NRNP 6645 Analyzing Group Techniques Paper

NRNP 6645 Analyzing Group Techniques Paper

NRNP 6645 Analyzing Group Techniques Paper

College of Nursing-PMHNP, Walden University NRNP 6645: Psychotherapy with Multiple Modalities 

Analyzing Group Techniques Example Paper

Management of substance abuse and addiction can be done effectively using individual therapy, group therapy, family therapy, and medication use. Group therapy involves about five to fifteen patients receiving therapy from one or more therapists in one session. Individuals in group therapy usually have no relationship outside the therapy sessions, which is the opposite of family therapy (Messina et al., 2021). This paper analyses a video about Interpersonal Group therapy for addiction by Tim Leighton and Devin Ashwood. The aim is to identify the technique of group therapy demonstrated in the video, explain what was done well by the therapist and anything I would do differently, give insight into how the therapist handles his group, and describe how I would lead my own group session.

There are various techniques for group therapy. The video by Leighton and Ashwood mainly uses the interpersonal process of group psychotherapy and interpersonal relapse prevention as the primary techniques. Interpersonal process group therapy is a method where a therapist leads and focuses on the interpersonal issues of individual group members in a less organized group. After psychotherapy, interpersonal group therapy aims to improve the patient’s mood and behavior. Relapse prevention is a technique that aims to reduce the likelihood of degeneration after terminating the problematic behavior such as addiction (Messina et al., 2021). Both group therapy techniques were well demonstrated and properly executed. This was done by developing cohesiveness and trustworthiness.

From the video, I noticed that the therapist directed the group discussion well, as he helped the group illuminate the process. An example is when she would intentionally let things flow and only interrupt the group when necessary to clarify something. She asks Jimmy to elaborate on what was unique about the group that enabled him to share his experiences. A good therapist’s qualities include forming a working alliance, empathy, and genuineness (Moe & Thimm, 2020). The therapist is seen connecting the group members constantly and focuses their attention on how each individual’s experiences relate to each other.

The therapist was not flawless, and I feel like he did not show empathy, especially toward Jimmy. Jimmy’s emotions escalated when he described how he used to steal his mother’s drugs. The therapist just asks him plainly to ‘go on.’ This was not empathetic, and I would have handled this situation differently. I would have been empathetic by telling the patient that everything was okay and he would be fine. Empathy makes the patient feel like they are cared for and that someone understands what they are going through. Empathy and the ability to relate to the feelings of patients battling addiction are the cornerstone of successful group therapy (Esagianet al., 2019).

The main insight gained from the therapist is that a therapist should avoid forcing patients to disclose things they are not comfortable enough to disclose. A therapist should let clients express what they are most comfortable with. I understand that I can make clients disclose more information by showing empathy. I can also share my experiences and encourage other group members to participate and interact more. This they can do by sharing their interpersonal experiences. The insight gained from watching this group session will help me effectively conduct group therapy.

Occasionally, group therapy may have a member or members who are challenging to deal with. If I were conducting a group therapy session with such a member, I would approach the situation by first trying to determine the reason for being in group therapy. I would want to know what they hope to learn and achieve by being in therapy. I would then proceed by identifying ways in which I can make the member more involved in a positive way.

For example, if the member does not share easily or at all, I would help the member ease to share by focusing on a specific topic of discussion. They could then share their experiences on that topic. I would encourage the patient to relate a particular topic to their past experiences or share how that topic makes them feel. If a member were disruptive, I would tell them to respect other patients’ right to expression.

I would politely request that they wait for their turn to speak. I would ensure that patients speak in turns or when directly asked to speak. To elicit participation from the group, I would intentionally seek out patients who have minimal contribution to the group. I would do this by asking direct questions to such patients.

Groups have various phases during their evolution. These are forming, storming, norming, performing, and the adjournment phase (Dietz, 2020). I anticipate finding different behaviors during each of these phases. I expect that members who are verbal will be most active in the frothing phase. The storming phase may be accompanied by some members who may give unsolicited comments, and some may compete for attention. In the norming stage, members may show cohesion. In the performing stage, members may relate with honesty and try to deal with difficult issues.

Group therapy has both its advantages and disadvantages. One advantage is that it reduces the feeling of isolation among patients. It also helps patients progress as they discover that other people also share their struggles. The critical challenges in group therapy include privacy issues and disagreements among patients with different personalities (Rosendahl et al.,2021).

