TIP 41: Group Therapy

Stages of Recovery

* Early * Middle * Late/Maintenance

3 Forms of Countertransference

- Feelings of having been there - Feelings of helplessness when the therapist is more invested in the treatment than the client is. - Feelings of incompetence due to unfamiliarity with culture and jargon

What is the direction of the relationship between substance abuse and healthy interpersonal attachment?

- Inverse relationship, A person who is actively abusing substances can rarely negotiate the demands of healthy interpersonal relationships successfully - substance abuse is viewed as an attachment d/o according to Attachment Theory

Some pretreatment techniques that appear to reduce the incidence of dropping out

- Role induction - Vicarious pretraining - Experiential pretraining - Motivational interviews

Skills development groups

- attempt to cultivate the skills people need to achieve and maintain abstinence - leader focus, specific topic, hetero/homogenous, high lvl of facilitator activity, 45-90 mins, basic w/spec trng

How can group leader move away from the center-stage?

- build skills in grp members - Encourage the group to learn the skills necessary to support and encourage one another because too much or too frequent support from the clinician can lead to approval seeking, which blocks growth and independence - Refrain from taking on the responsibility to repair anything in the life of the clients; leader can access resources helpful for clients in resolving issues

Middle recovery

- client feels fairly secure in abstinence. Cravings occur but can be recognized; risk of relapse remains. - will take at least a year to complete, but can last indefinitely; some relapse and go back to early recovery; some unable to progress to late recovery - Psychoeducation, Skills-Building, Cognitive-Behavioral, Support Interpersonal, Process, Relapse Prevention, Expressive, and Culture-Specific groups

Early Recovery

- clt moved into treatment, focusing on becoming abstinent and then on staying sober. they are fragile and particularly vulnerable to relapse. - last from 1 month to 1 year. - Psychoeducation, Skills-Building, Cognitive-Behavioral, Support, Interpersonal Process, Culture Specific group

Late/maintenance recovery

- clts work to maintain abstinence while continuing to make changes unrelated to substance abuse in their attitudes and responsive behavior - also may prepare to work on psychological issues unrelated to substance abuse that have surfaced in abstinence - since recovery is an ongoing process, this phase has no end - Cognitive-Behavioral, Support, Interpersonal Process, and Culture-specific

Support groups

- comprise a forum where members can debunk each other's excuses and support constructive change - bolster members' efforts to develop and strengthen the ability to manage their thinking and emotions and to develop better interpersonal skills as they recover from substance abuse - members also help each other with pragmatic concerns, - gp focus, non specific agenda, homo/heterogenous, low-mod lvl facilitator activity, 45-90 mins, specialized leader trng w/process oriented skills

Relapse Prevention Group

- 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 drug-free state - can be helpful for people in crisis or who are in some way susceptible to a return to substance use - is a double-level initiative type of group which aims both to upgrade a client's ability to manage risky situations and to stabilize a client's lifestyle through changes in behavior - focus on activities, problem-solving, and skills-building - groups draw on techniques used in a variety of other types of groups, especially the cognitive-behavioral, psychoeducational, skills development, and process-oriented groups.

Interpersonally focused group

- group dymanics that generally work from a theory of interactional group therapy, most often associated with the work of Irving Yalom - emphasis is on current interactions between and among group members - the group leader as a role model, monitors clients relate to one another, and reinforces therapeutic group norms, such as members responding to each other in an emphatic way; steps in to extinguish contratherapeutic norms that might damage group cohesion or to point out behavior that could inhibit empathic relationships

Group-as-a-whole focused group

- group dynamics that is associated with Tavistock's Group-as-a-Whole, Agazarian Systems-Centered Therapy for Group, Bion's primary assumption groups, and the focal conflict model - group leader focuses on the group as a single entity or system - generally is inappropriate for clients with substance use disorders as the sole approach to treatment - E.g., when the entire group seems to be sharing a mood, behavior, or viewpoint, a group leader may choose to use mass group process comments,

T/F: In late-stage treatment, client's focus shift from the symptoms of drug and alcohol abuse and more to the psychology of relational interaction.

