appropriate ways to facilitate the group’s the offense does not merit a report. Further
development (Wheelan 1997). Achieving a more, the needs of the
healthy, collaborative, and productive cothera group may sometimes
py team will require a “(1) commitment of time override courtesies
and sharing, (2) the development of [mutual] shown to an individu
respect…and (3) use of supervision to work out al. For example, a
differences and identify…problems” (Kahn group may have made
1996, p. 443). an agreement not to Group agreements
discuss any group
Inevitably, cotherapist relationships will grow member when that give the group def
and evolve over time. The relationship between member is not pre
the cotherapists and the group, too, will evolve. sent. If, however, a inition and clarity,
Both the cotherapists and the group should member should
recognize this process and be ready to adapt to relapse, become seri
and are essential
constant change and growth (Dugo and Beck ously ill, or experi
1997). The most successful cotherapy is carried ence some other dire
problem, the nodis for group safety.
out “by partners who make a commitment to
an ongoing relationship, who reason with each cussion rule has to be
other, and who accept responsibility to work on set aside if the group
the evolution of their relationship” (Dugo and leader is to allow the
Group Leadership, Concepts, and Techniques 97
members to express their concerns for the miss Acting in each client’s best interest
ing member and to consider how that person’s It is possible that the group collectively may
problem affects the group as a whole. validate a particular course of action that may
not be in a client’s best interest. For example,
Informing clients of options
if there is stress in one group member’s mar
Even when group participation is mandated, riage, other group members might support a
clients should be informed clearly of the course of action that could have dangerous or
options open to them. For example, the client harmful consequences. Similarly, the group
deserves the option to discuss with program might engage in problem solving in some area
administrators any forms of treatment or of a member’s life and recommend a course of
leadership style that the client believes to be action that would clearly be undesirable.
inappropriate. In such an instance, issues of
cultural competence should be kept in mind, It is the responsibility of the group facilitator to
because what is appropriate for an individual challenge the group’s conclusions or recommen
or a group is by no means universal. dations when they deny individual autonomy
or could lead to serious negative consequences.
Preventing enmeshment Any such challenge, however, should come in a
Leaders should be aware that the power of nonshaming fashion, primarily through the
groups can have a dark side. Although cohe review of other options.
sion is a positive outcome to be sought and
supported, the strong desire for affiliation also
Handling emotional
can place undue pressure on group members
who already are in contagion
the throes of a major Another’s sharing, such as an agonized account
transition from sub of sexual abuse, can stir frightening memories
stance abuse to and intense emotions in listeners. In this pow
The leader is obli abstinent lives. The erful and emotional atmosphere, the spreading
need to belong is so excitement of the moment, or emotional conta
gated to foster strong that it can gion, requires the leader to
sometimes cause a
cohesion while client to act in a way • Protect individuals. The group leader should
that is not genuine guard the right of each member to refrain
or consistent with from involvement. The leader makes it clear
respecting the that each group member has a right to pri
personal ethics.
Regardless of the vate emotions and feelings. When the group
rights and best pressures a member to disclose information,
kind of group, the
leader needs to be the leader should remind the group that
interests of indi aware of this possi members need only reveal information about
bility and to monitor themselves at levels with which they are com
viduals. group sharing to fortable.
ensure that clients • Protect boundaries. Group pressure or the
are not drawn into group leader’s interest should not obligate
situations that vio anyone to disclose intimate details that the
late their privacy or integrity. The leader is client prefers not to share. At the same time,
obligated to foster cohesion while respecting the clients are responsible for managing their
rights and best interests of individuals. feelings in the face of the group’s power and
deciding what they will and won’t share.
• Regulate affect. At all times, the therapist
should be mindful of the need to modulate
98 Group Leadership, Concepts, and Techniques
affect (emotionality), always keeping it at a thereby avoiding pow
level that enables the work of the group to erfully charged issues.
continue. Yalom (1995) suggests an interven It is easier, for exam
tion that group leaders could use to limit con ple, to deal with the
affect: “We’ve been expressing some intense scapegoat than it is to
overload, it might be valuable to stop what from addiction.
we’re doing and try together to understand clinician should
what’s been happening and where all these While it is natural for
powerful feelings come from” (p. 350). group members to
assume certain be sensitive to
roles––there are, after
Working within professional all, natural leaders–– issues of dual
limitations individual members
Group leaders never should attempt to use benefit from the relationships.
group techniques or modalities for which they opportunity to experi
are not trained. When new techniques are used ence different aspects
with any group, leaders should be certain to of themselves. Role
have appropriate training and the supervision variation also keeps
of experts familiar with the techniques to be the group lively and
employed. Therapists likewise should decline to dynamic. These benefits will be lost if the same
work with any population or in any situation group members consistently assume the same
for which they are unprepared. For example, roles in group. It is important for the group
an addiction counselor who has never run a facilitator to support role sharing within the
longterm therapy group and has not learned membership.
how to do so should not accept an assignment
to lead such a group. Further, a counselor can Avoiding role conflict
not read about psychodrama and, using a In all therapeutic settings, the clinician should
workbook, successfully apply this highly be sensitive to issues of dual relationships. A
charged technique with clients in an early stage group leader’s responsibilities outside the
of treatment. Such a misguided effort could group that place him in a different relationship
have serious psychological consequences. to group participants should not be allowed to
compromise the leader’s ingroup role. For
Ensuring role flexibility example, a client’s group leader should not also
Different group members may assume particular be that client’s Alcoholics Anonymous (AA)
roles within the group. Natural leaders may sponsor. Both roles and functions are impor
emerge, as may a member who expresses anger tant, but should not be performed by the same
for the group and someone who provides sup person. If the leader happens to be in recovery
port. One client may take on a scapegoat role and is attending selfhelp meetings at which
and then blame the group. group members are present, this possible role
conflict should be discussed with supervisors.
Playing different roles and examining their
dynamics can provide a corrective emotional Ethical behavior is absolutely essential to group
and interpersonal experience for the group. On leadership. As the best practice guidelines
the other hand, rigid roles can restrict group (1998) from the Association for Specialists in
work. If, for example, a group consistently Group Work (ASGW) declare, “ASGW views
places individuals in particular roles, they may ethical process as being integral to group work
use their placements as defense mechanisms, and views Group Workers as ethical agents.”
Group Leadership, Concepts, and Techniques 99
The ASGW statement is regarded as so and 3 for more detailed discussions of the
important that the entire text is reproduced in stages of change). Techniques to enhance
appendix E. motivation that are appropriate at one stage of
change may not be useful at another stage and
Leaders improve motivation may even trigger treatment resistance or non
compliance (CSAT 1999b). For example, clients
Client motivation is a vital factor in the success in the contemplation stage are weighing the
of treatment for substance use disorders. pros and cons of continued substance abuse.
Motivationboosting techniques have been An intervention for the action stage is appro
shown to increase both treatment participation priate for a client who has already made a
and outcomes (Chappel 1994; Easton et al. commitment to change. If such an intervention
2000; Foote et al. 1999). Motivation generally is used too early, the client understandably
improves when may fail to cooperate.
• Clients are engaged at the appropriate stage
of change. Leaders overcome resistance
• Clients receive support for change efforts. Resistance is especially strong among clients
• The therapist explores choices and their referred by the courts. It generally arises as a
consequences with the client. defense against the pain that therapy and
examining one’s own behavior usually brings.
• The therapist honestly and openly communi
In group therapy, resistance appears at both
cates care and concern for group members.
the individual and the group level. The group
• The therapist points out the client’s compe leader should have a repertoire of means to
tencies. overcome the resistance that prevents success
• Steps toward positive change are noted ful substance abuse treatment in groups
within the group and further encouragement (Milgram and Rubin 1992).
is provided.
The group therapist should be prepared to
The therapist helps clients enjoy their triumphs work effectively against intense resistance to
with questions such as, “What’s it like, Bill, to “experiencing, expressing, and understanding
communicate your thoughts so clearly to Claire emotions” (Cohen 1997, p. 443). In order to
and to have her understand you so well?” or overcome resistance to the experience of emo
“What was it like to be able to communicate tion, “the group members should experience
your frustration so directly?” feelings at a level of arousal wherein feelings are
undeniable, but not to the extent that the group
One effective motivational tool is the FRAMES member is overcome” (Cohen 1997, p. 445).
approach, which uses the six key elements of
Feedback, Responsibility, Advice, Menus (of
change options), Empathic therapy, and Self
Leaders defend limits
efficacy (Miller and Sanchez 1994). This Providing a safe, therapeutic frame for clients
approach engages clients in their own treat and maintaining firm boundaries are among
ment and motivates them to change in ways the most important functions of the group lead
that are the least likely to trigger resistance. er. For many group members, a properly con
The FRAMES approach is discussed in detail ducted group will be the first opportunity to
in chapter 2 of TIP 35, Enhancing Motivation interact with others in a safe, supportive, and
for Change in Substance Abuse Treatment substancefree environment.
(CSAT 1999b).
The boundaries established should be mutually
When this kind of supportive technique is agreed upon in a specific contract. When
employed, however, a client’s stage of change leaders point out boundaries and boundary
should be taken into account (see chapters 2 violations, they should do so in a nonshaming,
100 Group Leadership, Concepts, and Techniques
nonjudgmental, matteroffact way. Some possi connection” at one
ble ways of dealing with this situation might be end of the continuum
(Gans and Weber
• “This is a hard place to end, but . . .” 2000, p. 382). At the
• “I know how angry you’re feeling, but we other end is “unme The boundaries
have agreed . . .” tabolized shame,” or
shame that “in a nar established should
When boundary violations occur, group mem cissistically vulnerable
bers should be reminded of agreements and person produces its be mutually
given an opportunity to discuss the meaning pathological vari
and implication of the limitbreaking behavior ants…Whereas guilt agreed upon in a
as they see it. For example, if three group is a response to a
members are coming in late, the leader might thought or deed,
say, “It’s interesting that although everyone specific contract.
shame connotes a
who joined the group agreed to arrive on time, more pervasive (self)
many members are having a difficult time meet condemnation” (Gans
ing this agreement.” Or the leader might ask, and Weber 2000, p.
“How would this group be different if everyone 382). It is thus poten
came on time?” tially harmful to group members who are
The group members may respond, for example, struggling to be honest with themselves and
that they would not be obliged to repeat what with the other group members.
already has been said to help latecomers catch The group needs to feel safe without blaming or
up and, thus, get more out of each session. scapegoating an individual member. If a mem
This group involvement in limit setting is cru ber makes an openly hostile comment, the lead
cial. It transmits power and responsibility to er’s response should state clearly what has hap
the group, and the leader avoids the isolated pened and set a firm boundary for the group
role of enforcer. While leaders inevitably will that makes clear that group members are not to
be regarded as authority figures, they certainly be attacked. Sometimes, the leader simply may
want to avoid creating the image of an insensi need to state what has occurred in a factual
tive, punitive authority. manner: “Debby, you may not have intended
this effect, but that last remark came across as
Leaders maintain a safe really hurtful.”
therapeutic setting When group members’ responses lack empathy
Emotional aspects of safety or treat one group member as a scapegoat, this
Group members should learn to interact in pos targeted individual represents “a disowned
itive ways. In the process, leaders should part of other members of the group.” Members
expect that people with substance abuse histo may fault Sally repeatedly for her critical
ries will have learned an extensive repertoire of nature and lack of openness. The leader may
intimidating, shaming, and other harmful intervene with a comment such as, “We’ve
behaviors. Because such conduct can make taken up time dealing with Sally’s problems.
group members feel unsafe, the leader should My guess is that part of the reason the group is
use interventions that deflect the offensive so focused on this is that it’s something every
behavior without shaming the shamer. body in here knows a little about and that this
issue has a lot of meaning for the group.
Shame is not a point, but a range, some Perhaps the group is trying to kick this charac
researchers argue. “Healthy” shame “helps to teristic down and beat it out because it’s too
regulate a person’s behavior in the service of close to home and simply cannot be ignored”
preserving selfesteem, values, and personal (Vannicelli 1992, p. 125).
Group Leadership, Concepts, and Techniques 101
When individual guage” (Rosenthal 1999a, p. 159). The therapist
group members are can achieve this control by warning potential
It is the therapist’s verbally abusive and group members of the emotional hazards of
other group mem revealing their feelings to a group of strangers
responsibility to bers are too intimi and by helping new members regulate the
dated to name the amount of their selfdisclosure.
maintain the problem, the leader
should find a way to Substance use
provide “a safe envi In a group of people trying to maintain
appropriate level ronment in which abstinence, the presence of someone in the
such interactions can group who is intoxicated or actively using illicit
of emotion and be productively pro drugs is a powerful reality that will upset many
cessed and under members. In this situation, the leader should
stimulation in the stood—not only by intervene decisively. The leader will make it as
the attacking group easy as possible for the person who has
group. member but also by relapsed to seek treatment, but a disruptive
the other members member should leave the group for the present.
(who need to under The leader also will help group members
stand what is moti explore their feelings about the relapse and
vating their reluctance to respond)” (Vannicelli reaffirm the primary importance of members’
1992, p. 165). To accomplish this goal, the agreement to remain abstinent. Some sugges
leader may intervene with statements such as: tions follow for situations involving relapse:
Whatever intervention is used should show the Signs indicate that the client is not abstinent,
group “that it is appropriate to let people know but the client will not admit using alcohol or
how you feel, and that people can learn in the drugs. When signs (such as bloodshot eyes)
group how to do this in a way that doesn’t push indicate that the client is using substances
others away” (Vannicelli 1992, p. 166). repeatedly before coming to the group, but
the client does not admit the infraction, the
A client can be severely damaged by emotional leader might:
overstimulation. It is the therapist’s responsibil
ity to maintain the appropriate level of emotion • Use empathy to join with the client, letting
and stimulation in the group. This will “prevent the member know that the leader under
a too sudden or too intense mobilization of feel stands why it’s hard to acknowledge
ing that cannot be adequately expressed in lan substance use to the group.
102 Group Leadership, Concepts, and Techniques
• Describe the impasse, namely, that it is Boundaries and physical contact
important that both client and therapist feel When physical boundaries are breached in the
that they are in a credible relationship, but group, and no one in the group raises the issue,
the way things are shaping up, it must be the leader should call the behavior to the
increasingly difficult for the client to come in group’s attention. The leader should remind
week after week knowing that the therapist members of the terms of agreement, call atten
doubts him. tion to the questionable behavior in a straight
• Brainstorm, permitting the group to solve the forward, factual way, and invite group input
problem and get past the impasse (Vannicelli with a comment such as, “Joe, you appear to
1992). be communicating something nonverbally by
putting your hand on Mary’s shoulder. Could
A client has been using alcohol or drugs, but you please put your actions into words?”
will not acknowledge it. If other group mem
bers do not confront clients who are using sub Most agencies have policies related to violent
stances, the leader should raise the issue in an behavior; all group leaders should know what
empathic manner designed to encourage hon they are. In groups, threatening behavior
esty, such as, “It must be hard for you, Sandy, should be intercepted decisively. If necessary,
to find yourself in a group in which you don’t the leader may have to stand in front of a
feel safe enough to talk about your drinking” group member being physically threatened.
(Vannicelli 1992, p. 65). Some situations require help, so a lone leader
should never conduct a group session without
A client defiantly acknowledges using sub other staff nearby. On occasion, police inter
stances. A client who uses substances and vention may be necessary, which could be
clearly has no intention of stopping should be expected to disrupt the group experience
asked to leave the group. In contrast, a client completely.
who slips repeatedly needs an intervention that
invites the group’s help in setting conditions for The leader should not suggest touching, holding
continued participation: “It is clear, Maria, hands, or group hugs without first discussing
that you feel it is appropriate for you to stop this topic in group. This tactic will convey the
using and yet, so far, the ways that you have message that strong feelings should be talked
been dealing with the problem have not been about, not avoided. In general, though, group
adequate. Since it is important that your members should be
behavior, as well as your words, support the encouraged to put
group norm, we need to find ways that will be their thoughts and
more effective in supporting abstinence.” The feelings into words,
group may then help set up specific require not actions. A group may need
ments for Maria that will help her maintain
abstinence. Suggestions might include increased Whenever the thera
pist invites the group to set up specific
AA participation, the development of a relapse
prevention plan, increased supportive social to participate in any
contact, or the use of medications (like form of physical con requirements
Antabuse for alcoholism) (Vannicelli 1992, tact (for example, in
p. 68). psychodrama or to help a member
dance therapy), indi
Many outpatient groups have mandated clients viduals should be maintain
who are required to submit to urine tests. The allowed to opt out
counselor is required to report infractions or without any negative abstinence.
test failures. These stipulations should appear perceptions within the
in the group agreement, so they do not come as group. All members
a surprise to anyone. uncomfortable with
Group Leadership, Concepts, and Techniques 103
physical contact should be assured of permis leader should not express discomfort with the
sion to refrain from touching or having anyone level of emotion or indicate a wish to avoid
touch them. hearing what was being said. Leaders can say
something such as
Leaders also should
make sure that sug • “As I ask you to stop, there’s a danger that
gestions to touch are what you hear is, ‘I don’t want to hear you.’
Group leaders intended to serve the It’s not that. It’s just that for now, I’m con
clients’ best interests cerned that you may come to feel as if you
carefully monitor and not the needs of have shared more than you might wish.”
the therapist. Under • “I’m wondering how useful it would be for
the level of emo no circumstances you to continue with what you’re doing right
should a counselor now.” This intervention teaches individuals
tional intensity in ask for or initiate how to regulate their expression of emotions
physical contact. and provides an opportunity for the group to
the group. Like their clients, comment.
counselors need to
• “Let’s pause for a moment and every few
learn that such
minutes from now. How are you feeling right
impulses affect them
now? Let me know when you’re ready to
as well. Nothing is
move on.”
wrong with feeling attracted to a client. It is
wrong, however, for group leaders to allow A distinction needs to be made whether the
these feelings to dictate or influence their strong feelings are related to thereandthen
behavior. material or to hereandnow conduct. It is far
less unsettling for someone to express anger—
Leaders help cool down even rage—at a father who abused her 20 years
affect ago than it is to have a client raging at and
threatening to kill another group member.
Group leaders carefully monitor the level of Also, the amount of appropriate affect will
emotional intensity in the group, recognizing differ according to the group’s purpose. Much
that too much too fast can bring on extremely stronger emotions are appropriate in psy
uncomfortable feelings that will interfere with chodrama or gestalt groups than in psycho
progress––especially for those in the earlier educational or support groups.
stages of recovery. When emotionally loaded
topics (such as sexual abuse or trauma) come For people who have had violence in their
up and members begin to share the details of lives, strong negative emotions like anger can
their experiences, the level of emotion may be terrifying. When a group member’s rage
rapidly rise to a degree some group members adversely affects the group process, the leader
are unable to tolerate. may use an intervention such as
At this point, the leader should give the group • “Bill, stop for a moment and hear how what
the opportunity to pause and determine you’re doing is affecting other people.”
whether or not to proceed. The leader might • “Bill, maybe it would be helpful for you to
ask, “Something very powerful is going on right hear what other people have been thinking
now. What is happening? How does it feel? Do while you’ve been speaking.”
we want to go further at this time?”