References

Dietz L. J. (2020). Family-Based Interpersonal Psychotherapy: An Intervention for Preadolescent Depression. American Journal Of Psychotherapy, 73(1), 22–28. https://doi.org/10.1176/appi.psychotherapy.20190028

Esagian, G., Esagian-Pouftsis, S., & Kaprinis, S. G. (2019). Empathy in psychiatry and psychotherapy. Psychiatriki – Quarterly Journal of the Hellenic Psychiatric Association, 30(2), 156–164. https://doi.org/10.22365/jpsych.2019.302.156

Messina, I., Calvo, V., Masaro, C., Ghedin, S., & Marogna, C. (2021). Interpersonal Emotion Regulation: From Research to Group Therapy. Frontiers in Psychology, 12, 636919. https://doi.org/10.3389/fpsyg.2021.636919

Moe, F. D., & Thimm, J. (2020). Personal therapy and the personal therapist. Nordic Psychology, 1-26. https://doi.org/10.1080/19012276.2020.1762713

Rosendahl, J., Alldredge, C. T., Burlingame, G. M., & Strauss, B. (2021). Recent Developments in Group Psychotherapy Research. American Journal of Psychotherapy, 74(2), 52–59. https://doi.org/10.1176/appi.psychotherapy.20200031

ANALYZING GROUP TECHNIQUES IBSTRUCTIONS

Group therapy can alleviate feelings of isolation and foster a supportive and collaborative environment for sharing difficult feelings in order to facilitate healing. For many people, being part of a group that has a shared understanding of a struggle provides a unique opportunity to gain understanding of their own experiences.

As you examine one of the group therapy demonstrations from this week’s Learning Resources, consider the role and efficacy of the leader and the reasons that specific therapeutic techniques were selected.

  • Select one of the group therapy video demonstrations from this week’s required media Learning Resources.

Required Media

THE ASSIGNMENT

In a 3- to 4-page paper, identify the video you selected and address the following:

  • What group therapy techniques were demonstrated? How well do you believe these techniques were demonstrated?
  • What evidence from the literature supports the techniques demonstrated?
  • What did you notice that the therapist did well?
  • Explain something that you would have handled differently.
  • What is an insight that you gained from watching the therapist handle the group therapy?
  • Now imagine you are leading your own group session. How would you go about handling a difficult situation with a disruptive group member? How would you elicit participation in your group? What would you anticipate finding in the different phases of group therapy? What do you see as the benefits and challenges of group therapy?
  • Support your reasoning with at least three peer-reviewed, evidence-based sources, and explain why each of your supporting sources is considered Attach the PDFs of your sources.

Required Readings

NRNP 6645 Analyzing Group Techniques Paper

Case Study Transcript

00:00 00:00:01,935 –> 00:00:03,560 TIM LEIGHTON: I’m Tim Leighton, and I’m

00:03 the director of professional education and research

00:06 for the charity, Action on Addiction.

00:09 This charity provides services for alcohol and drug

00:11 users and their families.

00:13 And we provide degree level education

00:15 in addictions counseling in partnership

00:17 with the University of Bath.

00:19 I’m a registered cognitive analytic psychotherapist

00:22 and have published several papers and chapters

00:24 on this therapy model and on interpersonal group therapy.

00:28 In 1985, I started my career as an addictions counselor

00:32 at a residential treatment center.

00:34 And armed with Irvin Yalom’s book and a huge video

00:37 camera– in those days, they were

00:39 about the size of the cameras on Match

00:40 of the Day– I set out to train myself in this group model,

00:45 as I had become convinced it had enormous potential

00:47 for addictions treatment.

00:49 Later, I learned a lot more about it

00:51 and began to teach the model in my courses.

00:53 I hope you found this video resource helpful.

00:57 JAX BEATTY: My name is Jax Beatty.

00:59 I’m an addictions and family counselor.

01:01 I have been facilitating groups for eight years.

01:04 When I was first trained in this model,

01:06 I was very enthusiastic about it.

01:08 I wanted to learn how to use it to the best effect,

01:11 to help people to recover from addiction.

01:13 I’m currently a cognitive analytic therapy practitioner

01:17 and work in a range of settings with addicted people

01:20 and their family members.

01:21 DEVIN ASHWOOD: My name is Devin Ashwood.

01:23 I’m an addiction counselor and program leader

01:25 for the honors degree in addiction counseling offered

01:28 in the United Kingdom by Action on Addiction.