True; clts begin to manage their emotional states and cognitive processes more effectively, they can face situations that involve conflict or cause emotion; process group may be appropriate; focus on voc rehab; explore existential concerns

T/F: Twelve-Step programs can help keep the individual who abuses substances abstinent while group therapy provides opportunities for these individuals to understand and explore the emotional and interpersonal conflicts that can contribute to substance abuse

TRUE

T/F: Psychoeducational groups are highly structured and often follow a manual or a preplanned curriculum.

True

T/F: Women face greater challenges in securing employment, are more likely to have co-occurring mental illness, and encounter greater stigma for their substance use disorders than men.

True

T/F: Cognitive capacity usually begins to return to normal in the middle stage of treatment.

True, cognitive deficits persisted for at least 3 to 6 months after cessation of drug use. * Impt for clinician to be mindful that clients in this stage will have difficulties in: attending, concentrating, learning new material, remembering things heard or seen, producing words, and integrating visual and motor cues. * clt may also only remember the pleasant experiences associated to drug abuse and not the negative ramifications

Addiction is, in fact, frequently referred to as a __________ of __________

disease of denial

Motivation

the vital factor in the success of tx for substance abuse d/o

What is one of the feelings that the group leader needs to be able to empathize?

shame, which is common among people with substance abuse histories

What are the 3 Specialized Groups in Substance Abuse Treatment?

-relapse prevention -communal and culturally specific group -expressive group

Expressive Groups

- group includes a range of therapeutic activities that allow clients to express feelings and thoughts—conscious or unconscious—that they might have difficulty communicating with spoken words alone - generally foster social interaction among group members as they engage either together or independently in a creative activity - may use art, music, drama, psychodrama, Gestalt, bioenergetics, psychomotor, play (often with children) games, dance, free movement, or poetry

Fixed membership group

- groups are relatively small (not more than 15 members); membership is relatively stable - short-term therapy, skill building, psychoeducation, and relapse prevention - leader generally is less active than is the leader of a time-limited group, since the interaction among group members is more important than leader-to-member interactions - can be time-limited (short-term, skill bldg, psychoed, or relapse prevention gp) or ongoing (interpersonal process grp/support therapy grp)

Revolving Membership Groups

- groups frequently are found in inpatient treatment programs; As clients are admitted and discharged, people come and go in the group. - prudent to keep the group small enough (about 15 or fewer) - can be time-limited (expressive therapy, psychoed, skill-bldg) or ongoing (day hospital check-in, continuing care drop-in, transition gp, psychoed, expressive therapy, support/continuing care/maintenance gp)

Interpersonal process group psychotherapy (referred to hereafter as "interpersonal process groups" or "therapy groups"),

- groups use psychodynamics, or knowledge of the way people function psychologically, to promote change and healing. - group that enables clients to recreate their pasts in the here-and-now of group and rethink the relational and other life problems that they have previously fled by means of addictive substances - focus on the present - gp focus, non specific agenda, heterogenous, low-mod lvl facilitator activity1-2hrs, specialized trng in interpersonal process gp

3 group dynamics

- individually focused group - interpersonally focused group - group-as-whole focused group

How to address physical contact and boundaries in group?

- leader should call the behavior to the group's attention - remind members of the terms of agreement, call attention to the questionable behavior in a straightforward, factual way, and invite group input with a comment - encourage members to put their thoughts and feelings into words, not actions

Name some ethical issues that may arise in group therapy

- overriding group agreements - informing clt options - preventing enmeshment - acting in clt's best interest

When working with adolescents, what are some of the things to consider when placing them in group therapy?

- psychosocial and developmental issues - local, State, and Federal laws related to confidentiality; infectious disease control; parental permissions and notifications; child abuse, neglect, and endangerment; and statutory rape all can come into play when substance abuse treatment services are delivered to minors

Individually focused group

- this group dynamic concentrates on individual members of the group and their distinctive internal cognitive and emotional processes. - group leader generally works sequentially with one group member at a time - While one individual's issues are addressed, the other group members serve as observers, contributors, alter egos, or significant others - useful to identify the first concrete steps in coping with substance abuse - help clients become more aware of behavior and its causes, and increase client's range of options as to how to behave. - role playing - ideal result is the client's freedom from an unproductive or destructive behavior - applicable to CT, psychodrama, transactional analysis, expressive therapy, redecision therapy, Gestalt, and reality therapy

