DEMYSTIFYING THE CURATIVE FACTOR OF GROUP PSYCHOTHERAPY IN REHAB
Group therapy can be more more effective than one-to-one counselling – but how does it work? And what factors can help it to be more effective? Divine Charura offers top tips, from size of groups to grieving their natural endings.
Download AddictionToday135 – Group therapy
The purpose of this article is to explore and demystify the curative factor of group psychotherapy when working with people in a residential alcohol/drug addiction rehabilitation centre. The ideas in this article offer an exploration as to what it is about group therapy that is helpful – and how does group therapy work?
Group psychotherapy, or group therapy, is the therapeutic treatment of a group of people at one time. A broad theoretical assumption is that it helps a person to relate his/her experiences to others in the group. As a psychotherapist and clinician, I believe that inherent in people is the potential to change and move towards a positive direction, given the right conditions.
This article offers a description and exploration of group psychotherapy with people undergoing a residential rehabilitation programme. Issues of trust and resistance in groups are also explored. The importance of affirming abstinence and exploring relapse prevention will be discussed. Lastly, group endings and closure will be highlighted and a conclusive hypothesis of the curative process in group therapy given.
First, let us look at the size of groups. A common question is how many people is a good number to work with before the group is considered too large? A working definition for size is that it is not too big a group that the individuals’ voices cannot be heard by others in it due to the size of the group. In practice, I have worked with a small group of four people and found 6-8 people to be a reasonably sized group to work indepth with.
Second, the issue of cofacilitation depends on the size of the group. Where the group is large (more than eight people) then I believe cofacilitation is effective.
In the rehabilitation environments in which I have worked, group therapy is part of a holistic programme, so there is a degree of being mandated to attend group sessions. But residents attend the programme voluntarily, so there is an assumption that if they were not willing to attend they would not engage in the programme offered. The interplay of group formation, cohesion, conflict and group process is noted in literature (Tuckman 2001, Yalom and Lescz, 2005).
One of the major steps in a group is building trust; it is only after doing this that members of the group therapy session can engage fully with each other. It is important for the therapist to affirm the importance of confidentiality and for the group to establish ground rules. This should be done from the first session. It is also important to inform the group what its purpose is and establish individual goals. All members in the group have the commonality of addiction and rehabilitation so a desire to change is a natural common group goal to start exploring.
The structure I usually follow is that the group meets weekly for 1-2 hours depending on the size and needs of the group. Each group meets weekly for 10-12 weeks.
In the group process, exploration of individual life stories or narratives/scripts is an important part of the therapeutic process. This occurs when each member shares something with the group about his or her life experiences. Where appropriate, over the sessions I encourage group members to link their life story exploration with their addiction and help each other in the group to work on what they would like to change and how change can happen. This involves encouraging individuals to ask themselves questions like: What contributed to me being addicted? What contributes to my relapses? What gets in the way of successful abstinence?
It is important, however, to state that people are not forced to speak or say anything that they do not feel comfortable exploring or sharing with the group.
These questions can enable reflection, identification of corrective measures and plans to aid relapse prevention strategies. Opening up to other people with the same experiences proves to be more beneficial than having a one-on-one session with a therapist (Tuckman 2001, Yalom and Lescz 2005).
Challenges or criticisms to the facilitator or to other members of the group are inevitable in group therapy. An example is criticism of the programme in which the client is engaged. It is important for the therapist not to react from a position of authority but to listen, analyse and explore with the client these feelings and thoughts.
In the group process, it is important that the facilitator is tentative in responding to each person but also leaves space for group members to respond to each other. An example is to ask what other group members think of the criticism, frustration or thoughts of the individual. This enables a safe space in which group members can hear each others’ point of view as well as challenge each other, possibly learning a new way of being and of dealing with or resolving conflict.
The complexity of this process is that this might be the first time that these people have their thoughts, feelings and experiences challenged by others, while they are sober or not under the influence of drugs. An example is that someone might be given feedback by other group members that they are dishonest or that they need to listen and give others space to talk. This might be met with acceptance or, more often, resistance. But on reflection, the person might re-establish that listening and honesty are important in functioning in networks outside the group such as family or other social groups.