01:31 My specialities are interpersonal group therapy,

01:33 as well as Mindfulness-Based Relapse Prevention

01:36 and cognitive therapy.

01:39 LEIGHTON: It is important to say that for ethical reasons,

01:41 the clients in these clinical vignettes are played by actors.

01:44 The scenarios were developed from

01:46 the clinical and educational experience of Devin Ashwood

01:48 and myself, who between us, have been practicing and teaching

01:51 interpersonal group therapy in addiction settings

01:54 for over 40 years.

01:56 The final scripts for the vignettes you will see

01:58 were arrived at through a process

02:00 of initially loosely scripting the characters

02:02 and scenarios, which actors were then

02:05 encouraged to improvise around.

02:06 This had the intended effect of replicating

02:09 some of the realistic, difficult, messy, and

02:11 potentially confusing situations that so often characterize

02:15 real life interpersonal therapy groups in these settings.

02:19 It is sometimes the case that video teaching resources

02:22 present their material for clarity’s sake

02:25 in too neat a way to seem realistic to experienced

02:28 addictions therapists.

02:30 We wanted to retain an authentic feel

02:32 but also help therapists understand and develop

02:34 a clear model and rationale for their group therapy work.

02:39 Perhaps the first thing to say is that these videos are not

02:42 in themselves a substitute for a training course

02:44 or continuing supervision in the model.

02:48 They’re intended to supplement such activities

02:50 and to act as an aid to creative thinking about the model

02:52 and its application in addictions treatment.

02:55 Although future videos will be produced by us demonstrating

02:58 more technical aspects of group facilitation,

03:01 we predict that this set of scenarios

03:03 will primarily illuminate the model, the process

03:06 of the group, and how it helps group members,

03:09 rather than teach a full set of facilitation skills.

03:12 Such skills are required by practice

03:14 in the company of and with the help

03:16 of experienced practitioners who may act as colleagues, models,

03:20 and supervisors.

03:22 This training aid was developed to help address the clear gap

03:25 in education and skills evidenced

03:27 in the field of substance misuse treatment.

03:31 One of the main ways people suffering from addiction

03:33 problems are offered support is through some form of activity

03:38 in groups.

03:39 However, professionals who lead these groups

03:41 all too often don’t have a framework

03:44 to understand how best to use groups.

03:46 There was an absence of a theoretical model

03:48 and a lack of understanding of what

03:50 is likely to be helpful in a group.

03:51 What you see presented here is influenced strongly

03:54 by the work of Irvin Yalom and Philip Flores,

03:57 who have both written extensively on this topic.

04:01 It is, of course, not the only useful way

04:03 of working in groups with clients

04:04 in transition or early recovery from addiction.

04:07 Skills training, provision of information, motivational work,

04:11 and discussion about recovery may all happen in groups.

04:14 And there is some evidence supporting

04:16 the effectiveness of group-based cognitive behavioral

04:19 approaches.

04:20 Interpersonal group therapy is by no means

04:22 incompatible with such approaches.

04:24 But it needs to be carefully distinguished from them

04:26 in the minds of both therapists and clients.

04:29 The groups have different tasks and should

04:32 be timetabled separately.

04:33 As we shall see, the more clients

04:35 come to understand how this type of group therapy works,

04:38 the better the group is likely to go.

04:40 But for us, the main rationale for using interpersonal group

04:43 therapy for addictions is that we

04:45 think that, among other benefits,

04:47 it builds resilience to some of the best evidenced relapse

04:50 precipitants, interpersonal conflict,

04:53 and what Miller & Harris have described

04:55 as a state of demoralization and alienation.

04:59 We like to think of this model of group therapy

05:01 as interpersonal relapse prevention, which

05:05 you will notice is the subtitle of our training package.

05:08 It is the most suitable group therapy

05:10 for those who are entering in developing recovery.

05:13 For example, it is frequently used immediately

05:16 after detoxification, although we

05:18 see no reason to think it wouldn’t be beneficial to those

05:21 starting their recoveries supported by a substitution

05:24 pharmacotherapy.

05:26 As recovery progresses, the group model

05:28 remains relevant and forms a useful after care

05:31 intervention for those who have completed their rehab programs.

05:36 There is also reason to think that this form of therapy

05:38 might help people make the best use of mutual aid groups,

05:42 although the form of group interaction

05:43 is very different in those groups.