• “Bill, as you’ve been talking, have you
At times, when a client floods the room with noticed what’s been happening in the
emotional information, the therapist should group?”
mute the disturbing line of discussion. The
104 Group Leadership, Concepts, and Techniques
The thrust of such interventions is to modulate • Helping members
the expression of intense rage and encourage with difficulty ver
the angry person and others affected by the balizing know that
anger to pay attention to what has happened. their contributions In support and
Vannicelli (1992) suggests two other ways to are valuable and
modulate a highly charged situation: putting them in interpersonal
charge of requesting
• Switch from emotion to cognition. The leader assistance. The process groups,
can introduce a cognitive element by asking leader might ask, “I
clients about their thoughts or observations can see that you are
or about what has been taking place.
the leader’s prima
struggling, Bert. My
• Move in time, from a present to a past focus guess is that you are ry task is stimulat
or from past to present. carrying a truth
that’s important for
When intervening to control runaway affect, the group. Do you
ing communication
the leader always should be careful to support have any sense of
the genuine expressions of emotion that are how they can help
among group
appropriate for the group and the individual’s you say it?”
stage of change. members.
In general, group
Leaders encourage communi leaders should speak
often, but briefly,
cation within the group especially in timelim
In support and interpersonal process groups, ited groups. In group, the best interventions
the leader’s primary task is stimulating commu usually are the ones that are short and simple.
nication among group members, rather than Effective leadership demands the ability to
between individual members and the leader. make short, simple, cogent remarks.
This function also may be important on some
occasions in psychoeducational and skills
building groups. Some of the many appropriate Concepts, Techniques,
interventions used to help members engage in
meaningful dialog with each other are
and Considerations
• Praising good communication when it hap Interventions
pens.
Interventions may be directed to an individual
• Noticing a member’s body language, and or the group as a whole. They can be used to
without shaming, asking that person to clarify what is going on or to make it more
express the feeling out loud. explicit, redirect energy, stop a process that is
• Building bridges between members with not helpful, or help the group make a choice
remarks such as, “It sounds as if both you about what should be done. A welltimed,
and Maria have something in common . . .” appropriate intervention has the power to
• Helping the group complete unfinished busi • Help a client recognize blocks to connection
ness with questions such as, “At the end of with other people
our session last time, Sally and Joan were
sharing some very important observations. • Discover connections between the use of
Do you want to go back and explore those substances and inner thoughts and feelings
further?” • Understand attempts to regulate feeling states
• When someone has difficulty expressing a and relationships
thought, putting the idea in words and ask • Build coping skills
ing, “Have I got it right?”
Group Leadership, Concepts, and Techniques 105
• Perceive the effect of substance abuse on • In addition to using one’s own skills, build
one’s life skills in participants. Avoid doing for the
• Notice meaningful inconsistencies among group what it can do for itself.
thoughts, feelings, and behavior • Encourage the group to learn the skills neces
• Perceive discrepancies between stated goals sary to support and encourage one another
and what is actually being done because too much or too frequent support
from the clinician can lead to approval seek
Any verbal interven ing, which blocks growth and independence.
tion may carry Supporting each other, of course, is a skill
A process group important nonverbal that should develop through group phases.
elements. For exam Thus, in earlier phases of treatment, the
ple, different people leader may need to model ways of communi
that remains
would ascribe a cating support. Later, if a client is experienc
variety of meanings ing loss and grief, for example, the leader
leader focused lim to the words, “I am does not rush in to assure the client that all
afraid that you have will soon be well. Instead, the leader would
its the potential for used again,” and the invite group members to empathize with each
interpretation will other’s struggles, saying something like,
learning and vary further with the “Joanne, my guess is at least six other people
speaker’s tone of here are experts on this type of feeling. What
growth. voice and body lan does this bring up for others here?”
guage. Leaders • Refrain from taking on the responsibility to
should therefore repair anything in the life of the clients. To a
be careful to avoid certain extent, they should be allowed to
conveying an observation in a tone of voice that struggle with what is facing them. It would be
could create a barrier to understanding or appropriate, however, for the leader to
response in the mind of the listener. access resources that will help clients resolve
problems.
Avoiding a leadercentered
group Confrontation
Generally a counselor leads several kinds of Confrontation is one form of intervention. In
groups. Leadership duties may include a psy the past, therapists have used confrontation
choeducational group, in which a leader usual aggressively to challenge clients’ defenses of
ly takes charge and teaches content, and then a their substance abuse and related untoward
process group, in which the leader’s role and behaviors. In recent years, however, clinicians
responsibilities should shift dramatically. A have come to recognize that when “confronta
process group that remains leaderfocused lim tion” is equivalent to “attack,” it can have an
its the potential for learning and growth, yet all adverse effect on the therapeutic alliance and
too often, interventions place the leader at the process, ultimately leading to failure. Trying to
center of the group. For example, a common force the client to share the clinician’s view of a
sight in a leadercentered group is a series of situation accomplishes no therapeutic purpose
oneonone interactions between the leader and and can get in the way of the work.
individual group members. These sequential
interventions do not use the full power of the A more useful way to think about confrontation
group to support experiential change, and is “pointing out inconsistencies,” such as dis
especially to build authentic, supportive inter connects between behaviors and stated goals.
personal relationships. Some ways for a leader William R. Miller explains:
to move away from center stage:
106 Group Leadership, Concepts, and Techniques
The linguistic roots of the verb “to con response to a group member’s transference is
front” mean to come face to face. When referred to as countertransference. Vannicelli
you think about it that way, confronta (2001) describes three forms of countertrans
tion is precisely what we are trying to ference:
accomplish: to allow our clients to come
face to face with a difficult and often • Feelings of having been there. Leaders with
threatening reality, to “let it in” rather family or personal histories with substance
than “block it out,” and to allow this abuse have a treasure in their extraordinary
reality to change them. That makes con ability to empathize with clients who abuse
frontation a goal of counseling rather substances. If that empathy is not adequately
than a particular style or technique. . . understood and controlled, however, it can
[T]hen the question becomes, What is become a problem, particularly if the thera
the best way to achieve that goal? pist tries to act as a role model or sponsor, or
Evidence is strong that direct, forceful, discloses too much personal information.
aggressive approaches are perhaps the • Feelings of helplessness when the therapist is
least effective way to help people consid more invested in the treatment than the client
er new information and change their is. Treating highly resistant populations, such
perceptions (CSAT 1999b, p. 10). as clients referred to treatment by the courts,
can cause leaders to feel powerless, demoral
Confrontation in this light is a part of the ized, or even angry. The best way to deal
change process, and therefore part of the help with this type of countertransference may be
ing process. Its purpose is to help clients see to use the energy of the resistance to fuel the
and accept reality so they can change accord session. (See “Resistance in Group,” next
ingly (Miller and Rollnick 1991). With this section.)
broader understanding of what interventions
• Feelings of incompetence due to unfamiliarity
that “confront” the client really mean, it is not
with culture and jargon. It is helpful for lead
useful to divide therapy into “supportive” and
ers to be familiar with 12Step programs, cul
“confrontative” categories.
tures, and languages. If a group member uses
unfamiliar terms, however, the leader should
Transference and ask the client to
explain what the
Countertransference
term means to that
Transference means that people project parts person, using a The therapist’s
of important relationships from the past into question like,
relationships in the present. For example, “‘Letting go’ means emotional
Heather may find that Juan reminds her of her something a bit dif
judgmental father. When Juan voices his suspi ferent to each per response to a
cion that she has been drinking, Heather feels son. Can you say a
the same feelings she felt when her father criti little more about
cized all her supposed failings. Within the group member’s
how this relates to
microcosm of the group, this type of incident your situation?”
not only relates the hereandnow to the past, (Vannicelli 2001,
transference is
but also offers Heather an opportunity to learn p. 58).
a different, more selfrespecting way of referred to
responding to a remark that she perceives as When countertrans
criticism. ference occurs, the as counter
clinician needs to
The emotion inherent in groups is not limited bring all feelings asso
to clients. The groups inevitably stir up strong
transference.
ciated with it to
feelings in leaders. The therapist’s emotional
Group Leadership, Concepts, and Techniques 107
awareness and manage them appropriately. have been in sharing their feelings this evening
Good supervision can be really helpful. and in being so forthcoming about really speak
Countertransference is not bad. It is inevitable, ing up. My hope is that people will continue to
and with the help of supervision, the group be able to talk in this open way to make our
leader can use countertransference to support time together as useful as possible” (Vannicelli
the group process (Vannicelli 2001). 2001, p. 55).
Leaders should recognize that clients are not
Resistance in Group always aware that their reasons for nonatten
Resistance arises as an often unconscious dance or lateness may be resistance. The most
defense to protect the client from the pain of helpful attitude on the clinician’s part is curios
selfexamination. These processes within the ity and an interest in exploring what is happen
client or group impede the open expression of ing and what can be learned from it. Leaders
thoughts and feelings, or block the progress of need not battle resistance. It is not the enemy.
an individual or group. The effective leader Indeed, it is usually the necessary precursor to
will neither ignore resistance nor attempt to change.
override it. Instead, the leader helps the indi It would be a serious mistake, however, to
vidual and group understand what is getting in imagine that resistance always melts away once
the way, welcoming the resistance as an oppor someone calls attention to it. “Resistance is
tunity to understand something important always there for a reason, and the group mem
going on for the client or the group. Further, bers should not be expected to give it up until
resistance may be viewed as energy that can be the emotional forces held in check by it are suf
harnessed and used in a variety of ways, once ficiently discharged or converted, so that they
the therapist has helped the client and group are no longer a danger to the safety of the
understand what is happening and what the group or its members” (Flores 1997, p. 538).
resistant person or persons actually want
(Vannicelli 2001). When a group (rather than an individual) is
resistant, the leader may have contributed to
In groups that are mandated to enter treat the creation of this phenomenon and efforts
ment, members often have little interest in need to be made to understand the leader’s role
being present, so in the problem. Sometimes, “resistance can be
strong resistance is induced by leaders who are passive, hostile,
to be expected. Even ineffective, guarded, weak, or in need of con
this resistance, how stant admiration and excessive friendliness”
ever, can be incorpo (Flores 1997, p. 538).
rated into treatment.
For the group For example, the
leader may invite the Confidentiality
leader, strict group members to For the group leader, strict adherence to
talk about the diffi confidentiality regulations builds trust. If the
culties experienced
adherence to con bounds of confidentiality are broken, grave
in coming to the legal and personal consequences may result. All
session or to express group leaders should be thoroughly familiar
fidentiality regula their outrage at hav with Federal laws on confidentiality (42 C.F.R.
ing been required to Part 2, Confidentiality of Alcohol and Drug
tions builds trust. come. The leader Abuse Patient Records; see Figure 62) and rel
can respond to this evant agency policies. Confidentiality is recog
anger by saying, “I nized as “a central tenet of the practice of psy
am impressed by chotherapy” (Parker et al. 1997, p. 157), yet a
how open people
108 Group Leadership, Concepts, and Techniques
vast majority of States either have vague decide what to say
statutes dealing with confidentiality in group and what they want
therapy or have no statutes at all. Even where from the group. The
a privilege of confidentiality does exist in law, therapist can prompt Clinicians should
enforcement of the law that protects it is often clients to share infor
difficult (Parker et al. 1997). Clinicians should mation in the group warn clients that
be aware of this legal problem and should warn with a comment like,
clients that what they say in group may not be “I wonder if the group what they say in
kept strictly confidential. Some studies indicate understands what a
that a significant number of therapists do not hard time you’ve been
group may not
advise group members that confidentiality has having over the last 2
limits (Parker et al. 1997). weeks?” On the other
hand, therapists be kept strictly
One set of confidentiality issues has to do with should reserve the
the use of personal information in a group ses right to determine confidential.
sion. Group leaders have many sources of what information will
information on a client, including the names of be discussed in group.
the client’s employer and spouse, as well as any A leader may say
ties to the court system. A group leader should firmly, “Understand
be clear about how information from these that whatever you tell me may or may not be
sources may and may not be used in group. introduced in group. I will not keep important
Clinicians consider the bounds of confidentiali information from the group, if I feel that with
ty as existing around the treatment enterprise, holding the information will impede your
not around a particular treatment group. progress or interfere with your recovery.”
Clients should know that everyone on the treat Still other confidentiality issues arise when
ment team has access to relevant information. clients discuss information from the group
In addition, clinicians should make it clear to beyond its bounds. Violations of confidentiality
clients that confidentiality cannot be used to among members should be managed in the
conceal continued substance abuse, and the same way as other boundary violations; that is,
therapist will not be drawn into colluding with empathic joining with those involved followed
the client to hide substance use infractions. by a factual reiteration of the agreement that
Clinicians also should advise clients of the exact has been broken and an invitation to group
circumstances under which therapists are legal members to discuss their perceptions and feel
ly required to break confidentiality (see Figure ings. In some cases, when this boundary is vio
62). lated, the group may feel a need for additional
A second set of confidentiality issues has to do clarification or addenda to the group agree
with the group leader’s relationships with ment. The leader may ask, both at the begin
clients and clients with one another. When ning of the group or when issues arise, whether
counseling a client in both individual therapy the group feels it needs additional agreements
and a group context, for example, the leader in order to work safely. Such amendments,
should know exactly how information learned however, should not seek to renegotiate the
in individual therapy may be used in the group terms of the original group agreement. See
context. In almost every case, it is more benefi Figure 62 (see p. 110) for helpful information
cial for the client to divulge such information on confidentiality and the law.
than for the clinician to reveal it. In an individ Because a group facilitator generally is part of
ual session, the therapist and the client can the larger substance abuse treatment program,
plan how the issue will be brought up in group. it is recommended that the group facilitator
This preparation gives clients ample time to take a practical approach to exceptions. This
Group Leadership, Concepts, and Techniques 109
Figure 62
Confidentiality and 42 C.F.R., Part 2
Confidentiality is both an ethical and a legal issue. Federal law (Title 42, Part 2
or 42 C.F.R., Part 2, Confidentiality of Alcohol and Drug Abuse Patient
Records) guarantees strict confidentiality of information about all people receiv
ing substance abuse prevention and/or treatment services. Clients should be
fully informed regarding issues of confidentiality, and group leaders should do
all they can to build respect for confidentiality and anonymity within groups.
There are six conditions under which limited disclosure is permitted under the
regulations. These exceptions are
• The group member has signed a Release of Information document that allows
the group facilitator to communicate with another professional and/or agency.
• A group member threatens imminent harm to him or herself, and the group
facilitator believes that the client may act on this threat.
• A client threatens imminent harm to another named person, and the group
facilitator believes that there is a reasonable likelihood that the client will act
on the threat.
• A medical emergency requires that a client’s drug and alcohol status be
revealed in order to ensure that the client gets appropriate medical attention.
• A client is suspected of child neglect and/or abuse, as defined by the laws of the
State in which the substance abuse treatment services are being provided.
• A direct court order mandates the release of specific information related to a
client’s history and/or treatment. However, an authorizing court order alone
does not compel disclosure—for example, if the person authorized to disclose
confidential information does not elect to make the disclosure, he or she can
not be forced to do so unless there is a valid subpoena (i.e., the subpoena has
not expired) or other compulsory process introduced that would then compel
disclosure. An appropriate judge issues a court order. It specifies the exact
information to be provided about a particular client and is properly signed
and dated.
More detailed discussions of confidentiality can be found in TIP 25, Substance
Abuse Treatment and Domestic Violence (CSAT 1997b); TIP 8, Intensive
Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT 1994a); TAP
13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment
(Lopez 1994); and TAP 18, Checklist for Monitoring Alcohol and Other Drug
Confidentiality Compliance (CSAT 1996).
Source: Consensus Panel.
110 Group Leadership, Concepts, and Techniques
practical approach is to have the group facilita the clinician and then
tor discuss the potential application of the break into smaller
exceptions with the program director or mem groups to discuss,
ber of the program staff who is the lead on the practice, or roleplay
confidentiality regulation. the particular topic. Successful treat
Each group has a
Biopsychosocial and Spiritual client leader, and the
ment for substance
Framework—Treating the clinician circulates
among the groups to use disorders
Whole Person ensure that the topic
Substance use disorders include a wide range is understood and should address the
of symptoms with different levels of associated that discussion is pro
disability. Clients always bring into treatment ceeding. The clinician whole person.
vulnerabilities other than their alcohol or illicit does not participate in
drug dependencies. Group interventions may the groups. Research
be needed to resolve psychological problems, ers describing this
physical ailments, social stresses, and perhaps, model note that
spiritual emptiness or bankruptcy. In short, because the clinicians
successful treatment for substance use disor step back from assuming leadership roles in the
ders should address the whole person, includ groups, the clients become empowered to take
ing that person’s spiritual growth. group sessions in the necessary direction and
demonstrate feelings and insights that might
While the group experience is a powerful tool not occur in a group formally led by a clinician
in the treatment of substance use disorders, it (Goldberg and Simpson 1995).
is not the only tool. Other interventions, such
as individual therapy, psychological interven It is well known that 12Step programs are an
tions, pharmacological supports, and intensive important part of many therapeutic programs
case management, may all be necessary to (Page and Berkow 1998). While 12Step pro
achieve longterm remission from the symptoms grams have a proven record of success in help
of addictive disorders. ing people overcome substance use disorders,
there is a basic conflict inherent in them that
For example, people who are homeless with a group therapists need to reconcile. In the 12
cooccurring mental disorder have three com Step program, people are urged to cede control
plicated sets of problems that require a contin to a higher power. Yet, in group, the clinician
uous and comprehensive care system—one that is prompting clients to take control of their
integrates or coordinates interventions in (1) emotions, behavior, and lives.
the mental health system, (2) the addiction sys
tem, and (3) the social service system for home As a result, some researchers have stated that
less persons. In group therapy, each condition it is “impossible to integrate psychotherapy and
should be regarded as a primary interactive AA approaches dealing with addictions without
problem; that is, one in which each problem compromising one approach or the other”
develops independently but contributes to both (Page and Berkow 1998, pp. 1–2). Another
of the others (Minkoff and Drake 1992). researcher has argued that “the AA approach
is consistent with existential philosophy”
One model offered for treating homeless per because both stress that people should accept
sons with substance use disorder is a modified their “human limitations and securityseeking
training group designed to accommodate a behaviors” (Page and Berkow 1998, p. 2).
large number of members whenever a tradi Although the literature currently has few
tional small group is not possible. In this straightforward discussions of spirituality and
model, participants meet in a large group with
Group Leadership, Concepts, and Techniques 111
its role in the familiar with the selfhelp group. Matano and
dynamics of group Yalom (1991) strongly recommend that group
therapy, most clini leaders become thoroughly familiar with AA’s
cians would agree language, steps, and traditions because mis
Recent research that the spiritual conceptions about the program, whether by
wellbeing of the the client or therapist, can raise barriers to
client is essential to recovery.
has clearly demon breaking free of sub
stance abuse. Recent research has clearly demonstrated the
strated the ability ability of selfhelp groups to improve outcomes
When clients join (Tonigan et al. 1996). Research also has shown
of selfhelp groups selfhelp groups, that clients receiving mental health services as
they sometimes hear well as participating in 12Step meetings have
to improve out from individuals an even better prognosis (Ouimette et al. 1998).
who strongly oppose Marilyn Freimuth’s research on integrating
the use of any medi group psychotherapy and 12Step work has
comes.
cation. Some people shown that “if mere coparticipation in psy
in 12Step programs chotherapy and 12Step groups supports a
erroneously believe, client’s recovery, it is reasonable to expect that
for example, that the a more integrated approach will provide fur
use of pharmacologi ther benefits” (Freimuth 2000, p. 298). Both
cal adjuncts to ther activities “support abstinence and emotional
apy is a violation of the program’s principles. growth” (Freimuth 2000, p. 301). Together,
They consequently oppose methadone mainte the two modalities supply multiple relationship
nance, the use of Antabuse, or the use of medi models, potentially of immense value to the
cations needed to control cooccurring disor client.
ders.
