NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction
Assignment 1: Psychotherapeutic Approaches to Group Therapy for Addiction
When selecting a psychotherapeutic approach for a client, you must consider the unique needs and characteristics of that particular client. The same is true when selecting a psychotherapeutic approach for groups. Not every approach is appropriate for every group, and the group’s unique needs and characteristics must be considered. For this Assignment, you examine psychotherapeutic approaches to group therapy for addiction.
Learning Objectives
Students will:
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• Evaluate psychotherapeutic approaches to group therapy for addiction
To prepare:
• Review this week’s Learning Resources and reflect on the insights they provide on group therapy for addiction.
• View the media, Levy Family: Sessions 1-7, and consider the psychotherapeutic approaches being used.
The Assignment
In a 2-page paper, address the following:
• Identify the psychotherapeutic approach that the group facilitator is using and explain why she might be using this approach.
• Determine whether or not you would use the same psychotherapeutic approach if you were the counselor facilitating this group and justify your decision. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
• Identify an alternative approach to group therapy for addiction and explain why it is an appropriate option.
• Support your position with evidence-based literature.
• Note: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references.
Psychotherapy.net (Producer). (2015). Group therapy for addictions: An interpersonal relapse prevention approach [Video file]. Mill Valley, CA: Author.
TIM LEIGHTON: I’m Tim Leighton, and I’m the director of professional education and research for the charity, Action on Addiction. This charity provides services for alcohol and drug users and their families. And we provide degree level education in addictions counseling in partnership with the University of Bath. I’m a registered cognitive analytic psychotherapist and have published several papers and chapters on this therapy model and on interpersonal group therapy. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
In 1985, I started my career as an addictions counselor at a residential treatment center. And armed with Irvin Yalom’s book and a huge video camera– in those days, they were about the size of the cameras on Match of the Day– I set out to train myself in this group model, as I had become convinced it had enormous potential for addictions treatment. Later, I learned a lot more about it and began to teach the model in my courses. I hope you found this video resource helpful.
JAX BEATTY: My name is Jax Beatty. I’m an addictions and family counselor. I have been facilitating groups for eight years. When I was first trained in this model, I was very enthusiastic about it. I wanted to learn how to use it to the best effect, to help people to recover from addiction. I’m currently a cognitive analytic therapy practitioner and work in a range of settings with addicted people and their family members.
DEVIN ASHWOOD: My name is Devin Ashwood. I’m an addiction counselor and program leader for the honors degree in addiction counseling offered in the United Kingdom by Action on Addiction. My specialities are interpersonal group therapy, as well as Mindfulness-Based Relapse Prevention and cognitive therapy.
LEIGHTON: It is important to say that for ethical reasons, the clients in these clinical vignettes are played by actors. The scenarios were developed from the clinical and educational experience of Devin Ashwood and myself, who between us, have been practicing and teaching interpersonal group therapy in addiction settings for over 40 years.
The final scripts for the vignettes you will see were arrived at through a process of initially loosely scripting the characters and scenarios, which actors were then encouraged to improvise around. This had the intended effect of replicating some of the realistic, difficult, messy, and potentially confusing situations that so often characterize real life interpersonal therapy groups in these settings. It is sometimes the case that video teaching resources present their material for clarity’s sake in too neat a way to seem realistic to experienced addictions therapists. We wanted to retain an authentic feel but also help therapists understand and develop a clear model and rationale for their group therapy work.
Perhaps the first thing to say is that these videos are not in themselves a substitute for a training course or continuing supervision in the model. They’re intended to supplement such activities and to act as an aid to creative thinking about the model and its application in addictions treatment. Although future videos will be produced by us demonstrating more technical aspects of group facilitation, we predict that this set of scenarios will primarily illuminate the model, the process of the group, and how it helps group members, rather than teach a full set of facilitation skills. Such skills are required by practice in the company of and with the help of experienced practitioners who may act as colleagues, models, and supervisors. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
This training aid was developed to help address the clear gap in education and skills evidenced in the field of substance misuse treatment. One of the main ways people suffering from addiction problems are offered support is through some form of activity in groups. However, professionals who lead these groups all too often don’t have a framework to understand how best to use groups. There was an absence of a theoretical model and a lack of understanding of what is likely to be helpful in a group. What you see presented here is influenced strongly by the work of Irvin Yalom and Philip Flores, who have both written extensively on this topic.
It is, of course, not the only useful way of working in groups with clients in transition or early recovery from addiction. Skills training, provision of information, motivational work, and discussion about recovery may all happen in groups. And there is some evidence supporting the effectiveness of group-based cognitive behavioral approaches. Interpersonal group therapy is by no means incompatible with such approaches. But it needs to be carefully distinguished from them in the minds of both therapists and clients. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
The groups have different tasks and should be timetabled separately. As we shall see, the more clients come to understand how this type of group therapy works, the better the group is likely to go. But for us, the main rationale for using interpersonal group therapy for addictions is that we think that, among other benefits, it builds resilience to some of the best evidenced relapse precipitants, interpersonal conflict, and what Miller & Harris have described as a state of demoralization and alienation.
We like to think of this model of group therapy as interpersonal relapse prevention, which you will notice is the subtitle of our training package. It is the most suitable group therapy for those who are entering in developing recovery. For example, it is frequently used immediately after detoxification, although we see no reason to think it wouldn’t be beneficial to those starting their recoveries supported by a substitution pharmacotherapy. As recovery progresses, the group model remains relevant and forms a useful after care intervention for those who have completed their rehab programs.
There is also reason to think that this form of therapy might help people make the best use of mutual aid groups, although the form of group interaction is very different in those groups. Firstly, it’s important to point out that complex and sophisticated social relationships are a defining feature of the human species. Our place on the evolutionary tree is as the specialist in its personal relations. Our ability to form relationships may well explain our species’ survival and eventual dominance. And we now have a global social community with the ability to instantly communicate across continents. There is evidence that we are biologically set up to attach to others and have a fundamental need to be part of social groups. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction
It is also ensured that we will express distress and unhappiness when we feel outside of social groups. It’s a noted characteristic of addiction to drugs and alcohol that an obsessional relationship with substances almost always becomes harmful to human relationships. Some people begin addictive careers before ever fully developing the ability to have supportive adult relationships. But even those who become addicted later, by the time they are ready to seek treatment for their problems, years of obsessional drink or drug use is likely to have caused significant harm to any good relationships that may have developed.
In addition, people forget how to get their social needs met outside the context of drink or drugs. Substances invariably become a mediator in all major relationships. They may be a shared interest or used to get close to someone else. Or they may be used keep people away, or to express anger, or to punish others. There are many ways substances become pivotal in the relationships of those seeking help.
Learning how to have supportive mutual and satisfying relationships free of drink and drugs is a key task of recovery and the main aim of this form of group therapy. Interpersonal group therapy doesn’t assume that people with substance misuse problems or share a particular profile or personality type. But instead, identifies and directly addresses relevant problematic interpersonal behavior, whether that be isolating, ineffective ways of trying to be liked by others, intimacy issues, or any other maladaptive relational style.
An important characteristic of interpersonal group therapy in relation to other approaches is that it need not be too anxiety-provoking. Research has shown that people who are in early recovery from addiction are significantly more anxious than the general population. And approaches that focus on intentionally stimulating difficult feelings, on heavily challenging people, or intentionally provoking transference are likely to be too much for many clients to relax and trust the group process enough to express themselves and interact as freely as they would outside of therapy group. This natural expression is vital, if the problems that people need to work on are to become available to the group for therapy.
For interpersonal group therapy to be helpful, it’s essential that clients come to understand their substance use from a relational perspective. If they come to see how working on their relationships will support their recovery, it is far more likely that they will invest in the group. For this reason, making the model of therapy explicit at the outset is vital, as this helps clients set their goals as relational ones that groups can help with, rather than making practical, out of the group goals that tend not to be amenable to group therapy.
If clients learn to value sharing themselves with others and are able to develop supportive relationships, they’re again also more likely to gain from affiliation with 12-step or other mutual aid groups. And the evidence available suggests that it is those who become socially active in these recovery communities that can benefit the most.
The treatment setting you’ll be witnessing is offering interpersonal group therapy as part of a wider, structured day program and in a time-limited rolling format. Clients attend each weekday from 8:30 to 4:30 for several weeks, 12 in this fictional case, based on one of our treatment models. Without the support of other group and one-to-one interventions, working interpersonally might well be too challenging for many clients, as these groups often end with some people feeling exposed or vulnerable. If there are other therapeutic activities later in the day, this gives people a chance to process their feelings and be less vulnerable to relapse as a result.