05:45 Firstly, it’s important to point out

05:48 that complex and sophisticated social relationships are

05:51 a defining feature of the human species.

05:54 Our place on the evolutionary tree

05:57 is as the specialist in its personal relations.

06:00 Our ability to form relationships

06:02 may well explain our species’ survival

06:04 and eventual dominance.

06:06 And we now have a global social community

06:08 with the ability to instantly communicate across continents.

06:12 There is evidence that we are biologically

06:14 set up to attach to others and have a fundamental need

06:17 to be part of social groups.

06:19 It is also ensured that we will express

06:21 distress and unhappiness when we feel outside of social groups.

06:25 It’s a noted characteristic of addiction to drugs and alcohol

06:29 that an obsessional relationship with substances

06:31 almost always becomes harmful to human relationships.

06:35 Some people begin addictive careers

06:37 before ever fully developing the ability

06:39 to have supportive adult relationships.

06:41 But even those who become addicted later,

06:44 by the time they are ready to seek treatment

06:46 for their problems, years of obsessional drink or drug use

06:49 is likely to have caused significant harm

06:51 to any good relationships that may have developed.

06:55 In addition, people forget how to get

06:58 their social needs met outside the context of drink or drugs.

07:01 Substances invariably become a mediator

07:04 in all major relationships.

07:05 They may be a shared interest or used

07:08 to get close to someone else.

07:09 Or they may be used keep people away, or to express anger,

07:12 or to punish others.

07:13 There are many ways substances become pivotal

07:16 in the relationships of those seeking help.

07:20 Learning how to have supportive mutual and satisfying

07:23 relationships free of drink and drugs is a key task of recovery

07:28 and the main aim of this form of group therapy.

07:31 Interpersonal group therapy doesn’t assume that people

07:33 with substance misuse problems or share a particular profile

07:36 or personality type.

07:38 But instead, identifies and directly addresses

07:41 relevant problematic interpersonal behavior,

07:44 whether that be isolating, ineffective ways

07:46 of trying to be liked by others, intimacy

07:48 issues, or any other maladaptive relational style.

07:52 An important characteristic of interpersonal group therapy

07:55 in relation to other approaches is that it need not

07:58 be too anxiety-provoking.

08:00 Research has shown that people who

08:02 are in early recovery from addiction

08:04 are significantly more anxious than the general population.

08:07 And approaches that focus on intentionally stimulating

08:10 difficult feelings, on heavily challenging people,

08:13 or intentionally provoking transference

08:15 are likely to be too much for many clients

08:17 to relax and trust the group process enough to express

08:19 themselves and interact as freely as they would

08:22 outside of therapy group.

08:25 This natural expression is vital,

08:27 if the problems that people need to work on

08:29 are to become available to the group for therapy.

08:32 For interpersonal group therapy to be helpful,

08:35 it’s essential that clients come to understand their substance

08:37 use from a relational perspective.

08:40 If they come to see how working on their relationships

08:43 will support their recovery, it is far more likely

08:45 that they will invest in the group.

08:48 For this reason, making the model of therapy

08:50 explicit at the outset is vital, as this

08:53 helps clients set their goals as relational ones

08:56 that groups can help with, rather than making practical,

08:59 out of the group goals that tend not to be

09:02 amenable to group therapy.

09:04 If clients learn to value sharing themselves with others

09:07 and are able to develop supportive relationships,

09:10 they’re again also more likely to gain from affiliation

09:13 with 12-step or other mutual aid groups.

09:15 And the evidence available suggests

09:17 that it is those who become socially

09:18 active in these recovery communities that

09:21 can benefit the most.

09:22 The treatment setting you’ll be witnessing

09:24 is offering interpersonal group therapy

09:27 as part of a wider, structured day program

09:30 and in a time-limited rolling format.

09:32 Clients attend each weekday from 8:30 to 4:30

09:35 for several weeks, 12 in this fictional case,

09:38 based on one of our treatment models.

09:40 Without the support of other group and one-to-one

09:42 interventions, working interpersonally

09:45 might well be too challenging for many clients,

09:48 as these groups often end with some people

09:49 feeling exposed or vulnerable.

09:52 If there are other therapeutic activities later in the day,

09:55 this gives people a chance to process their feelings

09:58 and be less vulnerable to relapse as a result.

10:01 The rolling nature of the program

10:02 means that clients might enter at any time,

10:05 then receive 12 weeks of treatment

10:07 before leaving the group.