Some suggestions for maximizing the therapeu
Clinicians should be prepared to handle these tic potential of participation in both process
misapprehensions. One way to help would be and 12Step groups follow:
to refer apprehensive clients to the pamphlet,
The AA Member—Medications and Other Orientation should prepare new group mem
Drugs: A Report from a Group of Physicians bers who are also members of 12Step groups
in AA (Alcoholics Anonymous World Services for differences in the two groups. A key differ
1984). It stresses the value of appropriate ence will be the fact that members interact with
medication prescribed by a physician who each other. Such “cross talk” is discouraged at
understands addictive disorders and reassures 12Step meetings. “The new psychotherapy
clients that such use of medication is wholly group member may need to be told that the
consistent with AA and Narcotics Anonymous’ topic of conversation is much wider than the
12Step programs. 12Step meeting’s focus on addiction and recov
ery, and that it includes feelings and reactions
Many clients enrolled in a process group for toward other group members” (Freimuth
persons with substance use disorders are likely 2000, p. 300; see also Vannicelli 1992).
participating in a 12Step program or other
selfhelp groups as well. On occasion, appar During early recovery, it is particularly impor
ently conflicting messages can be an issue. For tant to avoid making the 12Step program’s
instance, many people with addiction histories encouragement of “unquestioning acceptance”
try to use AA and its jargon as material for a focus of analysis in group therapy. Too
resistance. Such problems can readily be man critical an interpretation offered too early may
aged, provided the therapist is thoroughly disrupt the 12Step program’s status as an
“ideal object,” belief in which “is critical to
112 Group Leadership, Concepts, and Techniques
maintaining early abstinence” (Dodes 1988; The following vignette illustrates a typical
Freimuth 2000, p. 305). intervention intended to clarify and harmonize
appropriate participation in 12Step and
Sometimes clients experience “splitting”— process groups:
seeing “the [12Step] program as the allgood
parent and all others, including the The group leader knew that Henry, who
therapist/group as the allbad/ambivalent was well along in recovery but new to
object.” Later, the split may be just the oppo group, had not expressed his anger at
site (Freimuth 2000). The group leader should Jenna for having cut him off for the
be attuned to this potential and should be pre third time. When asked how he experi
pared to work through these perceptions and enced Jenna, he simply replied that
the feelings underlying them. Further, when according to the program you are not to
the process group is perceived as the “less take another person’s inventory. The
than” modality and the client enthusiastically leader took the opportunity to say that
quotes insights from a 12Step group, the ther in group therapy it is important to con
apist should watch for possible countertrans sider one’s feelings about what others
ference and bear in mind the benefits the client say and do even if [the feelings] are
is receiving from both programs. negative. Expressing one’s own feelings
is different from focusing on another’s
Sponsors of 12Step members may distrust character (taking his inventory)
therapy and discourage group member from (Freimuth 2000, p. 308).
continuing in treatment. The leader should be
prepared to respond to a variety of potential No matter what the modality, however, group
issues in ways that avoid appearing to compete therapy is sure to remain an integral part of
with the selfhelp group. For example, if a substance abuse treatment.
client says, “In my AA group, they say I don’t
need to be here. As long as I’m not drinking, Addressing life issues
my life is fine.” The therapist might acknowl
edge the importance of continued sobriety, but Substance abuse affects every aspect of life:
remind the client of depression experienced home, family, friends, job, health, emotional
before the onset of heavy drinking. wellbeing, and beliefs. As clients move into
recovery, the wide range of issues they should
Group leaders should beware of their possible face may overwhelm them. Leaders need to
biases against 12Step groups that may be help clients rank the
based on inaccurate information. For example, importance of the
it is not true that the 12Step philosophy oppos challenges, taking
es therapy and medication, as AA World care to make the best
Service pamphlets clarify. It also is a miscon possible use of the
ception that 12Step programs encourage peo resources the client Naturally, clients
ple to abdicate responsibility for substance use. and the leader can
AA, however, does urge people with addiction bring to bear. will vary in their
problems to attend meetings in the early stages
of recovery, even though they may still be using Naturally, clients will ability to address
alcohol or illicit drugs. Finally, some clinicians vary in their ability to
believe that 12Step programs discourage address many con
many concerns
strong negative emotions. On the contrary, cerns simultaneously;
“there is no unilateral discouragement of nega capacity for change
also is variable. For simultaneously.
tive affects within [12Step] program philoso
phy; only when anger threatens sobriety is it example, some indi
considered necessary to circumvent negative viduals with cognitive
feelings” (Freimuth 2000, p. 308). impairments will have
a much harder time
Group Leadership, Concepts, and Techniques 113
than others engaging each client that continued substance abuse
in a change process. might jeopardize. For some individuals, it is
In the early stage of their job. For others, it is their spouse, health,
treatment, such family, or selfrespect. In some cases, it might
clients need simple be the threat of incarceration. Such knowledge
ideas, structures, can be used to encourage, and even coerce,
The leader should and principles. individuals to utilize the tools of treatment,
group, or AA (Flores 1997).
explore the impor As the client moves
forward, the clini
tance of spiritual cian can keep in Incorporating faith
mind the issues that While spirituality and faith may offer to some
life with the group. a client is not ready the hope, nurturing, sense of purpose and
or able to manage. meaning, and support needed to move toward
As this process goes recovery, people obviously interpret spiritual
on, the leader should matters in diverse ways. It is important not to
remember that the confuse spirituality with religion. Even if
client’s priorities clients are not religious, their spiritual life is
matter more than important. Some clinicians mistakenly conclude
what the leader that their own understanding of spirituality will
thinks ought to come next. Unless both client help the client. Other clinicians err in the
and leader operate in the same motivational opposite direction and are overly reluctant to
framework the leader will not be able to help address spiritual beliefs. Actually, a middle
the client make progress. ground is preferable. The leader should
explore the importance of spiritual life with the
No matter what is missing—even if it is a roof group, and if the search for spiritual meaning
over the client’s head—it is possible to engage is important, the clinician can incorporate it
the client in treatment. A client never should be into group discussions.
told to come back after problems other than
substance abuse have been resolved. On some For clients who lack meaningful connection to
front, constructive work can always be done. anything beyond themselves, the group may be
Of course, this assertion does not mean that the first step toward a search for meaning or a
critical needs can be ignored until treatment feeling of belonging to something greater than
for substance abuse is well underway. The the self. The clinician’s role in group therapy
therapist should recognize that a client preoc simply is to create an environment within
cupied with the need to find a place to sleep which such egotranscending connections can
will not be able to engage fully in treatment be experienced.
until urgent, practical needs are met.
Life issues facing the client provide two power Integrating Care
ful points of therapeutic leverage that leaders
can use to motivate the client to pursue recov Interaction with other health
ery. First, group leaders should be aware that care professionals
people with alcoholism and other addictions
will not give up their substance use until the Professionals within the entire healthcare net
pain it brings outweighs the pleasure it pro work need to become more aware of the role of
duces. Consequently, they should be helped to group therapy for people abusing substances.
see the way alcohol and drugs affect important To build the understanding needed to support
areas of their lives. Second, early in treatment, people in recovery, group leaders should edu
group leaders should learn what is important to cate others serving this population as often as
opportunities arise, such as when clinicians
114 Group Leadership, Concepts, and Techniques
from different sectors of the healthcare system cravings, the therapist
work together on a case. Similar needs for might talk with the
understanding exist with probation officers, physician to deter
families, and primary care physicians. mine whether appro
priate medication
Integration of group therapy could help the client
through the difficult
and other forms of therapy period following Conflict in group
It is common for a client to be in both individu substance abuse
al and group therapy simultaneously. The dual cessation. Therapists therapy is normal,
relationship creates both problems and oppor should be wary, how
tunities. Skilled therapists can use what they ever. From former healthy, and
discover in group about the client’s style of days of active sub
relatedness to enhance individual therapy. stance abuse, clients unavoidable.
Conversely, the individual alliance can help the may have ties to care
client use the group effectively. So long as the less physicians who
therapist does not collude consciously or enabled addiction by
unconsciously with the client to keep what is providing crossaddic
said as a secret between them, most obstacles tive medications. If an
can be overcome. evaluation of pre
scription medications
In conjoint treatment, that is, a situation in is needed, counselors
which one therapist sees a client individually should refer the client to a consulting physician
while another therapist treats the same client in working with the agency or to a physician
a group, the therapists should be in close com knowledgeable about chemical dependency.
munication with each other. Clinicians should Attention needs to be paid to medications pre
coordinate the treatment plan, keeping impor scribed for physical illnesses as well. For exam
tant interpersonal issues alive in both settings. ple, it would be important for the group leader
The client should know that this collaboration to know that a group member has diabetes and
routinely occurs for the client’s benefit. requires medication.
Medication knowledge base
Management of the Group
Clinicians need general knowledge of common
medications used to assist in recovery, relapse Handling conflict in group
prevention, and cooccurring disorders. Group
leaders should be aware of various medication Conflict in group therapy is normal, healthy,
needs of clients, the type of medications pre and unavoidable. When it occurs, the thera
scribed, and potential side effects. Prescribing pist’s task is to make the most of it as a learn
medication involves striking a balance between ing opportunity. Conflict can present opportu
therapeutic and detrimental pharmacological nities for group members to find meaningful
effects. For example, benzodiazepines can connections with each other and within their
reduce anxiety, but they can be sedating and own lives.
might lead to dependency. Handling anger, developing empathy for a dif
The pregroup interview for longterm groups ferent viewpoint, managing emotions, and
should ask what medications group members working through disagreements respectfully are
are taking and the names of prescribing physi all major and worthwhile tasks for recovering
cians so cooperative treatment is possible. For clients. The leader’s judgment and manage
example, if a client is awake all night with drug ment are crucial as these tasks are handled. It
is just as unhelpful to clients to let the conflict
Group Leadership, Concepts, and Techniques 115
go too far as it is to the therapist should consider the function the
shut down a conflict conflict is serving for the group. It actually may
before it gets worked be the most useful current opportunity for
After a conflict, it through. The thera growth in the group.
pist must gauge the
is important for verbal and nonver On the other hand, as Vannicelli (1992) points
bal reactions of out, conflicts can be repetitive and predictable.
every group member When two members are embroiled in an end
the group leader to
to ensure that every less loop of conflict, Vannicelli suggests that the
one can manage the leader may handle the situation by asking,
speak privately “John, did you know what Sally was likely to
emotional level of
the conflict. say when you said X?” and “Sally, did you
with group mem know what John was likely to say when you
The clinician also said Y?” “Since both participants are likely to
bers and see how facilitates interac answer, ‘Yes, of course,’ the therapist would
tions between mem then inquire what use it might serve for them to
each is feeling. bers in conflict and engage in this dialogue when the expected out
calls attention to come is so apparent to both of them (as well as
subtle, sometimes to other members of the group). This kind of
unhealthy patterns. distraction activity or defensive maneuver
For example, a should come to signal to group members that
group may have a member, Mary, who fre something important is being avoided. It is the
quently disagrees with others. Group peers leader’s task to help the group figure out what
regard Mary as a source of conflict, and some that might be and then to move on” (Vannicelli
of them have even asked Mary (the scapegoat) 1992, p. 121).
to leave so that they can get on with group
work. In such a situation, the therapist might Group leaders also should be aware that many
ask, “Do you think this group would learn conflicts that appear to scapegoat a group
more about handling this type of situation if member are actually displaced anger that a
Mary left the group or stayed in the group?” member feels toward the therapist. When the
An alternative tack would be, “I think the therapist suspects this kind of situation, the
group members are avoiding a unique opportu possibility should be forthrightly presented to
nity to learn something about yourselves. the group with a comment such as, “I notice,
Giving in to the fantasy of getting rid of Mary Joe, that you have been upset with Jean quite a
would rob each of you of the chance to under bit lately. I also know that you have been a lit
stand yourself better. It would also prevent you tle annoyed with me a since couple weeks ago
from learning how to deal with people who about the way I handled that phone call from
upset you.” your boss. Do you think some of your anger
belongs with me?”
Conflicts within groups may be overt or covert.
The therapist helps the group to label covert Individual responses to particular conflicts can
conflicts and bring them into the open. The be complex, and may resonate powerfully
observation that a conflict exists and that the according to a client’s personal values and
group needs to pay attention to it actually beliefs, family, and culture. Therefore, after a
makes group members feel safer. The therapist conflict, it is important for the group leader to
is not responsible, however, for resolving con speak privately with group members and see
flicts. Once the conflict is observed, the deci how each is feeling. Leaders also often use the
sion to explore it further is made based on last 5 minutes of a session in which a conflict
whether such inquiry would be productive for has occurred to give group members an oppor
the group as a whole. In reaching this decision, tunity to express their concerns.
116 Group Leadership, Concepts, and Techniques
Subgroup management Responding to disruptive
In any group, subgroups inevitably will form. behavior
Individuals always will feel more affinity and Clients who cannot stop talking
more potential for alliance with some members
than with others. One key role for the therapist When a client talks on and on, he or she may
in such cases is to make covert alliances overt. not know what is expected in a therapy group.
The therapist can involve the group in identify The group leader might ask the verbose client,
ing subgroups by saying, “I notice Jill and “Bob, what are you hoping the group will learn
Mike are finding they have a good deal in com from what you have been sharing?” If Bob’s
mon. Who else is in Jill and Mike’s subgroup?” answer is, “Huh, well nothing really,” it might
be time to ask more experienced group mem
Subgroups can sometimes provoke anxiety, bers to give Bob a sense of how the group
especially when a therapy group is made up of works. At other times, clients tend to talk more
individuals acquainted before becoming group than their share because they are not sure what
members. Group members may have used else to do. It may come as a relief to have their
drugs together, slept together, worked together, monolog interrupted (Vannicelli 1992, p. 167).
or experienced residential substance abuse
treatment together. Obviously, such connec If group members
tions are potentially disruptive, so when groups exhibit no interest in
are formed, group leaders should consider stopping a perpetually
whether subgroups would exist. filibustering client, it
may be appropriate to In managing
When subgroups somehow stymie full partici examine this silent
pation in the group, the therapist may be able cooperation. The subgroups, one
to reframe what the subgroup is doing. At group may be all too
other times, a change in the room arrangement willing to allow the key role for the
may be able to reconfigure undesirable combi talker to ramble on,
nations. On occasion, however, subtle to avoid examining
their own past failed
therapist is to
approaches fail. For instance, adolescents talk
ing among themselves or making obscene ges patterns of substance
tures during the session should be told factually abuse and forge a make covert
and firmly that what they are doing is not per more productive
missible. The group leader might say, “We future. When this alliances overt.
can’t do our work with distractions going on. motive is suspected,
Your behavior is disrespectful and it attempts the leader should
to shame others in the group. I won’t tolerate explore what group
any abuse of members in this group.” members have and
have not done to sig
Subgroups are not always negative. The leader nal the speaker that it is time to yield the floor.
for example may intentionally foster a sub It also may be advisable to help the talker find
group that helps marginally connected clients a more effective strategy for being heard and
move into the life of the group. This gambit understood (Vannicelli 1992).
might involve a question like, “Juanita, do you
think it might help Joe if you talked some Clients who interrupt
about your experience with this issue?” Interruptions disrupt the flow of discussion in
Further, to build helpful connections between the group, with frustrating results. The client
group members, a group member might be who interrupts is often someone new to the
asked, “Bob, who else in this group do you group and not yet accustomed to its norms and
think might know something about what you’ve rhythms. The leader may invite the group to
just said?” comment by saying, “What just happened?” If
Group Leadership, Concepts, and Techniques 117
the group observes, the group is very serious and should never be
“Jim seemed real done without careful thought and consultation,
anxious to get in it is sometimes necessary. It may be required
right now,” the lead because of a policy of the institution, because
er might intervene the therapist lacks the skills needed to deal
with, “You know, with a particular problem or condition, or
Sometimes, clients Jim, my hunch is because an individual’s behavior threatens the
that you don’t know group in some significant and insupportable
are unable to us well enough yet to way.
be certain that the
participate in ways group will pay ade Though groups do debate many issues, the
quate attention to decision to remove an individual is not one the
consistent with your issues; thus, at group makes. On the contrary, the leader
this point, you feel makes the decision and explains to the group in
quite a lot of pres a clear and forthright manner why the action
group agreements. was taken. Members then are allotted time to
sure to be heard and
understood. My work through their responses to what is bound
guess is that when to be a highly charged event. Anger at the
other people are group leader for acting without group input or
speaking you are acting too slowly is common in expulsion situa
often so distracted tions, and should be explored.
by your worries that
it may even be hard to completely follow what Managing Other Common
is going on” (Vannicelli 1992, p. 170).
Problems
Clients who flee a session
Clients who run out of a session often are act Coming late or missing
ing on an impulse that others share. It would sessions
be productive in such instances to discuss these Sometimes, addiction counselors view the client
feelings with the group and to determine what who comes to group late as a person who, in
members can do to talk about these feelings some sense, is behaving badly. It is more pro
when they arise. The leader should stress the ductive to see this kind of boundary violation
point that no matter what is going on in the as a message to be deciphered. Sometimes this
group, the therapeutic work requires members attempt will fail, and the clinician may decide
to remain in the room and talk about problems the behavior interferes with the group work too
instead of attempting to escape them (Vannicelli much to be tolerated.
1992). If a member is unable to meet this
requirement, reevaluation of that person’s
placement in the group is indicated. Silence
A group member who is silent is conveying a
Contraindications for contin message as clearly as one who speaks. Silent
messages should be heard and understood,
ued participation in group since nonresponsiveness may provide clues to
Sometimes, clients are unable to participate in clients’ difficulties in connecting with their own
ways consistent with group agreements. They inner lives or with others (Vannicelli 1992).
may attend irregularly, come to the group
intoxicated, show little or no impulse control, Special consideration is sometimes necessary
or fail to take medication to control a cooccur for clients who speak English as a second lan
ring disorder. Though removing someone from guage (ESL). Such clients may be silent, or
respond only after a delay, because they need
118 Group Leadership, Concepts, and Techniques
time to translate what has just been said into Fear of losing control
their first language. Experiences involving
strong feelings can be especially hard to trans As Vannicelli (1992) notes, sometimes clients
late, so the delay can be longer. Further, when avoid opening up because they are afraid they
feelings are running high, even fluent ESL might break down in front of others––a fear
speakers may not be able to find the right particularly common in the initial phases of
words to say what they mean or may be unable groups. When this restraint becomes a barrier
to understand what another group member is to clients feeling acute pain, the therapist
saying about an intense experience. should help them remember ways that they
have handled strong feelings in the past.
Tuning out For example, if a
female client says she
When the group is in progress and clients seem
might “cry forever”
present in body but not in mind, it helps to
once she begins, the
tune into them just as they are tuning out. The
leader might gently
leader should explore what was happening as
an individual became inattentive. Perhaps the
inquire, “Did that A group member
ever happen?” Clients
person was escaping from specific difficult
are often surprised to who is silent is
material or was having more general difficulties
realize that tears gen
connecting with other people. It may be helpful
erally do not last very conveying a mes
to involve the group in giving feedback to
long. The therapist
clients whose attention falters. It also is possi
can further assist this
ble, however, that the group as a whole is sage as clearly as
client by asking,
sidestepping matters that have to do with con
“How were you able
nectedness. The member who tunes out might one who speaks.
to stop?” (Vannicelli
be carrying this message for the group
1992, p. 152).
(Vannicelli 1992).