The rolling nature of the program means that clients might enter at any time, then receive 12 weeks of treatment before leaving the group. Because of this, in the first vignette, all the participants have been in treatment for differing lengths of time. And there are already established relationships between the members of the group.
There are elements of four groups captured in total, each within a week or two separating them. However, in this intensive treatment setting, interpersonal group therapy is offered on four days a week. So it’s important to remember that not all the interpersonal dynamics and developments are shown.
We’re not going to introduce each member of the group in any detail. But a biographical portrait of each is available in the accompanying material included in the training pack. We join the group just after Jimmy has read the group preamble, a short text that reminds everyone of the purpose and function of interpersonal group therapy.
BRIAN: My counselor’s asked me to bring something into group about me wanting to go carry on going out to pubs and clubs. I just want to bring that to the group, so I can get feedback from you guys.
NATHAN: Do you know what, Brian? I’m seriously worried about you having thoughts like that. What makes you think it’s okay to surround yourself with drugs and alcohol?
MARK: Come on, Brian, if you keep going into a barber shop, you’re going to end up getting a haircut.
BRIAN: I’ll be all right. Others do it. We are allowed to have fun.
NATHAN: I just think you’re making excuses not to change.
BRIAN: I’m willing to change. I’m here doing what I’m supposed to be doing. As I said, it’s not all about therapy. It’s not all about doing groups. I can have fun. It’s not I take life too seriously, I do.
JIMMY: Do you know what, Brian? I get where you’re coming from, because I did something similar when I first come into treatment. But they’re right. It’s too soon for you to be thinking about going to pubs and clubs.
BRIAN: See, this doesn’t really help, you all just having a go at me, being on my case.
SABINA: I’ve got something to bring. You see, my partner, last night, me and him had another row. It’s just getting worse and worse. He’s always on me. He’s just driving me nuts. He’s checking my phone. He’s checking my Facebook profile. It’s just so freaking claustrophobic. I can’t bear it. I don’t know what to do. He’s just on me all the time.
AMBER: Why don’t you just change your pin number?
SABINA: Because I thought marriage was about trust.
GEMMA: Have you ever thought about separation?
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NATHAN: I really couldn’t live with someone like that.
SABINA: Listen, I made my vows. And when I made them, I meant them. It’s just not an option. Separation is not an option.
MARK: Sounds like he has a problem. You thought about Al-Anon?
SABINA: He won’t go to anything like that. He says it’s my problem. I’ve been doing this for five weeks. Why isn’t he trusting me yet? He should be trusting me.
JIMMY: Yeah. Do you know what? I went and I pled to my family about a week ago. And I expected everything was going to be back to normal. They were going to be forgiving. And it’s not as simple as that. You know, these things take time. You can’t just expect everything to be back to normal straightaway.
AMBER: Why don’t you just change your Facebook account?
SABINA: I thought we were supposed to be working an “honest program”?
HORACE: Why don’t you try marriage counseling?
SABINA: And have someone analyzing every single aspect of the relationship? No. No.
LOUISE: Assertiveness training really helped me. Maybe should you just try and find a class.
SABINA: Mm, yeah, no.
NATHAN: I’m feeling really frustrated. Every time we try and give Sabina and Brian suggestions or advice, it’s like they’ve done it, or they just don’t want to hear it. I don’t think I’m getting anything out of them.
LEIGHTON: I think you’re making a good point, Nathan. I’d like to ask Sabina, do you feel you’re getting helped by this process in the group today?
SABINA: Well, yeah, all the comments are very nice and all and probably very helpful. But it’s not anything I haven’t really considered before. None of It’s really worked. And to be honest, I don’t think in the grand scheme of things it’s that big a deal, really. I think Gemma’s probably got bigger problems than me.
GEMMA: No, I just don’t see the point of this. I just don’t get it.
NATHAN: Maybe your problem is best addressed in one-to-one counseling, Gemma.
GEMMA: Well, that’s what I wanted in the first place. I just don’t get group.
MARK: At least, give it a go. Give it some time.
NATHAN: Gemma, don’t play with your towel now.
JIMMY: Yeah, do you know what? You’re a real valued member of this group. Don’t give up.
GEMMA: How?
LOUISE: Gemma, when I was struggling the other day, you really helped me.
MARK: I’m sorry. I think your problem is that you haven’t accepted powerlessness.
NATHAN: That’s a bit harsh right about now. She doesn’t really need to be hearing that, Mark.
MARK: Trying to help.
BEATTY: Gemma, can I ask you a question? What are you hearing from the group right now?
GEMMA: They just want me to accept I’m powerless.
AMBER: No one knows what they’re doing. How’s this going to help anyone?
ASHWOOD: Brian opens with an issue his counselor asked him to share with the group. This brings up some interesting questions. One possibility is that the counselor may be concerned about Brian’s intention to continue frequenting pubs and clubs, and hopes that his group might be able to persuade him that this isn’t a good idea. There are certain opportunities for group members to review the wisdom of proposed behavior in a group. And hearing a message from a number of people may be more persuasive than just one.
However, inviting this issue in this way also brings up a problem. There’s an implicit message that the function of the group is to get people to conform to a socially agreed norm of what recovery requires. And this detracts from communicating that the real power of the group is in helping people to see how they’re not getting their needs met through certain ways of relating and how they might better do this.
This being said, there is still an interpersonal process going on here that does create possibilities for learning. We see the group members frustrated with Brian, whose interpersonal style to date has been generally, although not exclusively, distant and dismissive of the wider group’s consensus. Many of the individual’s responses to him are typical of people who have been through certain kinds of treatment systems. Having inherited a particular philosophy of recovery, they believe that they need to confront anything they see as not in line with that philosophy.
The therapists do not, however, add to this confrontational style by challenging it. But instead, allow the group to feel the frustration of operating in this manner that doesn’t work so well. This way, members can learn for themselves what an ineffective group looks like and feels like, and later have an opportunity to contrast this with the group when it’s working more effectively. This helps the group to develop autonomy.
Various potentially problematic interpersonal styles are evident in this initial session. We see Mark trying to support people in a manner that comes across as aggressive. Nathan, appearing disconnected and critical. Even Jimmy, who seems much warmer, is still not willing to engage with Brian’s actual question. But instead, joins in the group consensus of concern about his intention to go to the pubs, maybe assuming he’s simply unmotivated for recovery.
As we will see in a number of examples in these vignettes, the content-focused advice giving format is found to be frustrating by the participants who feel their suggestions and concerns are not being given serious consideration. And they soon give up.
LEIGHTON: One important concept critical to understanding the model is that of process, as contrasted with content. It is fairly obvious what the content of the dialogue is. It’s the subject matter, what gets talked about. But what this model of group therapy intends us to understand is the process. That is, what do the way people talk to each other, the manner of their bringing material to the group, and its timing, and the way that group members respond to each other tell us about the nature and meaning of the relationships between them. It’s pretty obvious what the content of Sabina’s contribution is. It’s about the behavior of her husband. But what is the process as she interacts with her group?
Sabina complains about her husband. And clearly, there is little the members of the group can do to help her situation, as she’s presenting the problem as being his. There is a willingness from group members to try to help her by offering advice. However, this is typically dismissed by her, which is in itself indicative of something about Sabina that she brings to the group problems that cannot be addressed in the group.
Jimmy, who has been in treatment the longest and has had more chance to see how group works, offers his support in the form of identification. And this at least has the potential to develop the relationship between him and Sabina. The unsatisfying way the group is operating is not at this point highlighted by the therapists. They might, at some stage, point towards the process that’s going on. However, in this case, it’s not necessary, as Nathan comes in and makes an important comment about the process, that he is frustrated with all the advice giving and how ineffective it is.
NATHAN: I’m feeling really frustrated. Every time we try and give Sabina and Brian suggestions or advice, it’s like they’ve done it, or they just don’t want to hear it. I don’t think I’m getting anything out of them.
LEIGHTON: It’s almost always better if clients make commentary about group process themselves, rather than the therapist always taking the lead, as this helps the members of the group take responsibility for their own therapy. The group is much more productive if this is encouraged. And it makes it much more likely that group members will carry their gains on into recovery once treatment’s over. I encourage this by affirming and emphasizing Nathan’s comments, which will help develop the group norm, or unwritten rule, that clients can make process commentary.
I then attempt to highlight this learning further by asking if the process is helpful to Sabina. And while she acknowledged people’s efforts to support her, she clearly says that the advice isn’t very helpful. It might be that at this point, Sabina is uncomfortable about doing any more meaningful work and suggests her problems are less important than another group member’s. This again, shows an aspect of Sabina’s interpersonal style. But it isn’t picked up on. The group seemed happy to go with her suggestion of inviting Gemma to use group time.