Cognitive-behavioral groups

- this group focuses on rearranging thinking patterns and action that lead to addiction -leader/gp focused, can be any agenda, homo/heterogeneous, high lvl facilitator activity, 60-90 mins, leader w/specialized trng

Communal and Culturally Specific Groups

- this groups and practices that accentuate cultural affinity help curtail substance abuse by using a particular culture's healing practices and tapping into the healing power of a communal and cultural heritage - some common elements in treatment include storytelling, rituals and religious practices, holiday celebrations, retreats, and rites of passage practice (these may be particularly useful for adolescent clients).

Problem-focused group

- this type of group focuses to to "change, alter, or eliminate a group member's self-destructive or self-defeating target behavior. Such groups are usually short-term and historically have been used with addictive types of behavior (smoking, eating, taking drugs) as well as when the focus is on symptom reduction...or behavioral rehearsal - commonly is used in the early stages of recovery to help clients engage in treatment, learn new skills, and commit to sobriety - the group helps clients develop effective coping mechanisms to enable them to meet social obligations and to initiate recovery from substance abuse - e.f., grief group, cancer-support gp,

Psychoeducational groups

-major purpose of this group is expansion of awareness about the behavioral, medical, and psychological consequences of substance abuse - another prime goal is to motivate the client to enter the recovery-ready stage - leader focused, specific topic, can be hetero/homogenous, high lvl of facilitator activity, 15-90 mins, basic leader trng

6 conditions under which limited disclosure is permitted under the 42 CFR Part 2

1) clt signed a Release of Information for group leader to communicate w/ another person/agency 2) group member threatens imminent harm to him- or herself 3) client threatens imminent harm to another named person 4) medical emergency requires that a client's drug and alcohol status be revealed 5) client is suspected of child neglect and/or abuse 6) direct court order mandates the release of specific information related to a client's history and/or treatment; 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

5 stages of group process

1. Forming - Dependency, the initial stage of a group. Therapist might observe a dependency on the therapist for direction as members are uncertain of themselves and look to leadership for direction. 2. Storming - Conflict, which may be overt or covert. 3. Norming - Cohesion is a time when the group develops an identity and feels relaxed with one another and has a sense of cohesion. 4. Performing - Interdependence, time in which the primary work of the group begins. Members take on constructive roles and address personal issues. 5. Adjourning - group has completed the task and is disbanded

How should clinicians view relapse in group?

Clinicians should not view relapse failure, but as a clinical opportunity for both group leader and clients to learn from the event, integrate the new knowledge, and strengthen levels of motivation.

3 Classifications of Departing Clients from Group

Completers - have finished the work they came into group to do. Plateauers - are not really finished, but their progress has slowed or stopped for the time being. Fleers - feel an irresistible need to escape as rapidly as possible, often because they have encountered an upsetting reality in the group or in their lives outside the group

3 Stages of Treatment

Early Middle/working stage Late

What will the clinician have the client draw in order to help assess clients' relationships and their ability to participate productively in a group?

Ecomap, aka sociogram, is a graphic representation that depicts interpersonal relationships; An arrow from the center out means "I care about this person." An incoming arrow means "This person cares about me."

By enabling clients to express themselves in ways they might not be able to in traditional talking therapies, what type of therapy can help clients explore their substance abuse, its origins, the effect it has had on their lives, and new options for coping?

Expressive therapy

T/F: The therapist is responsible for resolving conflicts in group.

False, - clinician can facilitates interactions between members in conflict and calls attention to subtle, sometimes unhealthy patterns - it is important for the group leader to speak privately with group members and see how each is feeling - Conflict can present opportunities for group members to find meaningful connections with each other and within their own lives.

T/F: Research has found that relapse prevention groups does not reduce the intensity of relapse when it occurs. Groups also appear to be less effective than other approaches for clients who have "more severe levels of substance use, greater levels of negative affect, and greater perceived deficits in coping skills.

False, group reduces relapse intensity and more effective than other approaches

T/F: The group members does not need to be told and reminded that new intimate relationships are hazardous to early recovery and are therefore discouraged

False, important to discouraged clients to refrain from developing new intimate relationship, esp in early recovery

T/F: A counselor can guarantee confidentiality and privacy of group.