When a client’s fears
Participating only around the of breaking down or
issues of others becoming unable to
function may be
Even when group members are disclosing little founded in reality (for example, when a client
about themselves, they may be gaining a great has recently been hospitalized), the therapist
deal from the group experience, remaining should validate the feelings of fear, and should
engaged around issues that others bring up. To concentrate on the strength of the person’s
encourage a member to share more, however, a adaptive abilities (Vannicelli 1992).
leader might introduce the topic of how well
members know each other and how well they
want to be known. This topic could be explored Fragile clients with psycho
in terms of percentages. For instance, a man logical emergencies
might estimate that group members know about Since clients know that the group leader is
35 percent about him, and he would eventually contractually bound to end the group’s work
like them to know 75 percent. Such a discus on time, they often wait intentionally until the
sion would yield important information about last few minutes of group to share emotionally
how much individuals wish to be known by oth charged information. They may reveal some
ers (Vannicelli 1992). thing particularly sad or difficult for them to
deal with. It is important for the leader to rec
ognize they have deliberately chosen this time
to share this information. The timing is the
Group Leadership, Concepts, and Techniques 119
client’s way of Lan individually right after the session.
limiting the group’s Whatever the decision and subsequent action,
responses and avoid the leader should not simply drift casually and
ing an onslaught of quietly over the time boundary. The important
Clients may feel interest. All the message is that boundaries should be honored
same, the group and that Lan will get the help she needs. The
great anxiety after members or leader group leader can say explicitly that Lan’s needs
should point out will be addressed after group.
disclosing some this selfdefeating
behavior and Figure 63 shows that group leaders should
thing important. encourage the client be prepared to deal not only with substance
to change it. abuse issues, but with cooccurring psychiatric
concerns as well.
Near the end of a
session, for example, Anxiety and resistance after
a group leader has
an exchange with a group member named Lan, selfdisclosure
who has been silent throughout the session: Clients may feel great anxiety after disclosing
something important, such as the fact that they
Leader: Lan, you’ve been pretty quiet today. I are gay or incest victims. Often, they wonder
hope we will hear more about what is happen about two possibilities: “Does this mean that I
ing with you next week. have to keep talking about it? Does this mean
Lan: I don’t think you’ll see me next week. that if new people come into the group, I have
to tell them too?” (Vannicelli 1992, p. 160).
Further exploration reveals that Lan intends to
kill herself that night. In view of the approach To the first question, the therapist can respond
ing time boundary, what should the leader do? with the assurance, “People disclose in here
when they are ready.” To the second, the
In such a situation, the group leader has dual member who has made the disclosure can be
responsibilities. First, the leader should assured of not having to reiterate the disclosure
respond to Lan’s crisis. Second, the incident when new clients enter. Further, the disclosing
should be handled in a way that reassures member is now at a different stage of develop
other group members and preserves the integri ment, so the group leader could say, “Perhaps
ty of the group. Group members will have a the fact that you have opened up the secret a
high level of anxiety about such a situation. little bit suggests that you are not feeling that it
Because of their concern, some group leaders is so important to hide it any more. My guess is
are willing to extend the time boundary for that that this, itself, will have some bearing on how
session only, provided that all members are you conduct yourself with new members who
willing and able to stay. Others feel strongly come into the group” (Vannicelli 1992, p. 160
that the time boundary should be maintained & p. 161).
and that the leader should pledge to work with
120 Group Leadership, Concepts, and Techniques
Figure 63
Jody’s Arm
A longterm outpatient interpersonal process group meets in 90minute sessions
to support sustained recovery. The group, which includes five women and four
men, is relatively stable and successfully abstinent. Many of the clients, however,
still struggle with profound psychological concerns that require ongoing
attention.
In one group session, all members are present except Jody, a 43yearold client
who is opioiddependent and has cooccurring psychiatric difficulties. Jody
walks in approximately 35 minutes late, apologizing for her lateness. The group
facilitator makes a mental note that Jody is wearing several sweatshirts, despite
weather too mild to justify the need for layered clothing.
Approximately 15 minutes before the close of group, blood seeps through the top
layer of clothing covering Jody’s left arm. The group leader asks Jody if her
injured arm is making some statement to the group members. Is there something
specific that she wants from the group at this particular moment? The leader is
confident that Jody is saying something very important not only to, but for, the
group as a whole.
Jody indicates that the previous week she felt diminished by comments from a
number of members in the group. In an effort to deal with the anxiety and
shame associated with returning to the group, she has cut herself before
attending.
A number of group members quickly share their concern for her and hopes that
their comments of the previous week could be revisited and revised to be more
supportive. Jody shows the group the cut on her forearm, which has all but
stopped bleeding. She explains how deep her pain is and her desire for the
group not to judge her for that pain.
Because Jody appears to be in no imminent danger, the leader chooses to contin
ue with the group process, ending it at the regularly scheduled time. The group
meets at a major medical center, so the leader is able to walk with Jody to the
emergency room. The leader assures the group that Jody will receive the medical
attention she needs.
The next week, the entire group makes substantial gains. They carefully exam
ine their judgment and willingness to allow Jody to be the primary spokeswoman
for the profound emotional pain that each of them feels. The dramatic and
unexpected situation the previous week has not interrupted the group process. It
has instead been used adroitly to make the group even more productive.
Group Leadership, Concepts, and Techniques 121
7 Training and
Supervision
Overview
In This
Substance abuse counselors come to the field from a variety of back
Chapter…
grounds, education, and experience. Many have not had specific train
ing and supervision in the special skills needed to be an effective group
Training therapist. Counselors may be promoted to positions of supervision with
Training Opportunities
out the additional training in the skills needed to perform supervisory
Training Opportunities in
tasks, which are
Types of Group Therapy
• Administrative
Supervision • Evaluative
The Supervisor’s Essential
• Clinical
Skills
The Supervisory Alliance
• Supportive
Funding for Training and
Supervision Programs
This chapter describes the skills group therapy clinicians need, the pur
pose and value of clinical supervision, and how to get the training neces
sary to be a topflight group clinician or supervisor of clinicians.
Training
In a brief article, Geoffrey Greif lists “Ten Common Errors Beginning
Substance Abuse Workers Make in Group Treatment.” He contends
that these errors are common because people who abuse substances
are supremely adept at helping group leaders make mistakes. Some of
these are
• Impatience with the clients’ slow pace of dealing with change
• Inability to drop the mask of professionalism
• Failure to recognize countertransference issues
• Not clarifying group rules
• Conducting individual therapy rather than using the entire group
effectively
• Failure to integrate new members effectively into the group
(Greif 1996)
123
Training and educa Therapists need to become well versed in the
tion for group thera substance abuse treatment philosophy, its ter
pists working in the minology, and techniques of recovery, including
A group leader for substance abuse field the selfhelp approaches (Kemker et al. 1993).
can alleviate or elim
people in sub inate such errors. A group therapist with roots in the mental
Simultaneously, health field planning to become more compe
stance abuse treat additional training is tent in group work for the treatment of sub
becoming even more stance abuse will need to make a number of
ment requires critical because (1) adjustments. First, the therapist working with
the traditionally sep clients with substance use disorders should be
arate fields of mental able to screen and assess for substance abuse
competencies in
health and substance problems. On this subject, see TIP 11, Simple
abuse counseling Screening Instruments for Outreach for
both group work Alcohol and Other Drug Abuse and Infectious
increasingly overlap,
requiring more and Diseases (Center for Substance Abuse
and addiction. Treatment [CSAT] 1994b); TIP 24, A Guide to
more crossknowl
edge; and (2) an ever Substance Abuse Services for Primary Care
younger pool of Clinicians (CSAT 1997a); and TIP 31,
clients is presenting Screening and Assessing Adolescents for
with more cognitive deficits, abuse issues, and Substance Use Disorders (CSAT 1999c).
cooccurring disorders. Second, the therapist will need to recognize the
importance of abstinence. Third, the therapist
A group leader for people in substance abuse will need to be sensitive to a client’s anxiety
treatment requires competencies in both areas: and shame, especially in early stages of treat
group work and addiction. For example, facili ment for substance abuse. In a modified inter
tators should understand group process, group personal process group, for example, the group
dynamics, and the stages of group develop leader should create a safe, supportive envi
ment; they need to understand that group ther ronment free from the stigma of addiction while
apy is not individual therapy in a group setting. promoting a client’s attachment to other group
Further, facilitators should be aware that members, selfhelp groups, therapy, and the
although Alcoholics Anonymous (AA) or other entire healing community of which the group
12Step programs are complementary to sub is a part.
stance abuse treatment, these modalities are
distinct from group therapy. Group therapists who move into the treatment
of clients who are chemically dependent typi
As trends move toward integrated mental and cally need staff development in:
substance abuse treatment, counselors already
adept at working with groups of clients with • Theories and techniques. Theories may
substance abuse problems may need specific include traditional psychodynamic methods,
training to manage mental disorders such as cognitive–behavioral modes, and systems the
depression, which often cooccur with substance ory. From such theoretical bases are drawn
abuse. Further, counselors in recovery may be applications that pertain to a wide variety of
familiar with the stages of addiction treatment settings and particular client populations.
but lack a background in group therapy. • Observation. The observer can sit in on
group therapy sessions, study videotapes
On the other hand, group counselors who have of senior therapists leading group sessions
treated clients without addictions may not (ordinarily followed by a discussion), or
always have sufficient skills to combat addic watch groups live through oneway mirrors
tion and its effect on a group therapy situation. as experienced therapists lead groups.
124 Training and Supervision
• Experiential learning. With this approach, a pists do not perceive substance abuse problems
therapist may participate in a training group the same way, use different methods to treat
offered by an agency, become a member of a substance abuse, and differ in personality and
personal therapy group (these are often pro attitudinal traits.
cessoriented), or join in group experiences
at conferences, such as those offered at the Some people dismiss the notion that all people
Institute of the American Group Psycho with addictions prefer to work with a group
therapy Association’s annual conference. leader who is in recovery. They insist that, on
(For more on experiential training, see the the contrary, some people with addictions pre
section on “Experiential Learning” later in fer not to work with recovering leaders, fearing
this chapter.) that leaders in recovery will share the issues
and problems of people with addictions and
• Supervision. A large part of this type of thus will not be in a position to help them with
training is ongoing work with groups under
these issues.
the supervision of an experienced therapist.
Supervision may be dyadic, that is, supervi Others say that a staff of group leaders should
sor and supervisee, but while simple and include people in recovery. Those holding this
easy, this setting does not allow opportunities point of view reason that people with addic
for actual group work. Supervision of group tions are highly skilled at manipulating people
therapists ideally is conducted in a superviso and situations. With both recovering and non
ry group format. Supervision in a group recovering group leaders, a clinical team will
enables therapists to obtain firsthand expe be best positioned to see and treat the whole
rience and helps them better understand client––and not be duped by agreeable, but
what is happening in groups that they will false, façades.
eventually lead. Several other important ben
efits accrue as well. The supervisory group In group therapy with clients with substance
creates a safe place for trainees to reveal use disorders, it can be challenging to establish
themselves and the skills they need to devel and maintain credibility with all group clients.
op. It provides support from peers and a Facilitators not in recovery will need to antici
chance to learn from their experience. It pate and respond to group members’ questions
stimulates dialog around theory and tech about their experience with substances and will
nique and encourages a healthy kind of com need skills to handle group dynamics focused
petition. It expands the capacity for empathy on this issue. On the other hand, leaders who
(Alonso 1993). Finally, this kind of supervi are in recovery may
sion provides an opportunity for trainees to tend to focus too
explore sensitive issues, such as child abuse, much on themselves.
sexual abuse, and prostitution. (For more on Group leaders emo
supervisory groups, see the “Supervision” tionally invested in
section later in this chapter.) acting as models of Supervision in a
recovering perfection
Before leaving the matter of what group leaders are easy marks for group enables
treating substance abuse should know, it is clients.
desirable to assess the importance of the group therapists to
facilitator’s being a person who is in recovery. Of course, the main
There is some tension around this issue. issue is not whether
the leader is in recov
obtain firsthand
Culbreth (2000) reviewed 16 relevant studies
and concluded that while clients do not per ery. What matters
most is whether the experience.
ceive differences in treatment related to a ther
apist being in recovery or not, and no differ counselor knows the
ences in treatment outcomes could be dis fields of group thera
cerned, recovering and nonrecovering thera py and addiction
treatment and has
Training and Supervision 125
good judgment and leadership skills (see Figure Professional associations
71). Helping the group explore why the recov
ery status of the group leader is important can American Group Psychotherapy
be discussed if and when the issue is raised. Association (AGPA)
AGPA, founded in 1942, has more than 4,000
members and 33 local and regional affiliate
Training Opportunities societies, which provide a broad range of pro
National professional organizations are a rich fessional, educational, and social support for
source of training. Through conferences or group therapists in the United States and
regional chapters, national associations provide abroad. The organization publishes The
training—both experiential and direct instruc International Journal of Group Psychotherapy
tion—geared to the needs of a wide range of and The Group Circle.
professionals, from the novice to the highly
AGPA’s Special Interest Groups (SIGs) share
experienced therapist. More training options
ideas and knowledge through interaction with
are usually available in large urban areas. It is
colleagues. Some SIGs focus on substance
likely, however, that online training will make
abuse; children and adolescents; cotherapy;
some types of professional development acces
diversity; gay, lesbian, and bisexual clients; the
sible to a greater number of counselors in
medically ill; the severe and persistent mentally
remote areas. A number of professional
ill; and women in group therapy. SIGs are open
organizations that provide a variety training
to nonmembers of AGPA.
settings are listed below. Inclusion in the list
does not imply endorsement by the Substance At its annual conferences, AGPA offers train
Abuse and Mental Health Services Adminis ing institutes for individuals. Three of these
tration (SAMHSA). Note that not all of these institutes focus on substance abuse training.
organizations approach substance abuse The association can also provide inhouse
treatment through group therapy. training to agency staff at a very low cost.
Further, AGPA has developed basic and
Figure 71
How Important Is It for a Substance Abuse Group Leader To Be
In Recovery?
A leader who is in recovery will probably elicit trust more quickly from group
members, especially people with hardcore addictive backgrounds, because such
clients often assume––correctly or not––that a person in recovery can empathize
with the pain of addiction. Such group leaders, as success stories, have the
added advantage of serving as role models for group members struggling against
temptations and cravings in the early stages of recovery.
A leader having personally recovered, however, does not automatically make
that person an effective therapist. Many counselors in recovery cannot make the
switch from self to clientcentered approaches and hold rigid views of how to
manage the recovery process.
Source: Consensus Panel.
126 Training and Supervision
advanced core courses. They tend to be practi Psychology, and an Office of Ethnic Minority
cal in nature, and they contribute to certifica Affairs that provides publications and informa
tion. The certified group therapy program is tion. Recent APA books on this topic describe
available through the regional affiliates. relationships among AsianAmerican women
and healthpromoting and healthcompromis
American Psychiatric Association ing behaviors among minority adolescents.
(APA)
The American Psychiatric Association is a med American Society of Addiction
ical specialty society recognized worldwide. Its Medicine (ASAM)
more than 35,000 U.S. and international mem One of ASAM’s goals is educating health pro
ber physicians work together to ensure humane fessionals about addiction. The organization
care and effective treatment for all persons develops credentialing guidelines and publishes
with mental disorder, including mental retarda the comprehensive and influential volume,
tion and substancerelated disorders. To its Principles of Addiction Medicine (Graham et
members, the APA offers board certification al. 2003), among other books and journals.
and continuing medical education from online The society has also developed patient place
sources as well as at annual meetings. ment criteria called PPC2R (published in
2001), as well as screening and assessment
American Psychological Association tools. Each year, ASAM hosts several confer
(APA) ences and training meetings on various aspects
The APA College of Professional Psychology of addiction medicine. ASAM offers audiotapes
offers a Certificate of Proficiency in the of its conferences for continuing medical educa
Treatment of Alcohol and Other Psychoactive tion credit. Physicians certified by the society
Substance Use Disorders. This certificate is a in addiction medicine are listed in an ASAM
uniform nationally recognized credential directory.
offered exclusively to licensed psychologists
who meet specific criteria related to experience Association for the Advancement
in substance abuse treatment, including com of Social Work with Groups
pletion of an APA examination. (AASWG)
This international professional organization
Two of APA’s 55 subgroups may be of special has developed standards that reflect the distin
interest. Division 49, Group Psychology and guishing features of group work, as well as the
Group Psychotherapy, serves psychologists’ unique perspective that social workers bring to
interest in research, teaching, and the practice their practice with groups. These standards are
of group psychology and group therapy. applicable to the types of groups that social
Division 50, Addictions, centers on research, workers encounter in the various settings in
professional training, and clinical practice which they practice and allow the practitioner
dealing with a broad range of addictive behav to apply a variety of relevant group work mod
iors. Both divisions publish a newsletter and els. AASWG has also collected a 29page bibli
journal, and both have annual meetings and ography of books, monographs, and videos
award programs. available for practitioners, educators, and
APA has extensive resources on cultural diver researchers.
sity and ethnic/racial issues related to therapy,
including online brochures, a quarterly jour
nal, Cultural Diversity and Ethnic Minority
Training and Supervision 127
Association for Specialists in Group mentoring programs to support the work of
Work (ASGW) AfricanAmerican social workers.
A division of the American Counseling
National Association of Social
Association, the ASGW was founded to
Workers (NASW)
promote high quality in group work training,
practice, and research, both nationally and NASW is the world’s largest organization of
internationally. The organization has devel professional social workers. The association
oped Best Practice Guidelines, Principles for has developed practice standards and clinical
DiversityCompetent Group Workers, and indicators, a credentialing program, continuing
Professional Standards for the Training of education courses on national and State levels,
Group Workers. These criteria are available and numerous publications for members and
on the organization’s Web site: http://asgw.org. nonmembers.
The Web site also provides resources, including Distance learning courses are listed on NASW’s
products, institutes, and links to other Web Web site. Many topics are relevant to addiction
pages, along with a calendar describing upcom counselors, such as Chemical Dependency and
ing conferences and professional development the African American: Counseling Strategies
activities of interest to a broad spectrum of and Community Issues, Dual Diagnosis,
group leaders. HIV/AIDS and Substance Abuse, and
Multicultural Counseling—The New Paradigm
National Association of Alcohol
for Substance Abuse Professionals.
and Drug Abuse Counselors
(NAADAC) National Registry of Certified
NAADAC is the largest national organization Group Psychotherapists
for alcoholism and drug abuse professionals In an effort to maintain the highest standards
across the country. The association offers for group therapy practice, the National
opportunities for professional development, Registry certifies group therapists according to
such as workshops, seminars, and education nationally accepted criteria and promotes these
programs for members. In addition to a criteria among mental health professionals,
bimonthly magazine, The Counselor, NAADAC employers, insurers, education personnel, and
provides an Educational Resources Guide that clients. The registry has developed guidelines
lists colleges and universities offering degree that are clinically based, clientfocused service
and certification programs in addiction coun indicators to be used in discussions with
seling and a listing of approved education accrediting organizations regarding appropri
providers for trainers in each State. Through ate standards of quality. The guidelines also
its national certification program, including the apply in discussions with employers regarding
National Certified Addiction Counselor and the delivery of mental health services in groups, as
Masters Addiction Counselor designation, well as managed care and health maintenance
NAADAC recognizes counselors with advanced organizations. The registry’s newsletter, The
skill levels. Group Solution, provides uptodate informa
tion on the use of group therapy in the current
National Association of Black Social
behavioral health care atmosphere.
Workers (NABSW)
NABSW offers national and international
education conferences, as well as projects and
128 Training and Supervision
Frequent continuing education seminars are Institute on Drug Abuse, which provides
given by local affiliate societies and at the information on research and treatment.
annual meeting of the parent group, AGPA.
The National Mental Health Information
Center (NMHIC) at SAMHSA provides a
Other sources of training wealth of information for the public and
Many agencies mandate a certain number of for treatment professionals. A search for
trainings each year and provide inhouse “training” on its Web site resulted in a list of
training that draws on the resources of cre numerous opportunities for training and
dentialed senior management. Each of the technical assistance on a variety of topics as
States has a department of alcohol and drug well as bibliographies, publications, and
abuse services, and some may provide sub links.
stance abuse training for group therapy.