ASHWOOD: Gemma seems ambivalent about the group. But it shows that there is at least some healthy cohesion, that they encourage her to give it a go, and to show her that she is a valued member of the group. If she hadn’t asked for specific feedback about how she was valued, this would’ve been a perfect opportunity for the therapists to ask this of the members of the group, to be specific. A specific interpersonal feedback is always more helpful than generalized comments. In this case, though, Gemma asks the question herself. Again, allowing the group to take responsibility lets its members see themselves as agents of change, rather than looking for the professionals to provide this.
Louise, who is usually quite quiet, is able to offer a little interpersonal feedback by pointing out how Gemma has helped her. This kind of interpersonal commentary is therapeutic on a number of levels. It helps Gemma to see that she has intrinsic value, as she is able to be of help to others. It also develops group cohesiveness, as members build trust and learn to value the group.
Members of the group also see how they can mutually benefit each other. And it allows those witnessing the exchange to see how offering skillful interpersonal feedback in a group deepens relationships and relational understanding in a way that’s emotionally attractive to them. This models healthy group behavior and develops positive group norms for the future.
BEATTY: Mark’s notion of support received some initial feedback from Nathan, which gives Mark an opportunity to highlight his intentions, which he says are trying to help. This is a theme that gets little attention now but is picked up on in a later vignette. The possible merits of Mark’s suggestion are very dependent on him having a shared language with Gemma. However, even if they had this, Mark’s delivery comes across as a criticism, and so Gemma can’t engage with it.
I attempt to highlight the support Gemma is offered by asking her what she is hearing from the group. However, Gemma focuses on what she saw as the most critical comment, at the expense of missing all the encouragement she was getting. Her dismissiveness of help and support is not picked up on by the therapist just yet.
And it’s important when conducting interpersonal group therapy that the group leader doesn’t jump onto every sign of interpersonal pathology, as doing so tends to put people on their guard and inhibit the natural flow of the group. Instead, the members of the group are largely left to be themselves in the session. So their relational problems can be seen and addressed by the wider group once it is obvious they are not getting the desired results. The vignette ends with Amber echoing Gemma’s earlier comment and expressing her frustration at what she sees as a general lack of understanding about how group therapy works.
ASHWOOD: It’s worth mentioning that the participants all attended an introductory workshop to prepare them to take part in and make the best use of interpersonal groups. In this, the relevance of developing healthy relationships to recovery was explored in some depth to help the clients to understand that their task in these groups is to better understand and improve how they relate with others. This is an important prerequisite for working interpersonally. However, the relevance and importance of this way of operating isn’t always learned right away, especially if people are still in detox, or have only recently completed their medicated detox when being introduced to the model.
Without understanding how focusing on relationships will help support recovery, it’s difficult for clients to fully invest in the group. And therefore, cohesiveness is weakened. For this reason, part of the ongoing function of a group must be to help remind clients why and how group therapy operates. This doesn’t need to be done didactically. And it’s often best done experientially by allowing members of the group to see for themselves what works and what doesn’t. The identification of relational goals to work on in group therapy can always be gone back to in one-to-one sessions with the client outside of the group.
LEIGHTON: This vignette is one where the group is going through a stage of relative infancy, something that comes and goes in rolling groups, as stronger members leave and new members join. There is some evidence of cohesiveness, that members value each other and the group. They are willing to offer support in the form of advice. And Louise gave some supportive feedback about how helpful Gemma was to her. But one of the main ways the group communicates at this stage, by giving advice, is experienced as frustrating. Because it doesn’t seem to lead anywhere.
A lack of cohesiveness is evidenced most strongly by the group members’ awkwardness in engaging with each other. When there is feedback, one or two more vocal members tend to give this in a very critical way, leaving the group feeling less connected to each other. It’s unsurprising that group members find it difficult to give each other direct interpersonal feedback. It isn’t normal in our society to do this outside of very intimate relationships, or interactions between people with different levels of social power, such as schoolteachers or parents and children. Receiving specific feedback from others about how our behavior affects others, or how we are perceived by others, can make us feel childlike and stripped of power.
But when a group learns to do this in a mutual direct and respectful way, it engenders a depth of relationship that is energizing and often experienced by members as quite new. The therapist’s role in a group like this one is to help the group to build cohesiveness. This can be done in a number of ways– by focusing on identification, on similarities between group members, common goals, mutually supportive relationships, and also by pointing out the sense of vibrancy when the group are working in the here and now, rather than wrestling with external or historical issues.
When the group is struggling, encouraging feedback on each other’s strengths, rather than an interpersonal challenge or undermining a client’s defenses is more supportive and tends to produce a more positive and hopeful atmosphere. Best evidence suggests that group cohesiveness is a precondition of the trust and risk-taking required for effective group therapy. So it is important to help groups develop, maintain, or recover this sense of cohesiveness.
In addiction treatment, there are factors such as the common predicament, which are conducive to group cohesiveness. But the post-detoxification volatility, vulnerability, and anxiety of members also tends to threaten it.
The next scenario occurs a week after the first. And new member, Sam, has joined the group. Although new, he was a therapist in the field himself before his alcoholism stopped him from working. Now his detoxification is complete. And after attending just three sessions, he is often quiet. But when he does speak, he’s a very supportive group member.
SABINA: Okay, yeah, I want to talk again. It’s just my husband again. I just– I’m at the end of my tether. He’s saying, where am I? Am I actually at the agency? He’s checking my breath again. What am I supposed to do? It’s just driving me crazy.
MARK: We’ve spoken about this last week. We’re not here for your husband. We’re here for you. You need to start focusing on yourself. Start taking responsibility.
SABINA: You don’t get it.
MARK: If it’s all your husband’s fault, why isn’t he in treatment?
BRIAN: Sabina, it would be nice to hear something new from you, something different.
JIMMY: Yeah, I’ve got something I need to bring to the group.
BEATTY: Jimmy, could you go on, please?
JIMMY: It’s my mom, she died last year. I used to care for her. I used to have to give her her medication to stop her from being in pain. But I used to steal them. I’d steal them just for a hit.
NATHAN: Thanks for sharing that, Jimmy. That’s pretty big stuff.
BRIAN: We’ve all got secrets, mate.
AMBER: I’ve done stuff I’m not proud of.
HORACE: You’re still just you, Jimmy. When I was using, none of my family wanted nothing to do with me, except for my granddad. He’s the only one I had any contact with. He was pretty old, though. He used to send me down to the post office to get his pension every week. And I used to nick the money because I needed to use.
JIMMY: That’s just money. This is medication that actually stopped her from being in pain.
MARK: I’ve stolen from my family. Might not be the same circumstances, but I could certainly relate to the feelings of shame and guilt.
NATHAN: How did you cope, Jimmy?
JIMMY: Drugs– heroin, meth, just anything.
HORACE: That’s where our addiction takes us, brother.
LOUISE: Jimmy, this is really brave of you to bring this to group.
AMBER: Yeah, I agree.
BEATTY: Jimmy, do you think you could let the group know what it is about the group today that’s allowed you to share this?
JIMMY: The other day, Gemma, she got vulnerable, real vulnerable. I just felt closer to her, really close.
BEATTY: I’m wondering if you answered my question there. What was it, do you think, about this group that let you share that?
JIMMY: I don’t know, really. Maybe it’s trust a lot. I sort of trust them. Now you all know the real me.
LEIGHTON: Jimmy, it sounds like you’ve been holding this in for quite a while. What were you worried about? What were you frightened about if you told the group about this?
JIMMY: What was I afraid of? Who’s going to respect someone like me? Who’s going to respect someone that steals medication off their mom?
NATHAN: It hasn’t changed the way I feel about you, Jimmy. That took a lot of guts.
AMBER: Yeah, it did. You’ve done really well to trust us.
GEMMA: What you’ve just done, I could never do that. It’s really brave.
MARK: Just remember, that wasn’t you, Jimmy. That was the addict.
SAM: Jimmy, I just think it was great that you managed to get it out there.
ASHWOOD: We see at the start of this vignette, Sabina bringing up the same issues she did last week. Her peers have now become frustrated with her and point out the pattern. Mark suggests something that could be quite helpful. But once again, his interpersonal style comes across as attacking. And the group quickly give up on offering any more support to Sabina.
During this process, Jimmy’s clearly sitting in a lot of discomfort. And when he finally speaks, the rest of the group appear to detect this and give rapt attention. It’s clear something different is going on now. Disclosures such as Jimmy’s can be fairly common in addiction support groups when there’s enough cohesiveness in the group and readiness in the individual to disclose. They can be very powerful agents of change for a number of reasons but should never be forced.