10:08 Because of this, in the first vignette,

10:10 all the participants have been in treatment

10:12 for differing lengths of time.

10:14 And there are already established

10:15 relationships between the members of the group.

10:19 There are elements of four groups captured in total,

10:22 each within a week or two separating them.

10:25 However, in this intensive treatment setting,

10:28 interpersonal group therapy is offered on four days a week.

10:30 So it’s important to remember that not all the interpersonal

10:33 dynamics and developments are shown.

10:35

00:00 00:10:38,124 –> 00:10:39,790 We’re not going to introduce each member

10:39 of the group in any detail.

10:41 But a biographical portrait of each

10:43 is available in the accompanying material

10:45 included in the training pack.

10:46 We join the group just after Jimmy

10:49 has read the group preamble, a short text that

10:52 reminds everyone of the purpose and function

10:53 of interpersonal group therapy.

10:55

00:00 00:11:01,189 –> 00:11:03,230 BRIAN: My counselor’s asked me to bring something

11:03 into group about me wanting to go carry

11:08 on going out to pubs and clubs.

11:10 I just want to bring that to the group,

11:12 so I can get feedback from you guys.

11:16 NATHAN: Do you know what, Brian?

11:18 I’m seriously worried about you having thoughts like that.

11:21 What makes you think it’s okay to surround yourself

11:23 with drugs and alcohol?

11:26 MARK: Come on, Brian, if you keep going into a barber shop,

11:29 you’re going to end up getting a haircut.

11:30 BRIAN: I’ll be all right.

11:31 Others do it.

11:32 We are allowed to have fun.

11:35 NATHAN: I just think you’re making excuses not to change.

11:38 BRIAN: I’m willing to change.

11:40 I’m here doing what I’m supposed to be doing.

11:42 As I said, it’s not all about therapy.

11:44 It’s not all about doing groups.

11:46 I can have fun.

11:48 It’s not I take life too seriously, I do.

11:50 JIMMY: Do you know what, Brian?

11:52 I get where you’re coming from, because I did something similar

11:54 when I first come into treatment.

11:56 But they’re right.

11:58 It’s too soon for you to be thinking

11:59 about going to pubs and clubs.

12:03 BRIAN: See, this doesn’t really help,

12:04 you all just having a go at me, being on my case.

12:08

00:00 00:12:11,580 –> 00:12:14,970 SABINA: I’ve got something to bring.

12:14 You see, my partner, last night, me and him had another row.

12:18 It’s just getting worse and worse.

12:21 He’s always on me.

12:24 He’s just driving me nuts.

12:28 He’s checking my phone.

12:29 He’s checking my Facebook profile.

12:32 It’s just so freaking claustrophobic.

12:35 I can’t bear it.

12:37 I don’t know what to do.

12:38 He’s just on me all the time.

12:39

00:00 00:12:43,784 –> 00:12:46,810 AMBER: Why don’t you just change your pin number?

12:46 SABINA: Because I thought marriage was about trust.

12:49 GEMMA: Have you ever thought about separation?

12:51 NATHAN: I really couldn’t live with someone like that.

12:55 SABINA: Listen, I made my vows.

12:58 And when I made them, I meant them.

13:00 It’s just not an option.

13:01 Separation is not an option.

13:04 MARK: Sounds like he has a problem.

13:05 You thought about Al-Anon?

13:07 SABINA: He won’t go to anything like that.

13:09 He says it’s my problem.

13:11 I’ve been doing this for five weeks.

13:13 Why isn’t he trusting me yet?

13:14 He should be trusting me.

13:16 JIMMY: Yeah.

13:16 Do you know what?

13:17 I went and I pled to my family about a week ago.

13:20 And I expected everything was going to be back to normal.

13:23 They were going to be forgiving.

13:24 And it’s not as simple as that.

13:26 You know, these things take time.

13:28 You can’t just expect everything to be back

13:30 to normal straightaway.

13:31 AMBER: Why don’t you just change your Facebook account?

13:34 SABINA: I thought we were supposed to be

13:36 working an “honest program”?

13:37

00:00 00:13:39,674 –> 00:13:41,590 HORACE: Why don’t you try marriage counseling?

13:41 SABINA: And have someone analyzing every single aspect

13:44 of the relationship?

13:45 No.

13:46 No.

13:47 LOUISE: Assertiveness training really helped me.

13:49 Maybe should you just try and find a class.