Training in mental health issues is often
available through the mental health division Training Opportunities in
of government agencies, professional associ Types of Group Therapy
ations, and psychological and psychiatric
organizations. Most colleges, universities, Experiential learning
and community colleges offer relevant For the therapist in training, the experience
courses, many of them certified by profes of being in a group is particularly important
sional organizations. for both the development of skills and the
Several Federal entities offer resources for level of comfort with one’s developing lead
training. SAMHSA provides a number of ership style. Whether this experience is
resources, including publications for sub acquired through a process group, a super
stance abuse treatment professionals. These vision group, or experiences offered through
include the Technical Assistance Publication organizations like the AGPA, experiential
(TAP) series. TAP 21 is relevant to training: opportunities afford learners not only
Addiction Counselor Competencies: The insight into their personal growth, but a
Knowledge, Skills, and Attitudes of firstperson appreciation for the healing
Professional Practice (CSAT 1998a). power of group therapy.
professionals.
Training and Supervision 129
leadership of process groups provides one of classes in techniques and learning how to apply
the best continuing education tools available them with a population that has substance
to senior clinicians (Swiller et al. 1993). One abuse problems. The National Expressive
experienced supervisor of training groups for Therapy Association offers conferences,
therapists in training has found that “one of professional education, and in affiliation with
the most striking aspects of the supervision of the National Institute of Expressive Therapy,
group therapists in the group setting is its effec continuing education units, credentialing, and
tiveness in bringing about the identification, board certification.
emotional recognition, and resolution
of…untherapeutic behaviors, which we term Crosstraining
counterresistances” (Rosenthal 1999b, p. 201).
Though group therapists work in the field of
A great many institutions and individuals offer mental health, they generally have little train
workshops and courses in conducting group ing in the specifics of substance abuse treat
therapy. One of these is the A.K. Rice Institute ment. This situation will have to change if the
and its affiliate societies, which provides group fields of substance abuse treatment and mental
relations training based on the Tavistock health are to integrate their activities.
model, which originated at the Tavistock
Institute in England. The training, offered in To supplement courses that professional orga
weekend or longer conferences, is a model of nizations offer individuals, agencies can use a
experiential training that focuses exclusively on case study approach. Case studies that include
grouplevel dynamics. educational materials on diagnosis, symptoms,
and treatment serve as a good foundation for
The A.K. Rice Institute crosstraining. The cases that cause counselors
AnneMarie Kirkpatrick, R.N., Administrator to struggle the most could be analyzed. What
P.O. Box 1776 strategies were used? What were the outcomes?
Jupiter, Florida 334681776 What alternatives did other staff recommend?
Phone: (561) 7441350 Case conferences can be conducted at weekly
Fax: (561) 7445998 staff development sessions, as part of regular
meetings, or (more quickly) at morning feed
Expressive therapies back meetings on clinical topics. A case confer
ence might involve counselors, social workers,
A wide range of expressive therapies (therapy and psychologists.
based on an artist’s working process) is often
used in substance abuse treatment. Expressive
therapy groups may use dance, music, art, Legal issues
writing, psychodrama, drama, role playing, It is important for therapists to know Federal
adventure, and gestalt. Training in these areas regulations and the laws of their States, espe
is available through AGPA, ASGW, and APA. cially those concerning “duty to warn” stipula
The Gestalt Institute has training centers in tions regarding the abuse of children or elders,
most large cities and offers a certification in commitment procedures for psychiatric clients,
psychodrama. and confidentiality laws pertaining to HIV/
AIDS, adolescents, and managed care.
The National Institute of Expressive Psycho Practitioners should be familiar with the
therapy offers a 2year online program for Federal confidentiality regulation, 42 C.F.R.
those who have participated annually in the Part 2, Confidentiality of Alcohol and Drug
institute’s 2day residency. Professionals are Abuse Patient Records. In addition, there are
required to participate as a member of a role State laws that also guide the confidentiality of
playing or drama group before attending
130 Training and Supervision
alcohol and drug abuse information, and treatment professionals to a wide variety of
whichever is more restrictive (i.e., State law or useful information. ATTCs
Federal law) governs. Professional and legal
organizations usually address these topics in • Provide StatebyState credentialing
their coursework. It is best to find such courses information
at the regional or State level, so that attendees • Post news in the field
can grasp the laws governing residents in their • List new resources, including publications
specific geographical areas.
• Translate technical and academic journal
articles into easytoread language
Videos • List alcohol and other drug treatment pro
While impersonal media cannot replace the grams in each State
relationships between supervisors and trainees, • Provide a worldwide catalog of online courses
videos can be used to explain theoretical princi
ples, provide information on various types of To tap into ATTC’s lode of professional
drugs, and support skillsbuilding activities. development information, log onto
http://www.nattc.org.
Distance learning
Distance learning systems, which often commu Supervision
nicate via cable or satellite, can assist with
explaining concepts, theories, and case studies. Supervisory oversight is a significant training
Like videos, distance learning may lack the requirement for group therapists. Powell
close personal relationship with a supervisor, (1993) defines clinical supervision as “a disci
but interactive forms of distance learning do plined, tutorial process wherein principles
permit questions, comments, and requests for are transformed into practical skills with
clarification. four overlapping foci—administrative, evalu
ative, clinical, and supportive.” Powell’s
Group therapy for trainees using an online description points out that the clinical super
chat room is an interesting possibility and visor has an administrative task, namely the
could be especially helpful to people in remote development of an appropriate supervision
settings. Licensing boards, however, would first plan for clinician trainees. This task includes
need to resolve any potential legal issues planning, coordination, and delegation of
regarding confidentiality. Also, some critics responsibilities; determining appropriate
have worried that computerized communica staff assignments; and helping to define
tion would interfere with attachment (one of administrative polcies and procedures.
the most powerful therapeutic factors). This
problem does not seem to occur in educational In addition, the clini
seminars conducted online (see Figure 72 on cal supervisor has
p. 132). duties in the sphere
of evaluation. As the Every State has a
Every State has a credentialing process for skills and knowledge
substance abuse treatment professionals, and of new group facilita credentialing pro
NAADAC lists all the particulars at tors begin to grow,
http://www.NAADAC.org. At the same address, they need consistent, cess for substance
NAADAC posts training calendars and a useful feedback that
great deal of other information on training will direct their work abuse treatment
opportunities. and will support pro
fessional growth. In professionals.
The 14 regional Addiction Technology Transfer the early stages of
Centers (ATTCs), launched by SAMHSA’s
CSAT in 1993, connect substance abuse
Training and Supervision 131
Figure 72
Does Online Communication Impede Attachment?
As a faculty member with the Fielding Graduate Institute, a distance learning
program, I teach psychology in both on and offline formats. In many of the
online seminars, students post their papers and comment on the contributions of
others. The students are dispersed around the country, so few (if any) know
each other prior to the seminar.
Even though the students’ interactions are asynchronous (that is, not in real
time; a lag separates comment and response), a group of learners develops that
is indistinguishable from learners sitting in the same room together. Alliances
develop between students who share similar ideas, and disagreements take place
between opposing positions. The attachments that develop through the written
word outside of real time seem as genuine as any other relationships.
In the online seminars, some students find in cyberspace a safer format than
traditional classes. Not having to confront all the verbal cues that may distract
people in a facetoface conversation, learners are freer to be genuine. Several of
my students who were involved in a seminar with inperson and online compo
nents were more interactive and spontaneous in the online segment.
I don’t see why these dynamics would be different in supervisory groups. I don’t
know of any online therapy groups, but some AA meetings are conducted online.
Further, Haim Weinberg operates a discussion list that includes about 400 group
therapists from more than 30 countries. This arena for exchanging ideas about
group therapy behaves very much like any large group, with a few surprising
departures. Among them:
• In this highly diverse group representing many schools of thought, conflicts do
not arise over differing theoretical stances or the appropriateness of interven
tions. Instead, “word wars,” (commonly called “flaming”) break out due to
impatience or personal attitudes and exchanges. One member wrote, for exam
ple, “I thought you either have to be very young and inexperienced or very
rude and insulting.” Some of the flaming seems to stem from misunderstand
ings that in turn result from having only words as cues. What is meant in jest,
for example, may be taken seriously (Weinberg 2002).
• Traditionally, the larger the group, the more impersonal it was, but Weinberg
finds startling selfdisclosure and intimacy over the Internet. For example, a
man whose newborn son had died wrote, “My heart is broken. Words can’t
convey the grief, and I realize only now that the depth of this pain is beyond
comprehension. I feel waves of horrible sadness and utter bewilderment.”
Messages of condolence flooded back to the distraught father (Weinberg 2002).
Source: A Consensus Panel member.
132 Training and Supervision
group facilitation, answers to the question, will not only keep this question in mind, but
“How am I doing?” are extremely important, also provide clear, cogent responses to trainees.
but unfortunately, the question often goes Figure 73 gives an example of group experien
unanswered. Appropriate clinical supervision tial training.
Figure 73
Group Experiential Training
Through the Mountain Area Health Education Center in Asheville, North
Carolina, I conducted an 18month intensive group training and supervision
experience, which is one of many ways to provide clinicians with an expanded
knowledge base and the opportunity to sense the power of group therapy. The
group met one Saturday a month from 9:00 a.m. to 6:00 p.m.
The model had three main components. The first, conducted in a direct instruc
tion format, communicated basic, intermediate, and eventually advanced group
skills. It also highlighted the role of failed attachment in the expression of addic
tive disease and the theoretical means by which groups address these concerns.
The trainees’ experiential group process, the second component, took place
three times throughout the day. In these 1hour sessions, trainees participated in
a training group. From the outset, it was made clear that this training group was
not therapy. Although personal information inevitably was shared, the primary
purpose of the experience was trainees’ encounter with the hereandnow
aspects of interpersonal group process, while being exposed to the same anxi
eties, excitement, and achievements that clients feel within the context of group.
At the end of each experiential group process, trainees evaluated not only the
group process, but also reflected on aspects of the supervisor’s leadership style,
commenting on its facilitation of the process or difficulties it presented.
The third aspect of this training and supervision experience was an indepth
evaluation of the clinical experiences of the trainees. At each session, group
members brought in clinical issues that occurred in their practice for comment,
discussion, and review. They received information not only from the group
supervisor, but also from peers. This opportunity enabled trainees to integrate a
theory base with practice, thus satisfying one of Powell’s key components of clin
ical supervision, that is, “a tutorial process wherein principles are transformed
into practical skills” (Powell 1993).
After leading this intensive experience, as well as many less intensive 30hour
training courses in group therapy, the need for such continuing training oppor
tunities is clear to us. We can say with some authority that the continued
advancement of one’s personal skills is essential, from initiation into the field
throughout the trajectory of a professional’s career.
Source: A Consensus Panel member.
Training and Supervision 133
The clinical function lence. This reassurance is especially beneficial
that the supervisor to novice counselors. Further,
fulfills is the devel
opment of a basic
• Group disclosure increases the potential for
The supervisory selfdisclosure and confirmation, creating
core of knowledge
and skills, which
opportunities for growth.
alliance is needed
includes an indepth • Empathy and sharing of interests are avail
understanding of able to a greater extent than in individual
to teach the addictive disease, an supervision.
integrated model of • Working together over time, a group can
trainee the skills group process, reinforce its members’ personal growth.
group dynamics, and
and knowledge • Alternative clinical approaches and methods
the stages of group
of helping are available to a far greater
development.
extent than in dyadic supervision. As a
required to lead
The interaction result, group members acquire a broad
between supervisory perspective on counseling styles.
groups effectively.
personnel and • Each counselor can do reality testing,
trainees has a sup presenting perceptions for peer scrutiny, and
portive function, possibly, validation.
which is vital to the • The potential for critique is greatly expanded
growth of trainees. (Powell 1993).
When they begin to apply their newly acquired
knowledge is the time that they need the most For treatment facilities, group supervision is
support and the most discerning supervision. attractive in its efficiency and effectiveness:
Clinical supervision, as it pertains to group • It provides a costeffective way of supervising
therapy, often is best carried out within the more people in the same amount of time.
context of group supervision. Group dynamics • The diversity of people in the group increases
and group process facilitate learning by setting opportunities for learning. The number of
up a microcosm of a larger social environment. group members (up to the desired limit of
Each group member’s style of interaction will four to six members) exponentially expands
inevitably show up in the group transactions. the range of learning opportunities.
Given enough time, all the people in the super
visory group will interact with group members • Group supervision creates a working alliance
just as they interact with others in wider social among counselors, engendering a sense
and clinical spheres, and every person will of psychological safety and reducing self
create in the group the same interpersonal defeating behavior (Powell 1993).
universe inhabited outside the group. As this
process unfolds, group members, guided by the The Supervisor’s Essential
supervisor, learn to model effective behavior in Skills
an accepting group context.
A supervisor should be competent in several
For the beginning counselor, supervisory content areas, including substance abuse treat
groups reduce, rather than escalate, the level ment, group training, cultural competence, and
of threat that can accompany supervision. In diagnosis of cooccurring conditions. A supervi
place of isolation and alienation, group partici sor may be an administrator, an inhouse train
pation gives counselors a sense of community. er, or a therapist from another agency.
They find that others share their worries,
A recent survey of members of NAADAC
fears, frustrations, temptations, and ambiva
indicates that many counselors receive and are
134 Training and Supervision
satisfied with weekly clinical supervision. strategies to planning and managing
However, a significant percentage of the termination)
respondents (who were not differentiated as to • Comprehensive knowledge of substance abuse,
whether they work with individuals or groups) which, depending upon the treatment setting,
indicated they receive no clinical supervision could entail broad general knowledge of, or a
(Culbreth 1999). This finding is disturbing con thorough facility with, a particular field
sidering the benefits of clinical supervision for
• Knowledge of the preferred theoretical
the delivery of highquality service to clients
approach
and the professional development of counselors.
Other findings from the NAADAC survey have • Knowledge of psychodynamic theory
clear implications for supervisory training. For • Knowledge of group dynamics theory
example, respondents preferred a supervisor • Knowledge of the institution’s preferred
who is a knowledgeable professional in the field theoretical approaches
and supervision that is more proactive and
intentional than reactive (Culbreth 1999). • Diagnostic skills for determining cooccurring
disorders
• Capacity for selfreflection, such as recogniz
The Supervisory Alliance ing one’s own vulnerability and, when this
Some training experts believe the key to effec problem arises, the ability to monitor and
tive group therapy supervision is the develop govern behavioral and emotional reactions
ment of the supervisory alliance. This positive • Consultation skills, such as the ability to
working relationship between the supervisor consult with a referring therapist, provide
and trainee is a unique and appropriate setting feedback, and coordinate treatment in both
within which a new therapist can develop skills individual and group modes
in group analysis and refine an ability to devel
• Capacity to be supervised; for example,
op appropriate treatment strategies.
openness in supervision, setting goals for
The supervisory alliance is needed to teach the training, and discussing with supervisor one’s
trainee the skills and knowledge required to learning style and preferences (Kleinberg
lead groups effectively and to make sure that 1999)
the group accomplishes its purpose. The super
visor helps by establishing an open and collab Planning ways to train new
orative climate, identifying the unique learning counselors
needs and styles of the supervisory group
members, formulating a responsive supervisory In planning a training approach, a supervisor
contract, and pinpointing any problems that needs to consider the characteristics of the
emerge within the alliance (Kleinberg 1999). supervisory team, that is, the supervisor plus
Supervision also includes encouraging and the trainees. Variables to be considered include
mentoring students from specific cultural
• The sophistication of trainees’ knowledge
groups, since it is difficult to locate welltrained
and skills
therapists to treat certain populations.
• The supervisory setting
Assessment of trainee skills • The characteristics of the client population
The supervisor should be able to assess the • The nature of the supervised treatment
various domains that trainees are required • The personality fit of the members on the
to master. supervisory team
• The format of the supervision
• Clinical skills (from selecting prospective
group members and designing treatment • The theoretical compatibility of the supervi
sory team (Kleinberg 1999)
Training and Supervision 135
After weighing all these variables, the supervi Other options can be found through the
sor discusses the focus and goals of the work Foundation Center, a nonprofit library system
with the team. The particulars will take shape that
as the supervisory contract. The necessary
mastery of specified clinical subjects, as well as • Collects and disseminates information on
the skills associated with them, can be devel sources of funding
oped through reading assignments, video pre • Conducts and promotes research on trends in
sentations, written assessments, and both philanthropy
direct and indirect supervision. • Provides education on grant seeking
• Publishes The Foundation Directory, avail
Funding for Training and
able on CDROM through The Foundation
Center
Supervision Programs
Given the time and financial resources needed The five foundation libraries (located in
to create formal academic preparation pro Atlanta, Cleveland, New York, San Francisco,
grams, it is a challenge to provide extended and Washington) provide many resources with
training (beyond 1 and 2day seminars) that is information on grants for projects related to
well grounded in theory and application and health and education. The center has recently
that addresses the needs of substance abuse designed a virtual classroom to assist in
counselors, especially those leading therapy
• Researching philanthropy
groups. The best way to fund such training is
to incorporate it into an agency or organization • Writing proposals
budget. These outlays should be viewed as • Identifying nearby corporations, government
investments that pay handsome dividends. For agencies, and other sources of funds in spe
instance, opportunities for training can help cific geographical areas
attract new, highly motivated employees. • Training in fundraising
One alternative source of funding is a Federal • Online fundraising
or State grant. Such funds are often available, The Foundation Center can be reached at
though frequently they require a great deal of http://www.fdncenter.org. The Frequently
administrative work Asked Questions section on this Web site is a
and strict adherence useful introduction to the center’s services.
to specific guidelines
It is a challenge to for project direction, As with training, an inherent cost is associated
staffing, and evalua with highquality clinical supervision, both in
tion. Grants are also financial commitment and clinical time. Despite
provide extended the positive returns that stem from good, bet
available to agencies
and individuals ter, or best clinical supervision, staff resources,
training that is through certain pro agency or organizational requirements, and the
fessional and train needs of the leader in training often dictate the
well grounded in ing organizations. specific type of supervision available.
For example, AGPA
theory and gives scholarships to Every agency providing services to clients
students who wish to abusing substances should take clinical super
attend its annual vision seriously and direct appropriate
application.
meetings and train resources toward constant improvement
ing conferences. through the clinical supervision process.
136 Training and Supervision
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Appendix B: Adult Patient
Placement Criteria
Adult Patient Placement Criteria For the Treatment
of Psychoactive Substance Use Disorders
Levels of Care Dimensions Level I Level II Level III
Criteria
g
Outpatient Intensive Outpatient Medically
i
Treatment Treatment Monitored Intensive
Inpatient Treatment
1 Level IV Medically Managed No withdrawal risk. Minimal withdrawal
Acute Intensive Inpatient risk.
Intoxication Treatment
and/or
Withdrawal
Potential
2 Severe withdrawal Severe None or very None or nondistract
Biomedical risk but manageable withdrawal risk. stable. ing from addiction
Conditions and in Level III. treatment and man
Complications ageable in Level II.
3 Requires medical Requires 24hour Mild severity with Moderate severity
Emotional and monitoring but not medical, nursing potential to distract needing a 24hour
Behavioral intensive treatment. care. from recovery. structured setting.
Conditions and
Complications None or very stable.