Some clients get the message from certain treatment philosophies that you’re only as sick as your secrets, or that unless you expose your shame, it will eat you up and sabotage your recovery. There’s actually no evidence to support either of these views. However, if and when people are ready to disclose shameful aspects of themselves, it gives a clear message of trust, which almost always brings the group members closer together by giving others permission to take risks and make further disclosures themselves.
There are a number of benefits for the group and for the individual in this. As other group members identify with Jimmy, they also are taking risks and exposing their vulnerability, entering into the circle of trust with him. However, Jimmy seems too wrapped up in his remorse to receive the gifts offered to him at first. But the communication clearly takes the group to a much deeper and more involved level of interaction than previously. Even Mark shows some interpersonal sensitivity with his identification.
Rather than focusing historically on the content of the disclosure, as Nathan does, Jax takes the opportunity to stimulate the second stage of interpersonal learning in the here and now. After the first stage, a genuine, emotionally laden interpersonal experience has occurred, the therapist has the opportunity to help the group illuminate the process. In this case, Jax invites what we might call a meta disclosure, a disclosure about the disclosure, pointing the group into the here and now, inviting them to explore what the event said about the relationships between the people in the group.
By asking what allowed him to share his story, Jimmy is able to highlight how another member of the group has affected him, and how he feels towards them as a result. Jax probes further, and Jimmy is able to highlight how he’s developed trust with the members of the group. This will have a tangible effect on the relationships with the other members and on the group as a whole.
But by saying “Now you all know the real me,” Jimmy portrays continued feelings of shame. So Tim offers another classic intervention designed to elicit further meta disclosure by asking what he was afraid would happen if he shared this. Jimmy is then able to identify the root of his shame in the group, that people would reject him and disrespect him. This reveals an even deeper level of intimacy, as he shares his fears.
However, the feared catastrophe doesn’t occur. People are quite clear that, on the contrary, rather than looking down on him for his past actions, they admire and respect his current honesty and courage. When someone realizes that they are not judged by others about historical actions for which they judge themselves, it can be a great help to that person to give up their self-judgement and put those events in the past.
GEMMA: Thank you. Jimmy, I really appreciate what you said. I just don’t get this group. I just don’t see how it can help me.
LOUISE: Gemma, my take is you don’t get anything from group because you don’t give anything.
NATHAN: I kind of agree with that. You don’t participate.
MARK: How can we help you? We don’t know anything about you?
BRIAN: Gemma, I don’t know anything about you either.
LEIGHTON: You know, I get something of the same feeling, Gemma. I find it very hard to have anything to offer you, because I don’t think you really show yourself in the group.
BEATTY: Gemma, when you were out there drinking, how was it for you?
GEMMA: Fine. It made it bearable. It medicated the anxiety, matched the misery. I didn’t need anyone.
SABINA: Gemma, that’s how I kind of feel you are in here, like you don’t really need us.
BEATTY: Gemma, when you were out there drinking and keeping people away, it’s as if that’s what you’re doing here now with your group?
BRIAN: That’s right. It’s like you’re not even there.
HORACE: I’d like to hear more from you as well.
LOUISE: Gemma, I understand. When I came in here, I could not say anything.
JIMMY: Do you know what, Gemma? I found it hard to trust. I didn’t want anyone to see that I was scared. Why would I?
LEIGHTON: So how can the group help Gemma?
AMBER: Gemma, we’ve spent a bit of time together now, and I’ve gotten to know you. And it means a lot that you’ve opened up. I’ve got a friend, I’m going to have one now for a very long time.
LEIGHTON: So Gemma, how can you get the help that you need in this group?
AMBER: Do what you do with me. Just open up.
BEATTY: Can you do that?
GEMMA: I don’t know how.
LEIGHTON: Well, you’ve got a lot of help here.
GEMMA: I guess I have to.
LEIGHTON: Gemma returns to her previous week’s theme, her confusion about how group therapy can possibly help her. Louise offers what could be some quite challenging interpersonal feedback. However, the relationship she has with Gemma and her tentative delivery make it much easier for Gemma to hear. The rest of the group pick up on this and echo Louise’s comment.
I decided to let Gemma know that I agreed with the group’s perception and that I had some trouble finding a way to help her. I tried to be as gentle and respectful in tone as possible. But I wanted to add the authority of a facilitator to the idea that Gemma is to a great extent responsible for her own experience in the group, and that the answer to her question is in her own hands.
It is sometimes helpful for the therapist to share his or her own perception or feeling about what is happening in the group. Although facilitators are not group members, they are very much part of the process. Members are relating to them too and vice versa. They have the power to be good role models and to teach the group how to be more effective. But they must take great care not to undermine the group’s responsibility for its own functioning. Sharing one’s own perceptions judiciously and with respect also shows a human side. However, much more rarely, if ever, is it appropriate for therapists to regale the group with anecdotes about their own past or current issues, even if they are themselves recovered addicts identifying with material their clients are bringing,
Here, in fact, Gemma is showing some vulnerability, but in a rather controlled way. She’s avoiding acknowledging her feelings explicitly and not giving any indication of why she’s in treatment, and thereby appearing unavailable for help. The group are unsatisfied with this and try to highlight it to her. Jax makes a practical intervention by asking her how she was before coming into treatment. This does allow Gemma to show something of herself and deepen her relationship with the group and also helps her to reveal the reason for being there.
Importantly, Gemma highlights the personal connection between her alcohol misuse and her relational problems, and how she has brought the avoidant relational style she used to cope in addiction with her into the group. This is a well-recognized process where given a relatively unstructured group, people inevitably bring their interpersonal style into group. It’s an essential process for effective group therapy, as there is no need for people to explain their interpersonal problems. They are manifest first-hand, right in the here and now of the group.
Through feedback, clients can learn for themselves how the way they have learned to relate interpersonally isn’t working for them. And in the group, they have an opportunity to experiment with new styles of relating. In the case of Gemma, the group clearly point out to her how frustrating they find her not needing anyone attitude but also let her know that they do want to make a connection with her.
We also see here evidence of the increased cohesiveness and trust that has developed in the group. Members are able to offer feedback in a much more gentle and supportive manner, many focusing significantly more on identification, speaking from their personal experience. I ask how the group can help Gemma, highlighting that therapy is a two-way process. And it isn’t just Gemma’s responsibility to make the process work. This allows Amber to take a risk and offer some uncharacteristic softness by expressing her appreciation of Gemma’s friendship. She highlights Gemma’s ability to open up to her in one-to-one situations and encourages her to show that same courage in the group.
While Gemma’s confusion and distress is clearly evident, the support and cohesiveness of the group allows her to tolerate this and express her willingness to make an effort just the same. We join the group meeting a week later.
LOUISE: I’ve got something I want to say. I feel really ashamed because I don’t believe in hitting children. But when I was drunk, I smacked my daughter. I hurt her, and it’s bad.
GEMMA: Was it just the once?
LOUISE: No.
SABINA: Did you really hurt her?
LOUISE: I smacked her across the bedroom.
SAM: Hey, Louise, I’ve got kids. I know what it’s like. Tempers just flare up and they get too much. It all goes mad. I don’t know anyone who’s got kids and hasn’t hit them sometimes– sometimes in the wrong way.
LOUISE: Look, I was out of control. And I was drunk. It’s not okay. I smacked my daughter across the bedroom. It’s wrong.
LEIGHTON: Louise, when you bring this stuff today, what are you hoping for? What do you want from the group?
LOUISE: I didn’t know what to say. I didn’t know what they would say.
JIMMY: Well, do you know what, Louise? It takes a lot of guts, so hat’s off to you.
MARK: Yeah, people have done worse.
SABINA: You’ve moved on. You’re taking a risk. You’re very honest.
BRIAN: Yeah, we’ve all done stuff we’re not proud of.
LOUISE: Like what?
BRIAN: I’ve done stuff. Me and my girlfriend, when we were drinking, we used to get into arguments, heated debates. And yeah, I hit her. She even ended up in hospital And I had to spend the night in the cells because of her. I don’t believe it.
HORACE: Boo-hoo, poor you.
BRIAN: What do you mean? I was drinking. I just said that.
HORACE: That’s no excuse, hitting a woman. Look at the size of you.
BRIAN: Listen, you know what they’re like. They push your buttons. It’s what they do.
HORACE: That’s a bag out of order in my book.
SABINA: It’s what they do?
GEMMA: Brian, what you’ve just been saying has made me really angry.
SABINA: It’s really dismissive.
AMBER: You’re disgusting. I can’t do this anymore. I’m just not getting this. I’m really not getting this.
MARK: Here we go again, Amber, same old negativity. You never bring anything positive to the group. You’re just not getting this recovery, are you?
AMBER: I’m just saying how I feel.