Resistance in group therapy is another factor which should be acknowledged and challenged for group therapy to be helpful. Resistance can be evidenced by people retreating from acknowledging what their problems are or minimising the significance of these problems. It might also be evidenced by denial or the minimisation of the destruction that substance abuse, or addiction, is causing in their life. It can also be evidenced by avoiding meaningful interpersonal contact or responses in the group.
So group therapy with people in residential rehab requires a therapist who can challenge the members’ resistance because most acknowledge a pattern of resistance and denial to their addiction.
For change to occur, group therapy must provide people with the right conditions: space to explore difficult experiences and challenge their fears as well as identify shared experiences with others which might enable a realisation of not being alone or peculiar in addiction.
This in turn could enable skills and the motivation to begin a new approach to life as well as a realisation that life without alcohol/drugs can be an experience in a positive direction. This highly contributes to the curative factor of group therapy.
MANAGE GROUP ENDINGS AND SEPARATION
The last stage in group therapy is preparing for the group’s ending. The therapist/facilitator should prepare and manage the group ending process. This in many ways could be symbolic of an ending of individuals’ relationships with an old life. I have heard many people in groups acknowledge this as a process of bereavement or the loss of a friend – friend being the alcohol/drugs or lifestyle associated with this. It is also important to note that this process can be symbolic of other processes or endings in the client’s life which contributed to them using substances to cope with their experience.
Paradoxically, drinking/drug-taking could have also been a result of celebration, eventually spiralling to lack of control and dependence. In this end stage, it is important to reflect on the group therapy process and explore impact of endings. An important aspect is to affirm relapse prevention plans and for group members to challenge or affirm each others’ plans to ensure that each is fully aware of their own options and possibilities.
Developing new career plans, hobbies and interests should be paramount in any substance-abuse recovery programme. Participants must learn how to deal with their challenges and disappointments and as well as deal with successes in constructive ways. In the programmes I facilitate, the formation, involvement and maintenance of a healthy (supportive) social network is pivotal in affirming maintenance of a drug-alcohol free life.
It is also important to state that maintaining a healthier diet helps to ensure that the individual sustains good mental and physical health.
Group therapy does not work for everyone. Roback (2000) cites a study which showed that the condition of 10% of group members worsened as a result of group therapy. But there is more evidence to support its efficacy.
WHAT ARE THE CURATIVE FACTORS?
It is through group therapy that each participant would have shared about themselves, explored, learned and engaged with others in a therapeutic space. When working with people presenting with substance misuse/addiction, I thus believe that it is through the pure activity of fully engaging in group process which provides the right conditions by giving the opportunity to explore one’s life scripts, to be challenged on resistance and denial, to be listened to and be accepted. Reflecting on past failures/relapses and effects of participants’ lifestyle and impact it had on social networks can enhance motivation to change.
It is also through hearing others’ similar or different experiences and having one’s maintenance of abstinence goals affirmed which is curative. This allows a psychological re-adjusting process, enabling clients to go into “the real world” and be more committed to abstinence.
Divine Charura is a senior lecturer at Leeds Metropolitan University in Counselling and Psychotherapy. He is a UKCP-registered adult psychotherapist and has years of work experience working in diverse psychiatric/clinical and therapeutic settings including co-managing a detox and rehabilitation centre in Leeds. Among his other writing, he recently authored a chapter in the Transcultural Handbook for Counselling and Psychotherapy edited by Dr. Colin Lago (2011).
1. Barret-Leornard T (2003). Steps of a mindful journey.
2. Morgan-Lopez AA. Fals-Stewart W (May 2006). “Analytic complexities associated with group therapy in substance abuse treatment research: problems, recommendations, and future directions.” Exp Clin Psychopharmacol 14 (2): 265–73. doi:10.1037/1064-1222.214.171.1245. PMID 16756430.
3. Roback HB (2000) Adverse outcomes in group psychotherapy. Journal of Psychotherapy Practice and Research 9. (3) 113-122
4. Soyka M. Helten C, Scharfenberg CO (2001). “[Psychotherapy of alcohol addiction—principles and new findings of therapy research]”. Wien Med Wochenschr 151 (15–17): 380–8; discussion 389. PMID 11603209.
5. Tuckman, Bruce W (1996) Theories and Applications of Educational Psychology, McGraw Hill. 3rd edition with D Moneth 2001.
6. Yalom ID and Lescz M (2005) The theory and practice of Group Psychotherapy. Basic Books