(continued on next page)
149
Adult Patient Placement Criteria For the
Treatment of Psychoactive Substance Use
Disorders (continued)
Levels of Care Level I Level II Level III Level IV
Criteria
g
Outpatient Intensive Outpatient Medically Medically Managed
Treatment Treatment Monitored Intensive Intensive Inpatient
Dimensions i Inpatient Treatment Treatment
Source: American Society of Addiction Medicine 2001.
150 Adult Patient Placement Criteria
Appendix C: Sample
Group Agreement
Appleton Outpatient Psycho
therapy Group Ground Rules
The following is excerpted from Vannicelli 1992, pp. 295–296.
The behavior and feelings of members of the therapy group mirror in
important ways behavior and feelings in other important relationships.
Consequently, the group provides a setting in which to examine patterns
of behavior in relationships. The group also provides a context in which
members learn to identify, understand, and express their feelings. The
therapist’s role is to facilitate this group process.
To foster these goals, we believe that several group ground rules are
important. These are as follows:
1. Members joining longterm groups remain as long as they find the
group useful in working on important issues in their lives. We
recommend at least a year. Members are required to make an initial
3month commitment in order to determine the usefulness of this
particular group for them.
2. Regular and timely attendance at all sessions is expected. As a
member, it is your responsibility to notify the group in advance when
you know that you will be away or late for group. In the event of an
unexpected absence, you should notify the group at least 24 hours in
advance to avoid being charged for the missed session.
3. Members of Appleton substance abuse groups are committed to
maintaining abstinence. If a relapse does occur, it must be discussed
promptly in the group—as must thoughts or concerns about resuming
drug/alcohol use. Members of ACOA (Adult Children of Alcoholics)
and family groups are asked to be reflective about their own sub
stance use and to bring up changes in patterns of use or concerns that
may be associated with use.
151
4. Members will notify the group if they are 8. Outsideofgroup contact often has consid
considering leaving the group. Because leav erable impact on the group’s therapeutic
ing the group is a process, just as joining is, effectiveness. Therefore, any relevant inter
members are expected to see this process actions between members which occur out
through for at least 3 weeks following notifi side the group should be brought back into
cation of termination. the next meeting and shared with the entire
group.
5. Members will have a commitment to talk
about important issues in their lives that 9. What you share in the group will be shared
cause difficulty in relating to others or in with other members of the treatment team
living life fully. when we feel that it is important to your
treatment to do so.
6. Members will also have a commitment to
talk about what is going on in the group 10. Payments for group are due at the last
itself as a way of better understanding their meeting of the month unless other arrange
own interpersonal dynamics. ments are discussed and explicitly worked
out in the group. If for any reason timely
7. Members will treat matters that occur in the payment becomes problematic, members
group with utmost confidentiality. To that are expected to discuss this in the group.
end, members are expected not to discuss
what happens in the group with people who
are not members of the group.
152 Sample Group Agreement
Appendix D: Glossary
AA
Alcoholics Anonymous, the best known of the 12Step selfhelp
organizations.
ASAM
The American Society of Addiction Medicine is a national specialty
society of the American Medical Association and is dedicated to edu
cating physicians and improving the treatment of individuals with
alcoholism and other addictions. ASAM publishes the Patient
Placement Criteria for the Treatment of SubstanceRelated
Disorders: ASAM PPC2R (2001), a widely used system of criteria
for placing clients in appropriate treatment settings.
Basic teaching skills
Organizing the content to be taught, planning for participant
involvement in the learning process, and delivering information in
a culturally relevant and meaningful way.
Cognitive–behavioral groups
Groups formed to change learned patterns of thinking and behavior
that lead to substance abuse or other psychological and interperson
al disorders.
Cognitive therapy
Attempts to modify maladaptive behavior by influencing a client’s
beliefs, schemas, selfstatements, and problemsolving strategies.
Assumes that emotional problems are largely caused by irrational or
maladaptive thinking and that restructuring these cognitions will be
therapeutic.
Cohesion
A positive quality of groups denoting a sense of enthusiastic solidari
ty within the group; Yalom (1995, p. 48) notes that cohesive groups
“have a higher rate of attendance, participation, and mutual sup
port,” and that members “will defend the group standards much
more than groups with less esprit de corps.”
153
Communal and culturally effective for clients who have difficulty
specific groups verbalizing thoughts and feelings.
Groups formed to use the sense of belong
ing to a culture to reduce or eliminate drug Diversity
abuse and other negative behaviors. As used in this TIP, diversity refers to any
difference that distinguishes one individual
Conflict from another and that affects how clients
A basic dynamic in groups in which mem identify themselves and are identified by
bers have opposing views, beliefs, or emo others.
tions; conflict can be constructive by (1)
assisting members to consider and respect Emotional contagion
other opinions, (2) generating energy and Rapid and intense escalation of excitement
investment in the group, and (3) creating a in a group, which if uncontrolled, can
variety of options for change; conflict is threaten boundaries and an individual’s
detrimental when (1) it distracts members’ sense of wellbeing, potentially leading to
attention or allows them to avoid issues in premature termination of treatment.
the group, (2) any group member feels his Fixed membership groups
or her beliefs or world views are not under Relatively small group with a set number of
stood or viewed as valid, or (3) the conflict members who stay together over a long
leads to destructive behaviors, such as period of time; people in timelimited fixed
denigration or other verbal abuse. membership groups start and stay together,
Confrontation while ongoing fixed membership groups
A form of intervention that literally means bring in new members if a vacancy occurs.
“coming face to face” or “pointing out Gestalt therapy
inconsistencies” that keep clients from Developed by Friedrich S. and Laura
facing unpleasant realities (CSAT 1999b, Perls, gestalt therapy aims to enhance
p. 10). clients’ awareness, which frees them to
Content grow in their own consciously guided ways.
Information and feelings expressed in It seeks to reestablish stalled growth pro
group; its complement is process. cesses by helping clients become aware of
feelings they have disowned but that are a
Culture genuine part of them, and recognize feelings
Integrated patterns of human behavior that and values that they think are a genuine
include the language, thoughts, communi part of them but are borrowed from other
cations, actions, customs, beliefs, values, people.
and institutions of a racial, ethnic, reli
gious, or social group (Giachello 1995; Group agreement
Office of Minority Health 2001). A contract between provider and client
stipulating the responsibilities of clients and
Ecomap, or sociogram their expectations of other group members,
A graphic that clients construct to repre the leader, and the group; group agreements
sent their important social relationships. typically specify grounds for exclusion from
group, expectations of confidentiality,
Expressive groups restrictions on physical contact, conse
Groups formed to use some kind of creative quences for returns to substance use,
activity (such as painting, dance, play ther boundaries on contact outside the group,
apy, or psychodrama) to help clients expectations for participation in group,
explore their substance abuse, its origins financial responsibilities, and procedures
and effects, and new coping options; for termination (leaving the group).
expressive groups may be especially
154 Glossary
Group dynamics clients recreate past experiences in the
Forces at work among small groups of hereandnow microcosm of the group;
interacting people; collectively, group interpersonal process groups attend more
dynamics are a complex amalgam of indi to process (how people act and talk) and
vidual personalities and actions combined less to content (what people do and say).
with the overarching properties of the
group as a whole; put another way, group Interpersonal relationship dynamics
dynamics are the collective impact of indi How people relate to one another in group
vidual members on the group and the settings and how one individual can influ
impact the group has on each individual. ence the behavior of others in group, such
as by giving and receiving feedback from
Group process each other.
How events take place in group, in contrast
to content, which is what takes place; if, for Interventions
example, a question is raised, a processori Words or actions with a therapeutic pur
ented group leader might silently note cir pose; interventions may clarify what is
cumstances such as voice quality, facial happening in group, redirect energy, stop
expression, what came before and after the unhelpful processes, or present the group
question, and how the question was direct with a choice.
ed (to the leader? the group? to an individu Intrapsychic
al? away from someone?); overall, process Relating to events occurring within the psy
concerns include (1) the impact and quality che, mind, or personality; that is, internally
of interaction among group members, (2) without reference to any external factors.
the impact of group on individuals, and (3)
the life phases of the group. Leadership skills
Include helping the group get started in a
Heterogeneous groups session, managing (though not necessarily
Groups made up of a mixture of clients eliminating) conflict between group mem
whose only similarity is the need they share bers, helping withdrawn members of the
for a particular kind of group. group become more active, and making
Homogeneous groups sure that all group members have a roughly
Groups made up of clients who are alike in equal chance to participate.
some respect other than a common sub Problemfocused groups
stance use problem; homogeneous groups Groups formed to address a particular
may include, for example, only women, problem that contributes to substance
only adolescents or elderly people, or only abuse or limits recovery options; problem
people from a certain cultural heritage. focused groups also look at the process of
IPGP problemsolving so members can generalize
Interpersonal process group psychothera their experience in group to other life areas.
py, shortened in this TIP to interpersonal Process
process groups. How members interact in the group; its
Interpersonal process groups complement is content.
Formed to use group interactions to pro Processoriented therapy
mote change and healing; such groups are An approach to group therapy that empha
used after abstinence is well established; sizes group interaction as the healing agent;
they delve into major developmental issues the role of the leader is the promotion of
that contribute to addiction and interfere interaction among group members.
with recovery; the primary interest is how
Glossary 155
Projective identification Reality therapy
Involves projecting one’s disowned Developed by William Glasser, the basic
attributes onto another person (Yalom principle of reality therapy is that we are
1995). responsible for what we choose to do.
Reality therapy focuses on solving prob
Psychodynamic emphases lems and on coping with the demands of
The dynamic interplay of psychological reality in society by making more effective
forces conceptualized using psychodynamic choices.
theories. Within an individual these forces
influence behavior, interaction with others, Redecision therapy
and emotions. Is aimed at helping people challenge them
selves to discover ways in which they per
Psychodynamic therapy, ceive themselves in victimlike roles and to
psychodynamic approach take charge of their lives by deciding for
An approach to psychological growth and themselves how they will change.
change that emphasizes the evolution and
adaptation of the psychological structure Relapse prevention groups
within an individual. Psychodynamic ther Groups formed to help clients maintain
apy often focuses on changing behavior in abstinence or minimize the impact and
the present by reexamining and revising a duration of relapse.
person’s understandings and reactions to
events in the past. Resistance to therapy
An often subconscious defense against the
Psychotherapy (or therapy) groups pain of examining one’s own behavior, per
Groups formed to reduce or eliminate sub ceptions, beliefs, and feelings; resistance
stance abuse or other problematic behav can appear in many disguises: continual
iors by changing longstanding relational claims to be too upset to work on issues in
and intrapsychic difficulties. Psycho group, missing group or coming late, or
therapy groups differ from other groups aversion to strong emotions, such as anger.
traditionally used for substance abuse Resistance is a natural part of any change
treatment, such as problemsolving or sup process, but if it is not dealt with, it
port groups, in that the group (1) has a rel impedes growth and blocks the progress of
atively longterm contract; (2) focuses more individuals and groups.
on psychodynamic issues (rather than edu
cation, support, or problem solving); (3) Revolving membership groups
begins in later stages of treatment and Somewhat larger than fixed membership
recovery; (4) tolerates the expression of groups, revolving membership groups
more emotion; and (5) stresses process over acquire new members when they become
content. ready for its services; timelimited revolv
ing membership groups keep a member for
Psychoeducational groups a specified period of time, while ongoing
Groups formed to educate clients about revolving membership groups may have
substance abuse, related behaviors, and clients who (1) stay as long as they wish, (2)
the behavioral, medical, and psychological enter a group with a repeating cycle of top
consequences of use, abuse, and dependen ics and stay until they have completed all
cy; psychoeducational groups provide the topics, or (3) attend for a set time
information important for achieving absti (either consecutively or nonconsecutively).
nence and maintaining recovery.
156 Glossary
Skills development groups front and modify deeply ingrained relation
Groups formed to bring about or improve al problems and other psychological issues.
the skills needed to achieve and maintain A client’s stage of recovery is one determi
abstinence; such skills may relate directly nant of placement.
to substance abuse (such as ways to refuse
drugs or cope with urges to use them), or Stages of treatment
they may be designed to reduce or elimi In early treatment, clients are ambivalent
nate general life problems that imperil about relinquishing substance abuse, so
recovery (such as inadequate anger man heavy emphasis is placed on drawing clients
agement or an inability to relax). into a culture of recovery and helping them
get through each day without substances.
Splitting Strong challenges to the mental and emo
A divideandconquer tactic used to come tional state are set aside until later in treat
between cotherapists (Yalom 1995). ment. In the middle stage, clients’ mental
and emotional condition improves, but they
Stages of change have an acute need for satisfying new direc
Prochaska and DiClemente’s (1984) contin tions that can fulfill the role that substance
uum that describes the stages a client abuse once played in their lives. In late
moves through to achieve lasting recovery: treatment, clients sustain earlier gains, but
precontemplation, contemplation, prepara learn to anticipate temptations and triggers
tion, action, maintenance, and recurrence for relapse. Also, the client may need to
(for definitions, see chapter 2); the stage a address issues like poor selfimage, relation
client is in helps to determine what group ship problems, shame, or trauma.
treatment models and methods are appro
priate for that person. Support groups
Groups formed to (1) develop and strength
Stages (or phases) of group en clients’ abilities to manage their own
development thinking and emotions (2) improve inter
In the beginning phase, the group is pre personal skills, (3) manage daytoday life
pared to begin its work. Tasks in this period more effectively, and (4) boost selfesteem
involve introductions, a review of the group and selfconfidence.
agreement, and the establishment of a safe
environment and healthy norms. The mid Transactional analysis
dle phase, or actual work of the group, is Is both a theory of personality and an
the time for hereandnow interactions that organized system of interactional therapy.
help clients rethink behaviors and under Its basic assumption is that people make
take changes. The end phase is a mixture of current decisions based on past premises
recognition and celebration of work done that were at one time appropriate to
and goals achieved, mourning for the loss of survival but may no longer be valid.
the attachments formed in group, and Transactional analysis emphasizes the
reorientation toward the future. cognitive, rational, and behavioral aspects
of the therapeutic process.
Stages of recovery
In early recovery, clients establish absti Transference and countertransference
nence. During this period, they are fragile Transference is a perceptual distortion in
and highly prone to relapse. In middle which the characteristics of one person are
recovery, abstinence becomes stable attributed to another; in other words,
enough so that the client can begin to work parts of past relationships are projected
on life problems. In late recovery, clients onto relationships in the present; if, for
continue working to maintain abstinence example, group member A reminds mem
and make life changes, but may also con ber B of a dour, narrowminded father,
Glossary 157
member B may transfer the attributes of 12Step programs
his father to member A and react to him in Selfhelp programs that are based on mas
group with extraordinary and irrational tering a set of steps to achieve and maintain
hostility. In a narrow sense, countertrans abstinence; they are often loosely organized
ference occurs when clients’ transference around a drug of abuse: Alcoholics
evokes (often unconscious) emotional Anonymous (alcohol), Narcotics
responses in therapists. In recent years, the Anonymous (opioids and illicit drugs),
concept has widened to include any emo Cocaine Anonymous.
tional reaction in a therapist brought on by
a client.
158 Glossary
Appendix E: Association
for Specialists in Group
Work Best Practice
Guidelines
Approved by the ASGW Executive Board, March 29, 1998
Prepared by: Lynn Rapin and Linda Keel, ASGW Ethics
Committee CoChairs
The Association for Specialists in Group Work (ASGW) is a division
of the American Counseling Association whose members are interested in
and specialize in group work. We value the creation of community;
service to our members, clients, and the profession; and leadership as a
process to facilitate the growth and development of individuals and
groups.
The Association for Specialists in Group Work recognizes the commit
ment of its members to the Code of Ethics and Standards of Practice (as
revised in 1995) of its parent organization, the American Counseling
Association (ACA), and nothing in this document shall be construed to
supplant that code. These Best Practice Guidelines are intended to clari
fy the application of the ACA Code of Ethics and Standards of Practice
to the field of group work by defining Group Workers’ responsibility
and scope of practice involving those activities, strategies, and interven
tions that are consistent and current with effective and appropriate
professional ethical and community standards. ASGW views ethical
process as being integral to group work and views Group Workers as
ethical agents. Group Workers, by their very nature in being responsible
and responsive to their group members, necessarily embrace a certain
potential for ethical vulnerability. It is incumbent upon Group Workers
to give considerable attention to the intent and context of their actions
because the attempts of Group Workers to influence human behavior
through group work always have ethical implications. These Best
Practice Guidelines address Group Workers’ responsibilities in planning,
performing, and processing groups.
159
Section A: Best Practice in potential group leaders regarding group
work, client attitudes regarding group work,
Planning and multicultural and diversity considera
tions. Group Workers use this information as
A.1. Professional Context and the basis for making decisions related to their
Regulatory Requirements group practice, or to the implementation of
Group Workers actively know, understand, groups for which they have supervisory, eval
and apply the ACA Code of Ethics and uation, or oversight responsibilities.
Standards of Best Practice, the ASGW
Professional Standards for the Training of
Group Workers, these ASGW Best Practice A.4. Program Development and
Guidelines, the ASGW diversity competencies, Evaluation
the ACA Multicultural Guidelines, relevant a. Group Workers identify the type(s) of
State laws, accreditation requirements, rele group(s) to be offered and how they relate to
vant National Board for Certified Counselors community needs.
Codes and Standards, their organizations’
b. Group Workers concisely state in writing the
standards, and insurance requirements impact
purpose and goals of the group. Group
ing the practice of group work.
Workers also identify the role of the group
members in influencing or determining the
A.2. Scope of Practice and group goals.
Conceptual Framework
Group Workers define the scope of practice c. Group Workers set fees consistent with the
related to the core and specialization compe organization’s fee schedule, taking into con
tencies defined in the ASGW Training sideration the financial status and locality of
Standards. Group Workers are aware of per prospective group members.
sonal strengths and weaknesses in leading d. Group Workers choose techniques and a
groups. Group Workers develop and are able leadership style appropriate to the type(s) of
to articulate a general conceptual framework to group(s) being offered.
guide practice and a rationale for use of tech
niques that are to be used. Group Workers e. Group Workers have an evaluation plan con
limit their practice to those areas for which sistent with regulatory, organization and
they meet the training criteria established by insurance requirements, where appropriate.
the ASGW Training Standards.
f. Group Workers take into consideration cur
rent professional guidelines when using tech
A.3. Assessment nology, including but not limited to Internet
a. Assessment of self. Group Workers actively communication.
assess their knowledge and skills related to
the specific group(s) offered. Group Workers
assess their values, beliefs, and theoretical A.5. Resources
orientation and how these impact upon the Group Workers coordinate resources related to
group, particularly when working with a the kind of group(s) and group activities to be
diverse and multicultural population. provided, such as: adequate funding; the
appropriateness and availability of a trained co
b. Ecological assessment. Group Workers leader; space and privacy requirements for the
assess community needs, agency or organiza type(s) of group(s) being offered; marketing and
tion resources, sponsoring organization mis recruiting; and appropriate collaboration with
sion, staff competency, attitudes regarding other community agencies and organizations.
group work, professional training levels of
160 Association for Specialists in Group Work Best Practice Guidelines
A.6. Professional Disclosure insurance usage). Group Workers have the
Statement responsibility to inform all group partici
Group Workers have a professional disclosure pants of the need for confidentiality, poten
statement which includes information on confi tial consequences of breaching confidentiality
dentiality and exceptions to confidentiality, the and that legal privilege does not apply to
oretical orientation, information on the nature, group discussions (unless provided by
purpose(s) and goals of the group, the group State statute).
services that can be provided, the role and
responsibility of group members and leaders, A.8. Professional Development
qualifications to conduct the specific group(s), Group Workers recognize that professional
specific licenses, certifications and professional growth is a continuous, ongoing, developmental
affiliations, and address of licensing/credential process throughout their career.
ing body.
a. Group Workers remain current and increase
knowledge and skill competencies through
A.7. Group and Member
activities such as continuing education, pro
Preparation
fessional supervision, and participation in
a. Group Workers screen prospective group personal and professional development
members if appropriate to the type of group activities.
being offered. When selection of group mem
bers is appropriate, Group Workers identify b. Group Workers seek consultation and/or
group members whose needs and goals are supervision regarding ethical concerns that
compatible with the goals of the group. interfere with effective functioning as a
group leader. Supervisors have the responsi
b. Group Workers facilitate informed consent. bility to keep abreast of consultation, group
Group Workers provide in oral and written theory, process, and adhere to related ethi
form to prospective members (when appro cal guidelines.
priate to group type): the professional dis
closure statement; group purpose and goals; c. Group Workers seek appropriate profession
group participation expectations including al assistance for their own personal problems
voluntary and involuntary membership; role or conflicts that are likely to impair their
expectations of members and leader(s); poli professional judgment or work performance.
cies related to entering and exiting the
group; policies governing substance use; d. Group Workers seek consultation and
policies and procedures governing mandated supervision to ensure appropriate practice
groups (where relevant); documentation whenever working with a group for which all
requirements; disclosure of information to knowledge and skill competencies have not
others; implications of outofgroup contact been achieved.
or involvement among members; procedures
e. Group Workers keep abreast of group
for consultation between group leader(s) and
research and development.
group member(s); fees and time parameters;
and potential impacts of group participation.