MARK: Yeah, but it’s never constructive. All you do is moan and criticize. It’s about being positive. You need to get with the program.
NATHAN: He’s got a point, Amber.
BRIAN: You’re just aggressive.
AMBER: That’s rich, coming from you.
SABINA: I guess I think sometimes, Amber, it is really hard to give you feedback, I’m quite worried that you’ll attack me.
LOUISE: I agree.
MARK: You never bloody listen, Amber. Do you know what I think you should do? Take the cotton wool out of your ears and stick it in your mouth.
AMBER: I can’t do this.
BEATTY: Amber, I think if you can stick with this, there might be something really useful for you.
AMBER: Look, I really don’t feel safe in this group.
LOUISE: I agree.
SABINA: Yeah, you’re right. It is like any time anyone brings anything important to– into this group, there’s just this massive judgment.
SAM: That’s what I think. I just think this has all become too judgmental. This has all just been judgment.
LEIGHTON: So where do you think the judgment is coming from?
LOUISE: It’s coming from the guys.
SABINA: Yeah, I think it is.
HORACE: It’s not coming from me. I mean, Brian, yeah, and Mark as well, and even Nathan a bit.
AMBER: Mark’s been judging.
LEIGHTON: Mark, when you were giving feedback to Amber just now, what were you trying to achieve for her?
MARK: I was trying to help her.
LEIGHTON: And what are the group saying about the way you do give feedback?
MARK: They’re saying I’m being judgmental, and I don’t believe it.
LEIGHTON: Mark, it seems as though, despite wanting to be helpful, you’ve come across as judgmental to quite a few of the group. Are you satisfied with that?
MARK: No, of course not.
LEIGHTON: So why don’t you ask the group to give you some explanation of how you’re coming across in that way?
JIMMY: I’d hate to be running this group.
SABINA: I don’t think it’s just the women.
SAM: No. No, it isn’t.
LEIGHTON: Can we tell Mark how he’s coming across?
HORACE: Yeah, well, Mark, I mean, you’re always telling other people what to do, like you should do this, you should do that. It just be better if you speak for yourself, just talk about your own feelings.
NATHAN: Yeah. Mark, you’re always just full of 12-step cliches. You’re quoting from the book, always giving lip service.
SAM: Mark, I just feel it’s disrespectful. You’re always telling people what to think.
LEIGHTON: Mark, it sounds like several people are saying that the way you give feedback is not very effective. How can Mark be more effective? How can you be more effective when you give your feedback?
JIMMY: Well, Mark, you actually have quite a lot of talk for the group. People are getting in touch with their vulnerability here, and you should do the same. Don’t be Mr. Recovery all the time, man.
HORACE: Yeah, I like you, Mark. You’re a good guy. And just speak for yourself, just how they keep saying use “I” statements.
NATHAN: Yeah, stop quoting from the book. Start to identify.
LEIGHTON: So it sounds like people are saying that you’ve got a lot to give the group, that you often have some sensible ideas, but that you need to speak from your own position and talk more about yourself. How do you feel you could do with that? I mean, do you feel that’s a doable thing?
MARK: Well, it’s lots to take onboard. And I had no idea, really, how I came across. But yeah, it’s a lot to think about.
LOUISE: I really do hope you take it onboard, Mark, because you have a lot to offer.
ASHWOOD: The group cohesiveness that has built up through particular individuals taking some risks– sharing, identifying, supporting one another, and beginning to offer interpersonal feedback– seems to have set up an adaptive spiral which has begun to allow some of the more reserved clients to share aspects of themselves that previously didn’t feel safe to expose.
At the beginning of this session, Louise follows Jimmy’s example and discloses things that she did whilst in active addiction. While this is external material or content, there’s still an interpersonal process occurring. She’s showing a level of trust and openness to the group that she hadn’t before. However, in response to this, many of the group are still struggling to go beyond focusing on the content of the disclosure. And this doesn’t seem to offer much support for learning or change.
Sam chose a deeper level of interpersonal sensitivity by trying to normalize Louise’s behavior and hints that maybe he’s done similar but doesn’t quite go as far as admitting this. It isn’t entirely clear what Louise is wanting for the group in making her disclosure. To highlight the asking for detail about the event isn’t what she’s looking for. Tim makes the question of her intention explicit. She doesn’t seem sure, but by saying, I didn’t know what they’d say, it hints there’s some interpersonal anxiety about the group’s response.
Jimmy appears to pick up on this and offers support by affirming her courage in bringing this to the group. Other group members follow this lead, but Louise doesn’t seem to want to let it in. Finally, she chooses to challenge Brian’s rather generalized comment, “We’ve all done stuff we’re not proud of.” and this changes the dynamic of the group significantly. As Brian discloses his violence while under the influence- NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
BEATTY: How the group respond to Brian’s disclosure is starkly different to any of the previous sharings. He blames his violence on drink and on his partner. Some of the group make efforts to try to explain their reaction to him, essentially, that he’s not taking responsibility for his actions, which is a treasured group norm. The attacks escalate. But Brian’s lack of response leaves an uncomfortable silence.
There was a useful opportunity here for the therapist to invite the group to explore the difference between the way Brian’s disclosure was received and that of Jimmy and Louise’s. This could have addressed what happened in a way that allowed Brian to take part in an exploration of the process from an observer’s stance, and so be less defensive. This might have offered him a better opportunity to understand what it was about his manner that left him outside the group.
Also, other members in observing the process this way might have been able to see whether they came across in a way that was congruent with their intentions when giving feedback. However, in this instance, Tim and I choose to stay with the discomfort that is evident in the room and give the group an opportunity to find its own way. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
LEIGHTON: When Amber expresses her frustration, Mark attacks her with what might have been helpful feedback, if it had been delivered more appropriately. Other group members try to pick up on the point that Mark is making. But the attack has left her defensive. Mark’s final assault is too much for Amber, and she gets up to leave. Jax’s quick and careful verbal and gestural intervention supports her in staying. But I would point out, this doesn’t always happen. If group members leave in situations like this, it’s useful to have an arrangement about how it’s dealt with. This might mean one of the therapists present leaving, or asking a senior member of the group to encourage them back in, or alert staff elsewhere in the building to do this.
While we do what we can to moderate the anxiety levels in this personal group therapy, they can become emotionally charged. And this is a high-risk situation for people in early recovery. Getting people back into a group they couldn’t tolerate is almost always the most therapeutic outcome. A skillful exploration of the process right at that person’s growing edge helps them to understand what occurred, what was theirs, and what were other people’s parts in it, and also to realize that they can tolerate tension and conflict. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
ASHWOOD: The group dynamic shifts, and Gemma, Sabina, and Sam start to identify what they see as unhelpful, the things that are undermining the cohesiveness of the group. They highlight in general terms how they’re feeling judgment. Generalized comments like this can often be turned into opportunities for interpersonal learning by asking people to be more specific. Till now, Mark’s way of communicating has gone unchallenged. And in early recovery, it’s often better to help people to use their defenses constructively than to confront them head-on in an attempt to eradicate them.
However, Mark’s relational style has experienced a somewhat aggressive and undermining of group cohesiveness. But something needs to be done to help him work as part of the group. Tim asks for people to give more specific feedback. And they then begin to focus their comments on individuals. Amber, staying in the room, begins to bear fruit, as she’s able to name Mark. This is the start of an important process for him, and one that illustrates how interpersonal learning can be so effective of facilitating character change.
Tim’s first intervention helps Mark to understand and state his intention in giving Amber feedback. Then he asked him how he’s hearing he comes across to others. This highlights the dissonance between his intentions and the reality of the situation. Initially, Mark characteristically denies he is this way. This is reasonable. He doesn’t see himself as judgmental. But the power of Tim’s next intervention isn’t in challenging Mark’s perception of himself. Instead, it’s in asking him if he’s content that he comes across to others quite differently to how he sees himself. The fact that Mark wants others to see him as he does offers the therapeutic leverage to ask him to invite feedback on how he’s perceived and how he might do things differently. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
AMBER: I want some help from this group. I’m not getting it. Can somebody help me?
MARK: People have tried to help you, Amber. I don’t think you can be helped.
NATHAN: You just ooze negativity, Amber.
LOUISE: So angry.
MARK: It’s hard to help somebody who looks like they don’t want it.
SAM: Amber, do you want to be helped?
BEATTY: Amber, you know this struggle that you’ve got into with the group, is this familiar?
AMBER: I don’t know.
BEATTY: You’ve been here before?
AMBER: I don’t understand.
BEATTY: When you came to me, and we had an assessment, and you asked for help, what were you feeling like then?
AMBER: I was weak. I’ve reached my rock bottom. I left my flat. I’m no one.