13:52 SABINA: Mm, yeah, no.

13:55 NATHAN: I’m feeling really frustrated.

13:57 Every time we try and give Sabina and Brian suggestions

14:01 or advice, it’s like they’ve done it,

14:03 or they just don’t want to hear it.

14:04 I don’t think I’m getting anything out of them.

14:07 LEIGHTON: I think you’re making a good point, Nathan.

14:09 I’d like to ask Sabina, do you feel

14:11 you’re getting helped by this process in the group today?

14:14 SABINA: Well, yeah, all the comments

14:16 are very nice and all and probably very helpful.

14:18 But it’s not anything I haven’t really considered before.

14:21 None of It’s really worked.

14:23 And to be honest, I don’t think in the grand scheme of things

14:27 it’s that big a deal, really.

14:28 I think Gemma’s probably got bigger problems than me.

14:31

00:00 00:14:33,350 –> 00:14:36,040 GEMMA: No, I just don’t see the point of this.

14:36 I just don’t get it.

14:36

00:00 00:14:40,260 –> 00:14:42,120 NATHAN: Maybe your problem is best addressed

14:42 in one-to-one counseling, Gemma.

14:44 GEMMA: Well, that’s what I wanted in the first place.

14:46 I just don’t get group.

14:52 MARK: At least, give it a go.

14:53 Give it some time.

14:54

00:00 00:14:57,170 –> 00:14:59,501 NATHAN: Gemma, don’t play with your towel now.

14:59 JIMMY: Yeah, do you know what?

15:00 You’re a real valued member of this group.

15:03 Don’t give up.

15:04 GEMMA: How?

15:05 LOUISE: Gemma, when I was struggling the other day,

15:07 you really helped me.

15:10 MARK: I’m sorry.

15:11 I think your problem is that you haven’t accepted powerlessness.

15:14

00:00 00:15:19,449 –> 00:15:21,240 NATHAN: That’s a bit harsh right about now.

15:21 She doesn’t really need to be hearing that, Mark.

15:24 MARK: Trying to help.

15:27 BEATTY: Gemma, can I ask you a question?

15:30 What are you hearing from the group right now?

15:34 GEMMA: They just want me to accept I’m powerless.

15:37

00:00 00:15:40,750 –> 00:15:43,067 AMBER: No one knows what they’re doing.

15:43 How’s this going to help anyone?

15:44

00:00 00:15:54,260 –> 00:15:56,910 ASHWOOD: Brian opens with an issue his counselor asked

15:56 him to share with the group.

15:58 This brings up some interesting questions.

16:01 One possibility is that the counselor

16:03 may be concerned about Brian’s intention

16:05 to continue frequenting pubs and clubs,

16:08 and hopes that his group might be able to persuade him

16:11 that this isn’t a good idea.

16:14 There are certain opportunities for group members

16:16 to review the wisdom of proposed behavior in a group.

16:19 And hearing a message from a number of people

16:22 may be more persuasive than just one.

16:25 However, inviting this issue in this way

16:28 also brings up a problem.

16:31 There’s an implicit message that the function of the group

16:33 is to get people to conform to a socially agreed norm of what

16:37 recovery requires.

16:38 And this detracts from communicating

16:40 that the real power of the group is in helping people

16:44 to see how they’re not getting their needs met

16:47 through certain ways of relating and how they might better

16:50 do this.

16:51 This being said, there is still an interpersonal process

16:54 going on here that does create possibilities for learning.

16:59 We see the group members frustrated

17:01 with Brian, whose interpersonal style to date

17:03 has been generally, although not exclusively, distant

17:07 and dismissive of the wider group’s consensus.

17:10 Many of the individual’s responses to him

17:12 are typical of people who have been through certain kinds

17:15 of treatment systems.

17:16 Having inherited a particular philosophy of recovery,

17:19 they believe that they need to confront

17:21 anything they see as not in line with that philosophy.

17:25 The therapists do not, however, add

17:26 to this confrontational style by challenging it.

17:28 But instead, allow the group to feel

17:31 the frustration of operating in this manner that

17:33 doesn’t work so well.

17:35 This way, members can learn for themselves

17:37 what an ineffective group looks like and feels like,

17:41 and later have an opportunity to contrast this with the group

17:44 when it’s working more effectively.

17:46 This helps the group to develop autonomy.

17:49 Various potentially problematic interpersonal styles

17:52 are evident in this initial session.