A.9. Trends and Technological
c. Group Workers obtain the appropriate con Changes
sent forms for work with minors and other Group Workers are aware of and responsive to
dependent group members. technological changes as they affect society and
the profession. These include but are not limit
d. Group Workers define confidentiality and
ed to changes in mental health delivery sys
its limits (for example, legal and ethical
tems; legislative and insurance industry
exceptions and expectations, waivers implicit
reforms; shifting population demographics and
with treatment plans, documentation and
Association for Specialists in Group Work Best Practice Guidelines 161
client needs; and technological advances in B.5. Meaning
Internet and other communication and delivery Group Workers assist members in generating
systems. Group Workers adhere to ethical meaning from the group experience.
guidelines related to the use of developing
technologies.
B.6. Collaboration
Group Workers assist members in developing
Section B: Best Practice in individual goals and respect group members as
Performing coequal partners in the group experience.
B.1. Self Knowledge
B.7. Evaluation
Group Workers are aware of and monitor their
Group Workers include evaluation (both for
strengths and weaknesses and the effects these
mal and informal) between sessions and at the
have on group members.
conclusion of the group.
B.2. Group Competencies
B.8. Diversity
Group Workers have a basic knowledge of
Group Workers practice with broad sensitivity
groups and the principles of group dynamics,
to client differences including but not limited to
and are able to perform the core group compe
ethnic, gender, religious, sexual, psychological
tencies, as described in the ASGW Professional
maturity, economic class, family history, physi
Standards for the Training of Group Workers.
cal characteristics or limitations, and geograph
Additionally, Group Workers have adequate
ic location. Group Workers continuously seek
understanding and skill in any group specialty
information regarding the cultural issues of the
area chosen for practice (psychotherapy, coun
diverse population with whom they are working
seling, task, psychoeducation, as described in
both by interaction with participants and from
the ASGW Training Standards).
using outside resources.
B.3. Group Plan Adaptation
B.9. Ethical Surveillance
a. Group Workers apply and modify knowl
Group Workers employ an appropriate ethical
edge, skills, and techniques appropriate to
decisionmaking model in responding to ethical
group type and stage, and to the unique
challenges and issues and in determining cours
needs of various cultural and ethnic groups.
es of action and behavior for self and group
b. Group Workers monitor the group’s members. In addition, Group Workers employ
progress toward the group goals and plan. applicable standards as promulgated by ACA,
ASGW, or other appropriate professional orga
c. Group Workers clearly define and maintain nizations.
ethical, professional, and social relationship
boundaries with group members as appro
priate to their role in the organization and
Section C: Best Practice in
the type of group being offered. Group Processing
C.1. Processing Schedule
B.4. Therapeutic Conditions and
Dynamics Group Workers process the workings of the
group with themselves, group members, super
Group Workers understand and are able to
visors, or other colleagues, as appropriate.
implement appropriate models of group devel
This may include assessing progress on group
opment, process observation, and therapeutic
and member goals, leader behaviors and tech
conditions.
niques, group dynamics and interventions,
162 Association for Specialists in Group Work Best Practice Guidelines
developing understanding, and acceptance of professional research literature. Group
meaning. Processing may occur both within Workers follow all applicable policies and
sessions and before and after each session, at standards in using group material for
time of termination, and later follow up, as research and reports.
appropriate.
b. Group Workers conduct followup contact
with group members, as appropriate, to
C.2. Reflective Practice assess outcomes or when requested by a
Group Workers attend to opportunities to syn group member(s).
thesize theory and practice and to incorporate
learning outcomes into ongoing groups. Group
Workers attend to session dynamics of mem
C.4. Consultation and Training
bers and their interactions and also attend to
With Other Organizations
the relationship between session dynamics and Group Workers provide consultation and
leader values, cognition, and affect. training to organizations in and out of their
setting, when appropriate. Group Workers
seek out consultation as needed with competent
C.3. Evaluation and FollowUp professional persons knowledgeable about
a. Group Workers evaluate process and out group work.
comes. Results are used for ongoing program
planning, improvement and revisions of Source: ASGW 1998. Reprinted with
current group, and/or to contribute to permission.
Association for Specialists in Group Work Best Practice Guidelines 163
Appendix F:
Resource Panel
Note: The information given indicates each participant's affiliation during the time the panel was
convened and may no longer reflect the individual's current affiliation.
Candace Baker Edwin M. Craft, Dr.P.H.
Clinical Affairs Manager KAP Alternate Project Officer
Lesbian, Gay, Bisexual, and Transgender Office of Evaluation, Scientific Analysis
Special Interest Group and Synthesis
National Association of Alcohol and Drug Center for Substance Abuse Treatment
Abuse Counselors Rockville, Maryland
Alexandria, Virginia
Christina Currier
Nancy Bateman, LCSWC, CAC Public Health Analyst
Senior Staff Associate Office of Evaluation, Scientific Analysis
Division of Professional Development and and Synthesis
Advocacy Center for Substance Abuse Treatment
National Association of Social Workers Rockville, Maryland
Washington, DC
Dorynne Czechowicz, M.D.
Carole Chrvala, Ph.D. Medical Officer
Senior Program Officer Treatment Development Branch
Board on Neuroscience and Behavioral Division of Treatment Research and
Health Development
Institute of Medicine National Institute on Drug Abuse
Washington, DC Bethesda, Maryland
Peggy Clark, M.S.W., M.P.A. Jennifer Fiedelholtz
Center for Medicaid and State Operations Public Health Analyst
Centers for Medicare and Medicaid Office of Policy and Program Coordination
Services Substance Abuse and Mental Health
Baltimore, Maryland Services Administration
Rockville, Maryland
Sandra M. Clunies, M.S., ICADC
Derwood, Maryland Hendree E. Jones, Ph.D.
Assistant Professor
Cathi Coridan, M.A. Department of Psychiatry and Behavioral
Senior Director for Substance Abuse Sciences
Programs and Policy Johns Hopkins University Center
National Mental Health Association Baltimore, Maryland
Alexandria, Virginia
165
Edith Jungblut Stanley Smith, M.A., TEP
Project Officer Clinical Director
Center for Substance Abuse Treatment MidAtlantic Chapter
Rockville, Maryland American Society of Group Psychotherapy
and Psychodrama
Tom Leibfried, M.P.A. c/o Adolescence and Family Growth
Vice President of Government Relations Center, Inc.
National Council for Community Springfield, Virginia
Behavioral Healthcare
Rockville, Maryland
Richard T. Suchinsky, M.D.
Associate Chief for Addictive Disorders
Emeline Otey, Ph.D. and Psychiatric Rehabilitation
Program Official Mental Health and Behavioral Sciences
Adult Psychotherapy and Prevention Services
Resource Branch Department of Veterans Affairs
National Institute of Mental Health Washington, DC
Bethesda, Maryland
Jan Towers, Ph.D., CRNP
Anne Pritchett, M.P.A. Director
Policy Analyst Health Policy
Executive Office of the President American Academy of Nurse Practitioners
Office of National Drug Control Policy Washington, DC
Washington, DC
Elizabeth Rahdert, Ph.D.
Program Administrator
National Institute on Drug Abuse
Bethesda, Maryland
166 Resource Panel
Appendix G: Cultural
Competency and Diversity
Network Participants
Note: The information given indicates each participant's affiliation during the time the network
was convened and may no longer reflect the individual's current affiliation.
Elmore T. Briggs, CCDC, NCAC II Ford H. Kuramoto, D.S.W.
Program Manager National Director
Adolescent Recovery Center National Asian Pacific American Families
Vanguard Services, Unlimited Against Substance Abuse
Arlington, Virginia Los Angeles, California
African American Work Group Asian and Pacific Islanders Work Group
Maxine F. Carpenter, M.S. Frank Lemus, Jr., M.A.
President/Chief Executive Officer Clinical Director
McKinley Group, Inc. SageWind (Oikos, Inc.)
Atlanta, Georgia Reno, Nevada
African American Work Group Hispanic/Latino Workgroup
Magdalen Chang TingFun May Lai, M.S.W., CSW, CASAC
Center Manager Director
Bill Pone Memorial Unit Chinatown Alcoholism Center
Haight Ashbury Free Clinic HamiltonMadison House
San Francisco, California New York, New York
Asian and Pacific Islanders Work Group Asian and Pacific Islanders Work Group
Marty Estrada Tam K. Nguyen, M.D., LMSW, CCJS, DVC,
Career Services Specialist MAC
General Relief Team President
Ventura Intake and Eligibility Center Employee & Family Resources
Ventura, California Polk City, Iowa
Hispanic/Latino Workgroup Asian and Pacific Islanders Work Group
Adelaida Hernandez, M.S., LCDC Rick Rodriguez
M.U.H.E.R.E.S. Program Director Manager/Counselor
S.C.A.N., Inc. Services United
Laredo, Texas Santa Paula, California
Hispanic/Latino Workgroup Hispanic/Latino Work Group
167
Candace Shelton, M.S., CADAC Antony P. Stephen, Ph.D.
Clinical Director Executive Director
Native American Connections, Inc. Mental Health & Behavioral Sciences
Tucson, Arizona New Jersey Asian American Association
Lesbian, Gay, Bisexual, and Transgender for Human Services, Inc.
Workgroup Elizabeth, New Jersey
Asian and Pacific Islanders Workgroup
Mariela C. Shirley, Ph.D.
Assistant Professor Ednita Wright, Ph.D., M.S.W., CSW
Department of Psychology Independent Consultant/Counselor
University of North Carolina at Therapist
Wilmington
Garnett Health Center, Counseling
Wilmington, North Carolina
Psychological Service
Hispanic/Latino Workgroup
Ithaca, New York
Lesbian, Gay, Bisexual, and Transgender
Workgroup
168 Cultural Competency and Diversity Network Participants
Appendix H: Field Reviewers
Note: The information given indicates each participant's affiliation during the time the review was
conducted and may no longer reflect the individual's current affiliation.
Rosie AndersonHarper David W. Brook, M.D., CGP
Mental Health Manager/Treatment Department of Community and Preventive
Coordinator Medicine
Division of Alcohol and Drug Abuse Mount Sinai Medical Center
Missouri Department of Mental Health New York, New York
Jefferson City, Missouri
Nina W. Brown, Ed.D.
Nancy Bateman, LCSWC, CAC President
Senior Staff Associate MidAtlantic Group Psychotherapy Society
Division of Professional Development and Virginia Beach, Virginia
Advocacy
National Association of Social Workers Barry S. Brown, Ph.D.
Washington, DC Professor (Adjunct)
University of North Carolina at
Michele W. Beck, M.S.W., LSBCAC, ICRC Wilmington
Acting Director of Treatment Carolina Beach, North Carolina
Office for Addictive Disorders
State of Louisiana Maxine F. Carpenter, M.S.
Baton Rouge, Louisiana President/Chief Executive Officer
McKinley Group, Inc.
Marion A. Becker, R.N., Ph.D. Atlanta, Georgia
Associate Professor
Department of Community Health Bruce Carruth, Ph.D., LCSW
Louis de la Parte Florida Mental Health Private Practice
Institute Boulder, Colorado
Tampa, Florida
Annabelle Casas, B.A.
Janice S. Bennett, M.S., CSAC Family Drug Court Coordinator
Program Coordinator 65th District Court Family Drug Court
Hawaii Drug Court Program Program
Honolulu, Hawaii El Paso, Texas
Elmore T. Briggs, CCDC, NCAC II Magdalen Chang
Program Manager Center Manager
Adolescent Recovery Center Bill Pone Memorial Unit
Vanguard Services Unlimited Haight Ashbury Free Clinic
Arlington, Virginia San Francisco, California
169
Sharon D. Chappelle, Ph.D., M.S.W., LCSW Kathleen J. Farkas, Ph.D., LISW, ASCW
President/Chief Executive Officer Associate Professor
Chappelle Consulting and Training Case Western Reserve University
Services, Inc.
Cleveland, Ohio
Middletown, Connecticut
Saul Feldman, Ph.D.
David E. Cooper, Ph.D. Chairman/Chief Executive Officer
Psychologist/Psychoanalyst United Behavioral Health
Former Director of the Lodge Day San Francisco, California
Program
Chestnut Lodge Hospital
Philip J. Flores, Ph.D., COP, FAGPA
Private Practice
Adjunct Clinical Supervisor
Chevy Chase, Maryland
Department of Psychology
Georgia State University
Cathi Coridan, M.A. Atlanta, Georgia
Senior Director for Substance Abuse
Programs and Policy Marilyn Joan Freimuth, Ph.D.
National Mental Health Association Bedford, New York
Alexandria, Virginia
Byron N. Fujita, Ph.D.
Eric Denner Senior Psychologist
Clinical Social Worker Clackamas County Mental Health Center
San Francisco General Hospital Oregon City, Oregon
San Francisco, California
Michael Galer, D.B.A., M.B.A., M.F.A.
Janice M. Dyehouse, Ph.D., R.N., M.S.N. Westminster, Massachusetts
Professor and Department Head
College of Nursing Charles Garvin, Ph.D.
University of Cincinnati Professor of Social Work
Cincinnati, Ohio School of Social Work
University of Michigan
Marty Estrada Ann Arbor, Michigan
Career Services Specialist General Relief
Team Jeffrey M. Georgi, M.Div., CGP, CSAC,
Ventura Intake and Eligibility Center LPC, CCS
Ventura, California Clinical Director
Department of Behavioral Science
Arthur C. Evans, Ph.D. Duke School of Nursing and Duke
Deputy Commissioner University Medical Center
Connecticut Department of Mental Health Senior Clinician
and Addiction Services
Duke Addictions Program
Hartford, Connecticut
Duke University Medical Center
Durham, North Carolina
170 Field Reviewers
Mary M. Gillespie, Psy.D., CASAC Margaret Mattson, Ph.D.
Psychologist Staff Collaborator
Private Practice National Institute on Alcohol Abuse and
Saratoga Springs, New York Alcoholism
Bethesda, Maryland
Paolo Giudici, LPCC, LADAC
Clinical Director Robert Meyer
AYUDANTES, INC. Chief Executive Officer/President
Santa Fe, New Mexico Rainbow Recovery Center, Inc.
Des Moines, Iowa
Paula R. James, M.A.
Department of Psychiatry Stacia Murphy
Community Support Services President
Bellevue Hospital Center National Council on Alcoholism and Drug
New York, New York Dependence, Inc.
New York, New York
Kathryn P. Jett
Director Ethan Nebelkopf, Ph.D., MFCC
California Department of Alcohol and Clinic Director
Drug Programs
Family and Child Guidance Center
Sacramento, California
Native American Health Center
Oakland, California
Michael W. Kirby, Jr., Ph.D.
Chief Executive Officer Thomas E. Nightingale
Arapahoe House, Inc. Director
Thornton, Colorado Bureau of Addiction Treatment Centers
New York State Office of Alcoholism and
Ford H. Kuramoto, D.S.W. Substance Abuse Services
National Director Albany, New York
National Asian Pacific American Families
Against Substance Abuse
Marlene O’Connell, R.N., M.S.N., LCPC,
Los Angeles, California
NCC, CCDC
Manager
TingFun May Lai, M.S.W., CSW, CASAC Behavioral Health Services Benefits
Director Healthcare
Chinatown Alcoholism Services Great Falls, Montana
HamiltonMadison House
New York, New York Gwen M. Olitsky, M.S.
Chief Executive Officer
Marlana Lalli The SelfHelp Institute for Training and
Program Manager Therapy
Ft. Des Moines OWI Program Lansdale, Pennsylvania
Des Moines, Iowa
Jerry M. Owens, M.S., LMHC, LMFT
Barry Levy Wadle and Associates
Executive Director Des Moines, Iowa
Community Resource Council
Long Beach, California
Field Reviewers 171
Thomas A. Peltz, M.Ed., LMHC, CAS Jocelyn Thevenote, B.A.
Therapist Outreach Director
Private Practice Office for Addictive Disorders
Beverly Farms, Massachusetts Pineville Alexandria Clinic
Pineville, Louisiana
Nancy A. Piotrowski, Ph.D.
Associate Scientist Ernie Turner
Alcohol Research Group Director
Berkeley, California Division of Alcoholism and Drug Abuse
Alaska Department of Health and Social
Jeffrey David Roth, M.D., FASAM, FAGPA Services
Independent Consultant Juneau, Alaska
Chicago, Illinois
Judy Tyson, Ph.D., CGP
Marvena A. Simmonds, M.P.A. MidAtlantic Group Psychotherapy Society
Public Health Advisor Bethesda, Maryland
Division of State and Community
Assistance Karen Urbany
Center for Substance Abuse Treatment Public Health Advisor
Rockville, Maryland Treatment and Systems Improvement
Branch
Darren C. Skinner, Ph.D., LSW, CAC Division of Practice and Systems
Director Development
Gaudenzia, Inc. Center for Substance Abuse Treatment
Gaudenzia House West Chester Rockville, Maryland
West Chester, Pennsylvania
Marsha Lee Vannicelli, Ph.D., FAGPA
Antony P. Stephen, Ph.D. Associate Clinical Professor
Executive Director Department of Psychiatry
Mental Health and Behavioral Sciences Harvard Medical School
New Jersey Asian American Association Belmont, Massachusetts
for Human Services, Inc.
Elizabeth, New Jersey
Ralph Varela, M.S.W.
Chief Executive Officer
Richard T. Suchinsky, M.D. Pinal Hispanic Council
Associate Chief for Addictive Disorders Eloy, Arizona
and Psychiatric Rehabilitation
Mental Health and Behavioral Sciences Albert J. Villapiano, Ed.D.
Services Director of Substance Abuse Product Line
Department of Veterans Affairs Inflexxion
Washington, DC Newton, Massachusetts
Judith S. Tellerman, Ph.D., M.Ed., MAT, Iris Wilkinson, Ed.D.