LEIGHTON: So how is Amber in the group? Do we see that side of her?
BRIAN: She’s angry.
MARK: Yeah, I’d say angry.
GEMMA: She’s supportive to me.
SABINA: A bit dismissive, bit like she doesn’t really care about us.
HORACE: Look how she puts up a shield.
SAM: Amber, you come across like you don’t want help, or need anyone, or anything.
JIMMY:I think you actually come across as quite a hard person.
LEIGHTON: Is that how you see yourself, Amber? Do you think you are a hard person?
AMBER: Life’s hard. It’s how I have to be. Life’s made me like that.
LEIGHTON: But is it how you would like to be seen?
AMBER: No.
BEATTY: Amber, you know when you were giving Gemma feedback, where were you coming from? Which part of Amber was that?
AMBER: She’s my friend.
NATHAN: See? You’re showing your vulnerability now, Amber. I feel a bit more closer to you.
JIMMY: Yeah, I mean, why can’t we see more of that?
BEATTY: So is this an Amber the group hasn’t seen before?
JIMMY: Definitely.
LEIGHTON: So when you come to group, and you are this hard, aggressive person, how do the group experience you? What are you hearing that they– how you come across to them?
AMBER: I don’t listen, then I’m aggressive.
LEIGHTON: Is that true?
AMBER: No.
LEIGHTON: So in order to survive, you’ve had to put up, as what Jax calls it, a shield– a hard, aggressive shield. But when you present this in the group, they can’t really get through to you. I mean, is it all right for Amber to be angry? NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
ALL: Yeah.
SAM: Yeah, sure.
LEIGHTON: Is it okay for her to be frustrated some of the time?
ALL: Yeah, of course.
LEIGHTON: So what would you like Amber to be showing the group? What would you like her to be bringing to you?
NATHAN: How she’s feeling.
MARK: If you have honesty, it would be good.
SABINA: Yeah, maybe let down some barriers.
JIMMY: When you start trusting the group, Amber, that’s when you’re going to get more of it.
LEIGHTON: Amber, do you trust anyone in the group?
AMBER: No.
LEIGHTON: Is there anyone you admire?
AMBER: Gemma and Jimmy.
LEIGHTON: So what is it about the way that they’re doing, presenting themselves, that makes you admire them?
AMBER: How Jimmy spoke about his mom. It must have been really hard.
LEIGHTON: How is Amber coming across right now?
SABINA: I feel like she’s listening.
MARK: And I feel like it’s the first time she’s actually getting real.
NATHAN: I’m actually seeing a much softer side to you, Amber.
JIMMY: I feel more willing to work with you now.
GEMMA: Much different.
BEATTY: How are you right now, Amber?
AMBER: It feels uncomfortable. It feels weird.
LEIGHTON: Dealing with Mark’s part in this process appears to have allowed Amber to come back to her confusion and frustration as to how the group might help her. They try to offer her interpersonal feedback with varying degrees of skill. Jax attempts to ratchet up the therapeutic leverage for Amber to take responsibility for her situation by connecting Amber’s present struggle in the group with previous observations. However, this isn’t something she can engage with. So Jax takes a different tack and invites her to show a different aspect of herself by reminding her of her vulnerability before coming into treatment.
I then highlight the difference between the vulnerable Amber and how she normally presents herself in the therapy group by asking the members to say how they usually see her. I pick up on Jimmy’s suggestion that she appears hard and ask Amber how she sees herself. Amber initially justifies her presentation by pointing out why she needs to be hard. However, when asked if she wants to be seen this way, it appears she doesn’t, once again illuminating the dissonance between how someone wants to appear and how they actually do.
Jax once again invites Amber to show a different side of herself by drawing her attention to the softness with Gemma, and the group appreciate the shift. I underline this learning by summarizing the process in collaboration with Amber and go on to validate her emotions, as it’s important that she and the rest of the group realize it isn’t the emotions themselves that are problematic, but the way they are expressed.
I then invite the group to suggest how she might relate to these feelings in a way they can better connect with. After this, I go on to invite further interpersonal learning for Amber by asking if she trusts anyone in the group. She honestly replies that she doesn’t. But since I am confident that she has some attraction to some of the group members, I ask if there’s anyone in the group she admires. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
The exploration of her admiration of Gemma and Jimmy warms the bonds between these people and develops group cohesiveness, as well as giving them affirmation of the qualities that are appreciated in them. In doing so, it also helps Amber to think about how she might be different and act differently in relationship with others. The warm and affirming feedback she receives is quite different to the way she’s been related to in the past. And although she is somewhat uncomfortable with it, she clearly likes this new found intimacy. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
ASHWOOD: Brian received quite an attack from the majority of the members of the group at the beginning of this vignette. And the session didn’t give much opportunity to resolve his rejection by the group. After this, he discharged himself from treatment and did not return. Sadly, not an uncommon event when working with substance misuse.
Whether the therapists might have been able to deal with the situation in a way that made it more likely he would stay is a question they’re left with and something they could pick up in clinical supervision. But apart from this, in many ways, it’s an example of a good and hardworking interpersonal group. Although the cohesiveness is still fragile, there is enough trust and value in the group for people to remain and to tolerate tension, to give and receive interpersonal feedback, even when it’s difficult. With the guidance of the therapists, Mark and Amber come away with significantly different experiences as a result of their peers’ abilities and willingness to offer more skilled feedback. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
We join our final vignette with Brian absent from the circle.
HORACE: We wound up sitting here. We sit in these groups day in, day out, just talking, talking, talking. And I just want to read like navel-gazing. This ain’t what recovery’s about. Recovery’s out there, man. I should be living my life, getting a job, earn some money, or something.
GEMMA: Horace, therapy’s just so self-indulgent. We’re all going to be out on our own anyway, so why don’t we just get on with it.
MARK: Well, this isn’t how we keep clean. We keep clean by going to meetings, getting a sponsor, and working the steps. It’s working a program. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
NATHAN: You’re still carrying on like the other day, Mark, full of cliches.
MARK: They’re not cliches. It’s life or death.
NATHAN: Not everybody gets recovery the way that you do.
MARK: That’s what I know.
SAM: This is all a diversion. I’ve said it before. It’s a waste of time. Can’t we just focus on what’s important?
JIMMY: Do you know what, Mark? We never get to hear about you– the real you.
LOUISE: What’s going on for me is, where is Brian? I’ve heard he’s using.
BEATTY: So what do we think is going on in the group?
LOUISE: I’m scared. Brian’s out there, and I’m thinking about it. He’s been in treatment three times, and he still doesn’t get it.
SAM: I’m scared too. This is for me. This is my last chance to learn. This is the last chance I get.
SABINA: Yeah, I’m scared too. It’s fear. I think I don’t have enough time left here. I need more time here.
You’ve been in recovery a few times, haven’t you, Mark?
MARK: Yeah, three times. And relapses got lower and lower. But I had two years clean time last time and determined to get it back. I’ll do it right this time. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
NATHAN: I’m sorry about Brian using, but I’m here for myself. You come in on your own. You’re going to leave here on your own.
HORACE: Well, it’s easy for you to say, Nathan. But tell you, I’m worried as well. I mean, look, Brian’s out there using. Mark said he’s relapsed before. There’s no guarantees, is there?
AMBER: We’ve had something to do with this, with Brian. We were really harsh on him.
LEIGHTON: So what’s bothering you, Amber?
AMBER: When Brian opened up about his girlfriend, I judged him. There was no empathy in the room.
GEMMA: Yeah, but he didn’t exactly open up, did he?
NATHAN: He just made a statement about his girlfriend and just left it open.
SABINA: Yeah, but I’m wondering if we could’ve given him more support.
GEMMA: I mean, it wasn’t what he shared. It was, well, he just had no remorse.
LOUISE: Do you know what? I don’t think it was that last group, though. Maybe he wasn’t serious from the start.
JIMMY: Yeah, I mean, Brian is out there using, and I’m gutted. But Brian knows what he has to do if he wants recovery. We’re all still here. Nathan, we are here for ourselves. But at the same time, we’re here for each other. And I’ve seen this group getting stronger and stronger.
SABINA: Wow, just listening to you, it’s like I know I’ve got so much respect for so many people in this room.
BEATTY: Can you say who?
SABINA: Amber, actually. She’s really changed.
LEIGHTON: Well, who’d have thought it?
LOUISE: Yeah, you’re really changing.
MARK: Yeah, even I could see a change in you.
JIMMY: Now I really feel like you’re one of us now.
BEATTY: It’s a bit of a special day today. It’s Jimmy’s last group.
LEIGHTON: Yep. You finished the program, Jimmy. You know the drill. I’m going to ask you to say a few words to your group about how treatment’s been for you.