17:54 We see Mark trying to support people in a manner that

17:56 comes across as aggressive.

17:58 Nathan, appearing disconnected and critical.

18:02 Even Jimmy, who seems much warmer,

18:04 is still not willing to engage with Brian’s actual question.

18:08 But instead, joins in the group consensus of concern

18:11 about his intention to go to the pubs,

18:13 maybe assuming he’s simply unmotivated for recovery.

18:17 As we will see in a number of examples in these vignettes,

18:20 the content-focused advice giving format

18:23 is found to be frustrating by the participants who

18:26 feel their suggestions and concerns are not being

18:29 given serious consideration.

18:31 And they soon give up.

18:33 LEIGHTON: One important concept critical to understanding

18:35 the model is that of process, as contrasted with content.

18:40 It is fairly obvious what the content of the dialogue is.

18:43 It’s the subject matter, what gets talked about.

18:46 But what this model of group therapy

18:48 intends us to understand is the process.

18:51 That is, what do the way people talk

18:53 to each other, the manner of their bringing material

18:55 to the group, and its timing, and the way

18:58 that group members respond to each other

19:00 tell us about the nature and meaning of the relationships

19:02 between them.

19:04 It’s pretty obvious what the content

19:05 of Sabina’s contribution is.

19:07 It’s about the behavior of her husband.

19:10 But what is the process as she interacts with her group?

19:15 Sabina complains about her husband.

19:16 And clearly, there is little the members of the group

19:19 can do to help her situation, as she’s presenting the problem

19:22 as being his.

19:24 There is a willingness from group members

19:26 to try to help her by offering advice.

19:29 However, this is typically dismissed by her,

19:31 which is in itself indicative of something about Sabina that she

19:35 brings to the group problems that cannot be addressed

19:37 in the group.

19:39 Jimmy, who has been in treatment the longest

19:41 and has had more chance to see how group works,

19:44 offers his support in the form of identification.

19:47 And this at least has the potential

19:49 to develop the relationship between him and Sabina.

19:53 The unsatisfying way the group is operating

19:56 is not at this point highlighted by the therapists.

19:59 They might, at some stage, point towards the process that’s

20:01 going on.

20:02 However, in this case, it’s not necessary,

20:05 as Nathan comes in and makes an important comment

20:07 about the process, that he is frustrated

20:10 with all the advice giving and how ineffective it is.

20:14 NATHAN: I’m feeling really frustrated.

20:16 Every time we try and give Sabina and Brian suggestions

20:20 or advice, it’s like they’ve done it,

20:22 or they just don’t want to hear it.

20:24 I don’t think I’m getting anything out of them.

20:27 LEIGHTON: It’s almost always better

20:29 if clients make commentary about group process themselves,

20:32 rather than the therapist always taking the lead, as this helps

20:36 the members of the group take responsibility

20:38 for their own therapy.

20:41 The group is much more productive

20:42 if this is encouraged.

20:43 And it makes it much more likely that group members

20:46 will carry their gains on into recovery once treatment’s over.

20:50 I encourage this by affirming and emphasizing

20:52 Nathan’s comments, which will help develop the group

20:55 norm, or unwritten rule, that clients

20:58 can make process commentary.

21:00 I then attempt to highlight this learning further

21:04 by asking if the process is helpful to Sabina.

21:07 And while she acknowledged people’s efforts

21:09 to support her, she clearly says that the advice

21:12 isn’t very helpful.

21:13 It might be that at this point, Sabina is uncomfortable about

21:16 doing any more meaningful work and suggests her problems are

21:19 less important than another group member’s.

21:22 This again, shows an aspect of Sabina’s interpersonal style.

21:26 But it isn’t picked up on.

21:28 The group seemed happy to go with her suggestion of inviting

21:31 Gemma to use group time.

21:33 ASHWOOD: Gemma seems ambivalent about the group.

21:36 But it shows that there is at least some healthy cohesion,

21:39 that they encourage her to give it a go,

21:41 and to show her that she is a valued member of the group.

21:44 If she hadn’t asked for specific feedback

21:46 about how she was valued, this would’ve

21:48 been a perfect opportunity for the therapists

21:50 to ask this of the members of the group, to be specific.

21:53 A specific interpersonal feedback

21:55 is always more helpful than generalized comments.

21:59 In this case, though, Gemma asks the question herself.