False. However, counselor should encourage members respect other members confidentiality

What is the appropriate action if a group member relapse or actively using?

Group leader will: - make it as easy as possible for the person who has relapsed to seek treatment - can ask disruptive member to leave the group for the day; ensure clt does not drive home or escorted - help group members explore their feelings about the relapse and reaffirm the primary importance of members' agreement to remain abstinent

What are some therapeutic strategies according to Yalom for clients in early stage of treatment?

Instilling hope Universality Imparting information Altruism Corrective recapitulation of the primary family group Developing socializing techniques Imitative behaviors Interpersonal learning Group cohesiveness Catharsis Existential factors

ASAM Levels of Care and 6 Dimension

LOC 0.5: Early Intervention I: Outpatient Services II: Intensive Outpatient Services/Partial Hospitalization (2.1 Intensive Outpt; 2.5 Partial Hosp) III: Residential/Inpatient Services (3.1 Clinically managed low intensity inpt; 3.3 Clinically managed pop-specific high intensity inpt; 3.5 Clinically managed high intensity inpt; 3.7 Med monitored high intensity inpt) IV: Medically Managed Intensive Inpatient Services 6 DIMENSION •Acute intoxication or withdrawal •Biomedical conditions and complications •Emotional, Behavioral, Cognitive conditions or complications •Readiness for Change •Relapse and continued use potential •Recovery environment

In working with women, would it be best for them to be assigned in same-sex group or with men?

Same-sex, and it is due to the unique needs that women present; Gender-specific treatment groups provide both the safety women often need to resolve the problems that fuel their substance use disorders and the healing environment they need to develop a healthier development of self and connections to other women

What should be the immediate and primary focus during early tx in group setting?

achieving abstinence preventing relapse learning ways to manage cravings

This type of group ___________ might be overstimulating for some clients in early stages of recovery, particularly those undergoing detoxification. They would benefit most from a group with a strong primary focus on __________ _____________ _______________ _____________.

an interpersonal process group; achieving and maintaining abstinence

Resistance

arises as an often unconscious defense to protect the client from the pain of self-examination - counselor can take a curious stance and an interest in exploring what is happening and what can be learned from it

T/F: potential group members does not need to achieve a period of abstinence before joining a relapse prevention group

false, potential members need a period of abstinence

T/F: Group therapy also is equivalent to 12-Step program practices

false, it is not the same

Attention to _________ is important early in group treatment

group cohesiveness

Double Trouble group

group for clients with co-occurring d/o. E.g., Double Trouble in Recovery, Dual D/O Anonymous, Dual Recovery Anonymous, Dual Diagnosis Anonymous

How can group leader address boundary violation?

group members should be reminded of agreements and given an opportunity to discuss the meaning and implication of the limit-breaking behavior as they see it

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 receiving substance abuse prevention and/or treatment services

What is the purpose of confrontation?

help clients see and accept reality so they can change accordingly (Miller and Rollnick 1991)

4 Stages of Group

initial stage transition stage working stage final stage

Active listening

is the leader's attention to language, nonverbal and tone around an individual's message. (verbal 50%; non-verbal 50%)

How can a group leader promote empathy amongst group members?

model empathy, asking group members to say what they think someone else is feeling and by pointing out cues that indicate what another person may be feeling

To achieve maximum involvement in group therapy during the initial sessions what are some techniques that a counselor may utilize?

motivational techniques, like psychoeducation and attendance prompts, may be used to engage the client.

Linking

occurs when group leadership assists members in recognizing their similarities.

Summarizing

occurs when leaders assist members in raising awareness of what occurs and how the group and membership have changed.

Blocking

occurs when leadership prevents unfocused members from being disruptive by redirecting or preventing them from monopolizing discussion.

What are the therapeutic factors to consider in middle stage (action stage) of group tx?

self-knowledge and altruism can be emphasized; Universality, identification, cohesion, and hope * goal is to help clients perceive the causal relationship between substance abuse and current problems in their lives

For clients with low levels of motivation to abstain should be placed in ____________ groups. They can help the client make the transition into the recovery ready stage

psychoeducational groups