JIMMY: First of all, I just want to thank Tim and Jax, really, for your support. And you’ve been amazing. I’ve been here 12 weeks now, and it’s been a struggle, I’ve got to admit. But at the same time, in a weird sort of way, I’ve really enjoyed it. I’ve learned a lot. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
I just want to, I suppose, take this opportunity to just say to a few people a few things. Gemma, for one, you’ve learned to trust the group. And trust is really important in this environment. In order for the group to work, there’s got to be trust in it. And I’ve seen that in you a lot.
Amber, I mean the change in you is amazing. You came in here, and I didn’t even want to speak to you. And now I feel I can have some sort of connection with you. I can have a conversation with you. And Sam, you’re the newest member in this group. And I can see you’re a clever bloke. I can see you’re going to be good for this group. You just make sure you keep putting in, and you’ll definitely get what you’re putting out. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
And last for Mark, my best mate in here. God, we’ve been through a lot. You’ve helped me through some hard times. The only thing I say to you, mate, is ease up on the recovery talk. Open up a little bit more, and I feel you’ll do fine.
MARK: Thanks, man.
JIMMY: Anything I say or advice I’ll give is just trust each other. Work with each other. You’re not here to fight. You’re here to get better. You’re here to help each other. And the thing, if you carry on going the way you’re going at the moment, I think you’re all going to have a brilliant recovery. I think you’re going to do really well. I just want to thank you all.
MARK: Cheers.
NATHAN: Cheers, Jimmy.
LEIGHTON: Well done, Jimmy. And we’ll see you at Aftercare on Thursday.
This group starts with a demonstration of many of the signs of an uncohesive group. People who till now have been dedicated group members, are devaluing therapy and the group, as well as looking forward to other activities external to the group for the support they need. This is an indication for attention and action on the part of therapists. As if members continue to mistrust the group, at best, it is unlikely they will invest in or learn anything from it. At worst, people will leave.
Nathan makes some attempt to highlight how people aren’t helping the group process. But his style is rather over-confrontational. Sam is able to step back from the process and suggest that the group could be more helpfully directed. But it isn’t until Louise names the elephant in the room– Brian’s absence– and Jax picks up on this, that the unspoken tensions become explicit.
It’s an axiom of interpersonal group therapy that when something important isn’t being acknowledged in a group, then very little meaningful work can be done in it. Once the clients start to express their real fears, the cohesiveness in the group builds again rapidly. Amber’s newfound willingness to show a little vulnerability is evidenced as she begins to worry about the group’s and indeed her own part in Brian leaving. This leads onto a useful and material exploration of how the members of the group may have played a role in Brian’s leaving. Some individuals focus more on their own part in it, and others focus on Brian’s, each expressing their individual tendencies for responsibility attribution.
This might have been a useful opportunity to highlight people’s different reactions to Brian’s absence. However, the importance dealing with the anxiety his leaving and relapse have engendered rightly takes precedence. The result was that the group were able to agree that Brian was primarily responsible for his own mistakes, that they still cared about him, and that his leaving did not mean that their own treatment was doomed to failure. The more experienced members come out of it reaffirming their commitment to and the value of the therapy group. And with the support of Jax, their valuing of each other.
BEATTY: This is Jimmy’s last group, so it ends with a somewhat formulized ritual for him, as he’s graduating from the treatment program. Giving senior clients an opportunity to say something to individual group members at the end of their last group, and to summarize their own journey, can help the other participants see how far a person has come during treatment. This has the important therapeutic effect of instilling hope for change. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
It’s also a chance for that person to offer specific interpersonal feedback to members they are concerned about, as he does with Mark. This ritual process can be done in different ways according to the traditions of the treatment setting. But some kind of empathic acknowledgement of the milestone they have achieved is an important part of the transition when an experienced person leaves the group, for the group as a whole, as well as the person leaving. At the end, Tim mentions the Aftercare program that Jimmy will be moving onto. This is a much less intensive support system than the one Jimmy has been using till now in his recovery but an important next stage to ease his move into an independent life.
LEIGHTON: Working therapeutically in the field of substance misuse is at least as challenging and complex as working with other mental or physical health problems for which regulated bodies ensure minimum standards of training for clinical practitioners. An absence of regulation in addiction work is not an excuse for an absence of standards. For this reason, although these vignettes and commentary offer a glimpse into the theory and practice of interpersonal group therapy and addiction treatment, they’re clearly not sufficient in themselves as a clinical training in the model. It’s essential that those wishing to lead therapeutic groups of individuals recovering from substance misuse seek out robust, accredited training programs, such as those offered currently and being developed by Action on Addiction.
Other ways of developing good practice involve forming special interest groups, peer supervision groups, and seeking competent external supervisors who understand and are experienced in using this model. It would be marvelous to be able to tell you about a robust body of research evidence supporting this model for addiction treatment. Unfortunately, at this time, we can only rely on a clear and convincing rationale– clinical experience, some promising unpublished research, and the experience of clients of well-run treatment programs who tell us with great consistency that group therapy was the most valuable component of their own treatment. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
One of the reasons why such research is lacking is the lack of well-trained, well-supervised practitioners who can conduct this model of group therapy and addiction treatment in a well-specified, consistent, and faithful way in order that meaningful research can be done. We are hoping that these materials may play a small part in encouraging the development of such a group of practitioners.
The Levy family
The Levy Family Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school. Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Sheri is in good physical condition and has recently found out that she is pregnant with their third child. As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Neither report having criminal histories. Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jake’s recent behaviors, they have slowly isolated themselves. My first encounter with Jake was at an intake session at the Veterans Affairs Health Care Center (VA). NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction. During this meeting, Jake stated that he came to the VA for services because his wife had threatened to leave him if he did not get help. She was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him his drinking had gotten out of control and was making him mean and distant. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He told me that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep. Jake admitted to drinking heavily nearly every day. He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He spent his evenings on the couch drinking beer and watching TV or playing video games. When we discussed Jake’s options for treatment he expressed fear of losing his job and his family if he did not get help. Jake worked in an office with civilians and military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he sometimes felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors. Based on the information Jake provided about his diagnosis and family concerns, we agreed that the best course of action would be for him to participate in weekly individual sessions with me and a weekly support group that was offered at the VA for Iraq veterans. I then offered a referral for couples counseling at the local mental health agency. I also printed out a list of local Alcoholics Anonymous (AA) meetings in his area if he decided he wanted to attend in order to address his drinking. He would continue to follow up with Dr. Zoe on a monthly basis to monitor the effectiveness of his medications. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction. The following session, I spent time explaining his diagnosis and the symptoms related to PTSD. Jake said that he did not really understand what PTSD was but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expressed concern that he would never feel “normal” again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased. I explained to Jake that PTSD is a severe anxiety disorder that develops after a person has experienced an event that results in psychological trauma. The event may involve the threat or perceived threat of death to oneself or to someone else. I also explained that the disorder is characterized by re-experiencing the traumatic event, including the symptoms of increased arousal, and by the desire to avoid stimuli associated with the trauma. We talked about how his behaviors fit into this cycle of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation and heavy drinking. He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for potential problems around him. He told me he always felt on edge and every sound seemed to startle him. He shared that he often thinks about what happened “over there” but tries to push it out of his mind. It is the night that is the worst as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. I gave him a handout on PTSD and reviewed the signs and symptoms. Jake seemed relieved to receive the information. I told 15 SESSIONS: CASE HISTORIES • THE LEVY FAMILY him that naming the issue or concern was often helpful in the healing process. During the first few sessions my goal was to help Jake feel safe and validate his feelings. We consistently assessed his feelings of safety, including any potential suicidal ideation. He was reluctant to attend AA at that time, so we began monitoring his drinking and his behaviors after several drinks. The Levy Family Jake Levy: father, 31 Sheri Levy: mother, 28 Myles Levy: son, 10 Jake began his individual sessions practicing techniques I had Levi Levy: son, 8 shown him to help reduce his anxiety symptoms. We used deep breathing and guided meditation to help him remain calm and in the moment. We started to chart when he had intrusive thoughts about the war, potential triggers to his hyperarousal, and when he tried to dissociate or numb in reaction to these episodes. Jake slowly began to share his experiences while in combat. I helped to gently guide him through the events that seemed to haunt him the most. I explained that telling one’s story in effect helped him “own it,” and in turn it would be integrated into his life on his terms. I told him that the act of telling his story can actually change the processing of the traumatic event in his brain. I was careful through this process not to push him into talking about events that seemed too traumatic for fear of re-traumatizing him. There were many sessions in which he started to share a specific event and then stopped mid-story and had to begin his relaxation exercises. During this time he had also started participating in the veterans’ support group. Jake reported that he was uneasy during the first couple of meetings because he did not know anyone, but that the other vets were supportive. He said it was helpful to hear from others who experienced the same feelings he had since he returned home. He said he no longer felt alone nor did he feel “crazy.” Jake also shared that he had started attending AA meetings. While I did not participate in the couples’ sessions, Jake felt it was important that I hear about how these sessions were going. He told me the social worker at the local mental health clinic helped Sheri understand what he was going through by teaching her about PTSD. The social worker explained how PTSD affected not only the individual, but the whole family and, in turn, the home environment. Jake said Sheri admitted that she did not understand what he was going through but that he was not the same person when he returned home from Iraq, and this scared her. Jake said Sheri seemed to be empathetic toward him and appeared to be relieved when the social worker explained his diagnosis. Jake said he and Sheri worked together to address her main concerns. She felt he drank too much, was not communicating with her, was isolating himself from the family, and appeared to be depressed. She was particularly concerned about his lack of interaction with his sons and lack of interest in the current pregnancy. She worried that he would be uninvolved in caring for this new baby just as he was uninvolved with his boys. Jake shared that in another couples’ session, Sheri talked about wanting to be able to communicate with Jake without feeling that she was “nagging him” or fearful that she was making him withdraw. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction. She said she avoided asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own. As it stood, she did not think she could talk with Jake about her concerns. She told him she missed socializing with friends and having family outings and felt isolated. Jake said just keeping his intrusive thoughts at bay took all the energy he could muster, so making small talk with friends was not something he felt he could do right now. Sheri admitted that she did not know that socializing affected him that way. He said the social worker explained that for veterans with PTSD, oftentimes crowds, loud noises, and open spaces triggered intrusive memories and caused anxiety attacks. He said that he and Sheri had developed a plan that would improve their communication. He said they were going to slowly begin planning outings that he felt he could handle, and that they also agreed that if at any time he felt uncomfortable while out that they would leave. Through individual, group, and couples sessions, Jake was able to address his trauma and his PTSD symptoms abated. He realized that drinking was being used as a way to avoid his feelings and attended AA meetings regularly. He has been able to maintain his sobriety and found a sponsor who is also a veteran. Sheri gave birth to a healthy baby boy, and Jake shared pictures of his son. He continues to attend group sessions and has become involved in some mentoring with young vets here at the VA. He feels strongly in giving back and has suggested that the VA begin a program that has been piloted in another state.