CGP
Associate Professor
Assistant Clinical Professor
Human Services Department
College of Medicine
School of Applied Studies
University of Illinois
Washburn University
Chicago, Illinois
Topeka, Kansas
172 Field Reviewers
William H. Williams, Jr., M.A., LCADC Janet Zwick
Substance Abuse Program Manager Deputy Director
Clinical Plans and Management Division of Substance Abuse and Health
Bureau of Medicine and Surgery Promotion
Department of Navy Iowa Department of Public Health
Washington, DC Des Moines, Iowa
Ednita Wright, Ph.D., M.S.W., CSW
Independent Consultant/Counselor
Therapist
Garnett Health Center, Counseling
Psychological Service
Cornell University
Ithaca, New York
Field Reviewers 173
Appendix I:
Acknowledgments
Numerous people contributed to the development of this TIP, including
the TIP Consensus Panel (see page ix), the KAP Expert Panel and
Federal Government Participants (see page xi), the Federal Resource
Panel (see Appendix F), the Cultural Competency and Diversity
Network Participants (see Appendix G), and the TIP Field Reviewers
(see Appendix H).
This publication was produced under KAP, a Joint Venture of The CDM
Group, Inc. (CDM), and JBS International, Inc. (JBS), for the
Substance Abuse and Mental Health Services Administration, Center for
Substance Abuse Treatment.
Christina Currier served as the SAMHSA TIPs Task Leader. Rose M.
Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP
Executive Deputy Project Director. Shel Weinberg, Ph.D., served as the
CDM KAP Senior Research/Applied Psychologist. Other CDM KAP per
sonnel included Raquel Witkin, M.S., Deputy Project Manager; Susan
Kimner, Managing Editor; James Girsch, Ph.D., Editor/Writer; Michelle
Myers, Quality Assurance Editor; and Sonja Easley, Editorial Assistant.
In addition, Sandra Clunies, M.S., I.C.A.D.C., served as Content
Advisor. Jonathan Max Gilbert, M.A., Susan Hills, Ph.D., and Mary
Lou Rife, Ph.D., were writers.
Acknowledgments 175
Index
Notes: Because the entire volume is about substance abuse treatment and group therapy, the
use of these terms as entry points has been minimized in this index. Reference locators for
information contained in figures appear in italics.
12Step groups, 111–113 American Psychological Association, 127
as different from interpersonal process American Society of Addiction Medicine, 127.
groups, 4, 6–7, 63 See also ASAM PPC2R
42 C.F.R. Part 2, 31, 70, 108–109, 110, 130 anger reduction, 19
anxiety alleviation, 15, 20, 63, 120
A APA. See American Psychiatric Association,
AA. See Alcoholics Anonymous American Psychological Association
AASWG. See Association for the ASAM PPC2R, 42–43
Advancement of Social Work with Groups ASGW. See Association for Specialists in
action stage, overview of, 10 Group Work
active listening, 92 assessment, 38–40
adaptation of trainee skills, 135
of group therapy to substance abuse Association for the Advancement of Social
treatment, 7–8 Work with Groups, 127
of instruction to learning style, 15 Association for Specialists in Group Work,
Addiction Technology Transfer Centers, 131 99, 128
adolescents, 41 best practice guidelines, 159–163
adult patient placement criteria, 149–150 Association for Supervision and Curriculum
Development, 15
advantages of group treatment, 3–6
attachment theory, 83
affect, 86, 98–99, 102, 104–105
ATTCs. See Addiction Technology Transfer
Agazarian SystemsCentered Therapy for Centers
Group, 28
AGPA. See American Group Psychotherapy B
Association beginning phase of group, 72–76
agreements, group, 68–69, 69, 71, 73, 97, behavior modeling by leaders, 96
151–152 benefits of groups, 1
A.K. Rice Institute, 130 best practice guidelines, 159–163
Alcoholics Anonymous, 6–7, 63, 112 Bion’s primary assumption groups, 28
American Group Psychotherapy Association, biopsychosocial issues, 111–114
126–127
boredom, group leader, 17
American Psychiatric Association, 127
boundaries, 100–101, 103, 118
Index 177
C confrontation, 6, 86–87, 106–107
characteristics of group models, 13
constancy, 92
cognitive–behavioral groups, 18–19
contact outside the group, 71–72
communal and culturally specific
contemplation stage
groups, 32
overview of, 10
expressive groups, 34
and psychoeducational groups, 12, 14
fixed and revolving membership
cotherapy, 96–97
groups, 62
countertransference, 107–108
problemfocused groups, 35
cultural sensitivity, 33, 98
psychoeducational groups, 13–14
culture
relapse prevention groups, 30
definitions of, 45
skills development groups, 16
of recovery, 81, 87
support groups, 20–21
resources on, 48
client
D
defensive features, 7
defensive features of clients, 7
not suited for group, 39–40, 118
disruptive behavior, 117–118
motivation, 65, 100
distance learning, 131, 132
retention, 64–66
diversity, 44–48
client placement, 37, 96
diversity wheel, 46
based on readiness for change, 44
dual relationships, 99–100
cognitive–behavioral groups, 3
characteristics of, 18–19
E
leadership skills and styles, 19
early recovery stage, 43, 80–85
purpose of, 18
ecomap, 38
techniques used in, 19
emotionality, 86, 98–99, 102, 104–105
cognitive capacity, 85
empathy
cognitive restructuring, 18
of group members, 64
cohesion, 73–74, 82
of leaders, 85, 93–94
communal and culturally specific treatment
end phase of group, 76–78
groups, 10, 31–34
enmeshment, 98
characteristics of, 32
ethical issues, 97–98
leadership characteristics and styles,
ethnicity, 47, 48
32–33
matching client and counselor, 55–56
purpose of, 32
etiologies of dependency, 18
techniques used in, 34
exclusion from group, 69
communication among group members, 105
experiential learning, 129–130, 133
confidentiality, 31, 41, 70, 108–109, 110, 130
experiential pretraining, 65
conflict, 48, 57, 74, 97, 99, 115–116
expressive groups, 10, 34–35, 130
178 Index
F Institute of the American Group
faith in a group setting, 114
Psychotherapy Association, 125
families and psychoeducational groups, 12
integrating care, 114–115
Family Care Program of the Duke Addictions
Interactional Model, 25
Program, The, 66
interpersonal dynamics, 23
feedback, 17, 76
interpersonal process groups, 3, 22–25
financial responsibility, 72
characteristics of, 24
fixed membership groups, 60, 62
as different from selfhelp groups, 4–5
focal conflict model, 28
leadership skills and styles, 24–25
Foundation Center, 136
purpose of, 22–23
FRAMES, 100
techniques used in, 25
Freudian psychoanalysis, 22–23
theoretical approaches, 22–23
funding for training programs, 136
Interpersonal Process Group Psychotherapy,
24
G
interpersonally focused groups, 27–28, 28
genderspecific groups, 40
interventions, 25–29, 105–107, 111
groupasawhole
interviews, pregroup, 63
dynamics, 23
intrapsychic dynamics, 23
focused groups, 28–29, 29
IPGP. See Interpersonal Process Group
group
Psychotherapy
advantages of, 3–6
K
agreements, 68–69, 69, 71, 73, 97,
151–152 Kwanzaa, 32
benefits of, 1
L
cohesion, 73–74, 82
late recovery/maintenance stage, 44, 88–89
contact outside of, 71–72 leader
exclusion from, 69
avoiding a leadercentered group, 106
influence of, 1–2 boredom, 17
model characteristics, 13, 13–14, 16
personal qualities of, 92–94
stability, 41–42 selfassessment for cultural issues, 49,
types not covered, 3
50–52
types related to models, 11
who is in recovery, 125, 126
guidelines to evaluating leader bias and prej
leadership
udice, 49
cognitive–behavioral group, 19
H communal and culturally specific
group, 32–33
hope as a therapeutic factor, 82
early treatment, 84–85
I
expressive group, 34–35
impulse control, 41
interpersonal process group, 24–25
inappropriate placement of clients, 39–40
latestage treatment, 89
individually focused groups, 26–27, 27
middlestage treatment, 86–88
Index 179
problemfocused group, 36
NMHIC. See National Mental Health
psychoeducational group, 14–15
Information Center
relapse prevention group, 31
norms, 74–75
skills development group, 16–17
P
support group, 20–21
participant feedback, 17, 76
levels of care, ASAM, 42
peer support, 3
life issues, 113–114
physical contact, 70, 103–104
listening skills, 92
placement considerations, 37, 40–43, 96
M for adolescents, 41
maintenance stage, overview of, 10
criteria, 42–43
matching client and counselor ethnicity,
and cultural issues, 47, 52–53, 54
55–56
for women, 40–41
middle phase of group, 76
posttraumatic stress disorder, 18–19
middle recovery stage, 44, 85–88
precontemplation stage
models related to group types, 11
overview of, 10
Modern Analytic Approach, 27
and psychoeducational groups, 12, 14
moodaltering substances, 70–71
pregroup interviews, 63
motivation, client, 65, 100
premature termination, 72
motivational interviews, 65
forestalling, 65, 89
N preparation stage, overview of, 10
NAADAC. See National Association of
preparing clients for group, 63–64
Alcohol and Drug Abuse Counselors
pretreatment techniques, 65
NABSW. See National Association of Black
problemfocused groups, 35
Social Workers
problemsolving exercises, 15
NASW. See National Association of Social
psychodynamics, 23
Workers
psychoeducational groups, 9, 12
National Association of Alcohol and Drug
characteristics of, 13–14
Abuse Counselors, 128, 131
leadership skills and styles of, 14–15
National Association of Black Social Workers,
128
purpose of, 12
National Association of Social Workers, 128
techniques used in, 15–16
National Clearinghouse for Alcohol and Drug
psychological emergencies, 119–120
Information, 129
PTSD. See posttraumatic stress disorder
National Mental Health Information Center,
Q
129
qualities needed in a group leader, 92–94
National Registry of Certified Group
Psychotherapists, 128–129
R
NCADI. See National Clearinghouse for
Alcohol and Drug Information
recurrence stage, overview of, 10
neuropsychological issues, 16
refusal skills, 16
180 Index
relapse, 102 overview of, 10
relapse prevention groups, 10, 29–31
stages of recovery, 43–44, 80
characteristics of, 30
subgroups, 117
leadership skills and styles, 31
supervision, 125, 131, 134–135
purpose of, 30
support groups, 3, 12, 20
techniques used in, 31
characteristics of, 20–21
resistance, 20, 81, 100, 108
as different from interpersonal process
retention of clients in group, 64–66
groups, 20
revolving membership groups, 60–61, 62
leadership skills and styles, 21–22
role
purpose of, 20
induction, 65
techniques used in, 22
flexibility, 99
T
playing, 15, 26
Tavistock’s GroupasaWhole, 28
S techniques used
safety, 101–104
in cognitive–behavioral groups, 19–20
SageWind, 33, 67, 68
in communal and culturally specific
treatment groups, 34
samesex groups, 40
in expressive groups, 35
scapegoating, 55, 99, 101, 116
in interpersonal process groups, 25
selfdisclosure, 96
in problemfocused groups, 36
selfhelp groups, 111–112
in psychoeducational groups, 15–16
as different from group therapy in
general, 63
in relapse prevention groups, 31
as different from interpersonal process
in skills development groups, 17
groups, 4–5
in support groups, 22
as different from support groups, 20
termination, 72, 76–78
sensitivity training, 27
Tgroups, 27
shame, 74, 94, 95, 101
theoretical approaches, 10–11, 27, 28
silence, 118–119
therapeutic groups, definition, 2
skills development groups, 3
therapeutic factors
characteristics of, 16
in early recovery, 81–84
leadership skills and styles, 16–17
in late recovery, 88–89
purpose of, 16
in middle recovery, 85–86
techniques used in, 17
therapeutic services, 2
smoking cessation, 30
therapeutic styles of leaders, 94–96
spirituality, 114
time as a factor in recovery, 8
stability of groups, 41–42
TIPs cited
stages of change, 42, 80, 100
Brief Interventions and Brief Therapies
and client placement, 44
for Substance Abuse Treatment
(TIP 34), 17, 26, 30, 36
Index 181
Enhancing Motivation for Change in
development), 41
Substance Abuse Treatment (TIP 35),
Substance Abuse Treatment and Domestic
42, 100
Violence (TIP 25), 110
Guide to Substance Abuse Services for
Substance Use Disorder Treatment for
Primary Care Clinicians (TIP 24),
People With Physical and Cognitive
A, 124
Disabilities (TIP 29), 14, 32
Improving Cultural Competence in
training and education, 6–7, 99, 124–126,
Substance Abuse Treatment (in
129–130
development), 32, 56
funding for, 136
Integrating Substance Abuse Treatment
transference, 107–108
and Vocational Services (TIP 38), 43
treatment criteria, ASAM, 42–43
Intensive Outpatient Treatment for
Alcohol and Other Drug Abuse
U
(TIP 8), 110
universality as a therapeutic factor, 82, 86
Screening and Assessing Adolescents for
Substance Use Disorders (TIP 31),
V
124
vicarious pretraining, 65
Simple Screening Instruments for
W
Outreach for Alcohol and Other
women, and placement considerations, 40–41
Drug Abuse and Infectious
Diseases (TIP 11), 124
wraparound services, 66
Substance Abuse Treatment: Addressing
the Specific Needs of Women (in
182 Index
SAMHSA TIPs and Publications Based on TIPs
What Is a TIP?
Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers,
program managers, policymakers, and other Federal and nonFederal experts to reach consensus on stateoftheart treatment practices. TIPs
are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)
to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.
Ordering Information
Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call
1877SAMHSA7 (18777264727) (English and Español).
TIP 1 State Methadone Treatment Guidelines—Replaced by TIP 13 Role and Current Status of Patient Placement
TIP 43 Criteria in the Treatment of Substance Use
Disorders
TIP 2 Pregnant, Substance-Using Women—Replaced by Quick Guide for Clinicians
TIP 51
Quick Guide for Administrators
TIP 3 Screening and Assessment of Alcohol- and Other KAP Keys for Clinicians
Drug-Abusing Adolescents—Replaced by TIP 31
TIP 14 Developing State Outcomes Monitoring Systems for
TIP 4 Guidelines for the Treatment of Alcohol- and Other Alcohol and Other Drug Abuse Treatment
Drug-Abusing Adolescents—Replaced by TIP 32
TIP 15 Treatment for HIV-Infected Alcohol and Other Drug
TIP 5 Improving Treatment for Drug-Exposed Infants Abusers—Replaced by TIP 37
TIP 6 Screening for Infectious Diseases Among Substance TIP 16 Alcohol and Other Drug Screening of Hospitalized
Abusers—Archived Trauma Patients
Quick Guide for Clinicians
TIP 7 Screening and Assessment for Alcohol and Other
Drug Abuse Among Adults in the Criminal Justice
æ KAP Keys for Clinicians
System—Replaced by TIP 44
183
TIP 22 LAAM in the Treatment of Opiate Addiction— TIP 31 Screening and Assessing Adolescents for Substance
Replaced by TIP 43 Use Disorders
See companion products for TIP 32.
TIP 23 Treatment Drug Courts: Integrating Substance Abuse
Treatment With Legal Case Processing TIP 32 Treatment of Adolescents With Substance Use
æ
Quick Guide for Administrators Disorders
Quick Guide for Clinicians
KAP Keys for Clinicians KAP Keys for Clinicians
TIP 25 Substance Abuse Treatment and Domestic Violence TIP 34 Brief Interventions and Brief Therapies for Substance
Linking Substance Abuse Treatment and Domestic Abuse
Violence Services: A Guide for Treatment Providers Quick Guide for Clinicians
Linking Substance Abuse Treatment and Domestic KAP Keys for Clinicians
Violence Services: A Guide for Administrators
Quick Guide for Clinicians TIP 35 Enhancing Motivation for Change in Substance Abuse
KAP Keys for Clinicians Treatment
Quick Guide for Clinicians
Substance Abuse Among Older Adults: A Guide for
Treatment Providers TIP 36 Substance Abuse Treatment for Persons With Child
Substance Abuse Among Older Adults: A Guide for Abuse and Neglect Issues
Social Service Providers Quick Guide for Clinicians
Substance Abuse Among Older Adults: Physician’s KAP Keys for Clinicians
Guide Helping Yourself Heal: A Recovering Woman’s Guide to
Quick Guide for Clinicians Coping With Childhood Abuse Issues
KAP Keys for Clinicians Also available in Spanish
Helping Yourself Heal: A Recovering Man’s Guide to
TIP 27 Comprehensive Case Management for Substance Coping With the Effects of Childhood Abuse
Abuse Treatment
Also available in Spanish
Case Management for Substance Abuse Treatment: A
Guide for Treatment Providers TIP 37 Substance Abuse Treatment for Persons With
æ
Case Management for Substance Abuse Treatment: A HIV/AIDS
æ
Guide for Administrators Quick Guide for Clinicians
Quick Guide for Clinicians KAP Keys for Clinicians
Quick Guide for Administrators Drugs, Alcohol, and HIV/AIDS: A Consumer Guide
Quick Guide for Administrators
Quick Guide for Clinicians
KAP Keys for Clinicians
Quick Guide for Administrators
KAP Keys for Clinicians
184
TIP 40 Clinical Guidelines for the Use of Buprenorphine in TIP 50 Addressing Suicidal Thoughts and Behaviors in
the Treatment of Opioid Addiction Substance Abuse Treatment
Quick Guide for Physicians
Quick Guide for Clinicians
KAP Keys for Physicians
Quick Guide for Administrators
TIP 41 Substance Abuse Treatment: Group Therapy TIP 51 Substance Abuse Treatment: Addressing the Specific
Quick Guide for Clinicians Needs of Women
Quick Guide for Clinicians
Occurring Disorders
Quick Guide for Clinicians
TIP 52 Clinical Supervision and Professional Development
Quick Guide for Administrators
of the Substance Abuse Counselor
KAP Keys for Clinicians
Quick Guide for Clinical Supervisors
Quick Guide for Administrators
TIP 43 Medication-Assisted Treatment for Opioid Addiction
in Opioid Treatment Programs TIP 53 Addressing Viral Hepatitis in People With Substance
Quick Guide for Clinicians
Use Disorders
KAP Keys for Clinicians
Quick Guide for Clinicians and Administrators
KAP Keys for Clinicians
TIP 44 Substance Abuse Treatment for Adults in the
Criminal Justice System TIP 54 Managing Chronic Pain in Adults With or in
Quick Guide for Clinicians
Recovery From Substance Use Disorders
KAP Keys for Clinicians
Quick Guide for Clinicians
KAP Keys for Clinicians
TIP 45 Detoxification and Substance Abuse Treatment You Can Manage Your Chronic Pain To Live a Good
Quick Guide for Clinicians
Life: A Guide for People in Recovery From Mental
Quick Guide for Administrators
Illness or Addiction
KAP Keys for Clinicians
TIP 55 Behavioral Health Services for People Who Are
Homeless
TIP 46 Substance Abuse: Administrative Issues in
Outpatient Treatment TIP 56 Addressing the Specific Behavioral Health Needs of
Quick Guide for Administrators Men
TIP 48 Managing Depressive Symptoms in Substance Abuse TIP 59 Improving Cultural Competence
Clients During Early Recovery
Quick Guide for Physicians
KAP Keys for Clinicians
185
Substance Abuse Treatment:
Group Therapy
This TIP, Substance Abuse Treatment: Group Therapy, presents an
overview of the role and efficacy of group therapy in substance
abuse treatment planning. This TIP offers research and clinical find-
ings and distills them into practical guidelines for practitioners of
group therapy modalities in the field of substance abuse treatment.
The TIP describes effective types of group therapy and offers a theo-
retical basis for group therapy’s effectiveness in the treatment of sub-
stance use disorders. This work also will be a useful guide to supervi-
sors and trainers of beginning counselors, as well as to experienced
counselors. Finally, the TIP is meant to provide researchers and clini-
cians with a guide to sources of information and topics for further
inquiry.
Collateral Products
Based on TIP 41
Quick Guide for Clinicians