Levy Family Psychotherapy Approaches
Identify the psychotherapeutic approach that the group facilitator is using, and explain why she might be using this approach.
The specific psychotherapeutic approach applied by the group facilitator is a support model. That is because the group interactions are focused on discussing among themselves to develop a solution with minimal input from the facilitator. In fact, activities revolve around managing feelings, resolving conflicts, preventing relapse, early recovery, education on substance abuse, observation of culture, and education on family roles. In this model, the discussion is fixated on the group members, with a non-specific agenda to solve any existing social problems that revolve around substance abuse as a vice. Additionally, the discussion is open ended, facilitator involvement and activity is moderate, treatment duration is open ended, and the facilitator has specialized training that include process-oriented skills (Smith, 2012). In fact, Leighton (the group facilitator) is registered cognitive analytic psychotherapist with extensive experience. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
Other evidence of the support model as applied is seen in the first group scene when Brian approaches the group for advice on whether or not he can continue visiting pubs even though he is on the road to recovery. The group advices him that avoiding pubs would help in preventing a relapse. The therapist does not offer any advice. Rather, he guides the discussion by keeping the group on topic and highlighting areas that require emphasis such as Nathan’s point that Sabina and Brian keeping ignoring group suggestions, and asking Sabina whether she feels that the group discussions have been helpful. It is clear that all the group members are addicts who are seeking treatment and are holding an open ended discussion on how to solve their problems with the facilitator’s role being to guide them minimally (Psychotherapy.net, 2015). The facilitator is using the identified model since it offers the best match for the group and facilitator. Based on the facilitator’s skills, this model offers a good therapeutic experience for the group members (Smith, 2012). In this respect, the group facilitator has applied a support model since it matched the group members’ needs, their objective for seeking treatment, and the facilitator’s skills.
Determine whether or not you would use the same psychotherapeutic approach if you were the counselor facilitating this group, and justify your decision.
It is my opinion that the support model is a good psychotherapeutic approach for solving the addiction problem plaguing the group members. That is because it allows the group members to develop personalized solutions that fit their needs and that they can easily apply. Still, there are three elements I would be keen on adding to improve the model’s success. Firstly, I would add elements of problem solving therapy. Problem-solving therapy is a focused psychological intervention that involves the addict being taken through a series of defined steps that clarify the existing problem, what an ideal non-addiction state would entail, and solutions on how to solve the problems and achieve the desired ideal state. Applying this approach to the group would entail clarifying each group member’s problems, identifying their desired goals, generating a list of feasible solutions to the problems through discussion, and implementing the solutions with feedback at each step. Secondly, I would apply psychodynamic psychotherapy elements that emphasize the important of building a therapeutic relationship that allows for transference and countertransference. Applying this approach to the group would use both supportive and expressive elements to allow the group members to identity how past difficulties have built up to cause the addiction, thereby permitting them to understand and change future outcomes. Finally, I would apply elements of reminiscence therapy that progressively returns the group members to past experiences for re-evaluation. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction. Using this element would involve increasing the group members’ awareness of past experiences that shaped their life into its present form, with a view to re-examining and re-integrating salient experiences. This element would allow them to place their past failures and successes in perspective, resolve lingering conflicts, and find a new purpose in life thereby addressing the root-cause of the addiction (Katona, Cooper & Robertson, 2012). I believe that adding the three elements would allow the support model to achieve a more positive outcome as a psychotherapeutic approach for solving the addiction problem plaguing the group members.
Identify an alternative approach to group therapy for addiction, and explain why it is an appropriate option.
Other than group therapy, the group members can be managed using a guided self-help approach that entails identifying each client (group member) for personalized treatment. This strategy involves providing the identified member with the literature on addiction and relapse so as to improve his/her understanding and facilitate the development of a step program as part of the treatment plan. It is designed as a self-administered intervention strategy whereby the therapist introduces a range of reading material that has been derived from evidence-based interventions and designed specifically for the case. The therapist then monitors the client’s use of the self-help reading materials, lending facilitative and supportive aid in helping the client to achieve a higher level of awareness that enables greater personal control and avoid a relapse (Carr, 2012). Applying this strategy would entail offering every group member literature that offers information on addiction and how best to tackle it for positive outcomes. In addition, they can be assigned to a self-help group with other recovering addicts. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction. The group activities should be facilitated by a qualified therapist who has been trained in facilitation, conflict management, and listening. The group would be linked to an addiction management facility that offers promotion, support, and resources for the clients’ recovery while using a recovery focused approach with confidentiality policies.
References
Carr, A. (2012).
Clinical Psychology: An introduction
. New York, NY: Routledge.
Katona, C., Cooper, C. & Robertson, M. (2012).
Psychiatry at a Glance
(5
th
ed.). Hoboken, NJ: Wiley-Blackwell.
Psychotherapy.net (Producer). (2015).
Group therapy for addictions: An interpersonal relapse prevention approach
[Video file]. Mill Valley, CA: Author.
Smith, G. (2012).
Psychological Interventions in Mental Health Nursing
. Berkshire: Open University Press.
Assignment 1: Psychotherapeutic Approaches to Group Therapy for Addiction
When selecting a psychotherapeutic approach for a client, you must consider the unique needs and characteristics of that particular client. The same is true when selecting a psychotherapeutic approach for groups. Not every approach is appropriate for every group, and the group’s unique needs and characteristics must be considered. For this Assignment, you examine psychotherapeutic approaches to group therapy for addiction.
Learning Objectives
Students will:
• Evaluate psychotherapeutic approaches to group therapy for addiction
To prepare:
• Review this week’s Learning Resources and reflect on the insights they provide on group therapy for addiction.
• View the media, Levy Family: Sessions 1-7, and consider the psychotherapeutic approaches being used.
The Assignment
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In a 2-page paper, address the following:
• Identify the psychotherapeutic approach that the group facilitator is using and explain why she might be using this approach.
• Determine whether or not you would use the same psychotherapeutic approach if you were the counselor facilitating this group and justify your decision. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.
• Identify an alternative approach to group therapy for addiction and explain why it is an appropriate option.
• Support your position with evidence-based literature.
• Note: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. NURS – 6650N Psychotherapy with Groups and Families : Levy Family Case Study – Psychotherapeutic Approaches to Group Therapy for Addiction.