22:02 Again, allowing the group to take responsibility

22:04 lets its members see themselves as agents of change,

22:08 rather than looking for the professionals to provide this.

22:11 Louise, who is usually quite quiet,

22:13 is able to offer a little interpersonal feedback

22:16 by pointing out how Gemma has helped her.

22:18 This kind of interpersonal commentary

22:20 is therapeutic on a number of levels.

22:23 It helps Gemma to see that she has intrinsic value, as she is

22:27 able to be of help to others.

22:28 It also develops group cohesiveness,

22:30 as members build trust and learn to value the group.

22:35 Members of the group also see how they can mutually

22:37 benefit each other.

22:38 And it allows those witnessing the exchange

22:40 to see how offering skillful interpersonal feedback

22:44 in a group deepens relationships and relational

22:47 understanding in a way that’s emotionally attractive to them.

22:52 This models healthy group behavior

22:54 and develops positive group norms for the future.

22:57 BEATTY: Mark’s notion of support received

22:59 some initial feedback from Nathan, which gives Mark

23:02 an opportunity to highlight his intentions, which he says

23:05 are trying to help.

23:07 This is a theme that gets little attention now but is picked up

23:11 on in a later vignette.

23:13 The possible merits of Mark’s suggestion

23:15 are very dependent on him having a shared language with Gemma.

23:18 However, even if they had this, Mark’s delivery

23:22 comes across as a criticism, and so Gemma can’t engage with it.

23:26 I attempt to highlight the support

23:28 Gemma is offered by asking her what

23:30 she is hearing from the group.

23:33 However, Gemma focuses on what she

23:35 saw as the most critical comment,

23:37 at the expense of missing all the encouragement she

23:39 was getting.

23:41 Her dismissiveness of help and support

23:43 is not picked up on by the therapist just yet.

23:47 And it’s important when conducting interpersonal group

23:49 therapy that the group leader doesn’t

23:52 jump onto every sign of interpersonal pathology,

23:55 as doing so tends to put people on their guard

23:58 and inhibit the natural flow of the group.

24:01 Instead, the members of the group

24:02 are largely left to be themselves in the session.

24:06 So their relational problems can be seen and addressed

24:08 by the wider group once it is obvious they are not

24:11 getting the desired results.

24:13 The vignette ends with Amber echoing Gemma’s earlier comment

24:17 and expressing her frustration at what

24:19 she sees as a general lack of understanding

24:22 about how group therapy works.

24:24 ASHWOOD: It’s worth mentioning that the participants all

24:27 attended an introductory workshop to prepare

24:29 them to take part in and make the best

24:31 use of interpersonal groups.

24:33 In this, the relevance of developing

24:35 healthy relationships to recovery

24:37 was explored in some depth to help the clients to understand

24:41 that their task in these groups is

24:42 to better understand and improve how they relate with others.

24:47 This is an important prerequisite

24:48 for working interpersonally.

24:50 However, the relevance and importance

24:52 of this way of operating isn’t always learned right away,

24:55 especially if people are still in detox,

24:57 or have only recently completed their medicated detox when

25:01 being introduced to the model.

25:02 Without understanding how focusing on relationships

25:06 will help support recovery, it’s difficult for clients

25:09 to fully invest in the group.

25:11 And therefore, cohesiveness is weakened.

25:15 For this reason, part of the ongoing function of a group

25:18 must be to help remind clients why

25:20 and how group therapy operates.

25:22 This doesn’t need to be done didactically.

25:24 And it’s often best done experientially by allowing

25:28 members of the group to see for themselves what works and what

25:31 doesn’t.

25:32 The identification of relational goals

25:34 to work on in group therapy can always

25:37 be gone back to in one-to-one sessions

25:39 with the client outside of the group.

25:41 LEIGHTON: This vignette is one where

25:43 the group is going through a stage of relative infancy,

25:46 something that comes and goes in rolling groups,

25:49 as stronger members leave and new members join.

25:52 There is some evidence of cohesiveness,

25:54 that members value each other and the group.

25:56 They are willing to offer support in the form of advice.

25:59 And Louise gave some supportive feedback

26:01 about how helpful Gemma was to her.

26:04 But one of the main ways the group communicates

26:06 at this stage, by giving advice, is experienced as frustrating.

26:10 Because it doesn’t seem to lead anywhere.

26:13 A lack of cohesiveness is evidenced most strongly

26:16 by the group members’ awkwardness

26:18 in engaging with each other.

26:20 When there is feedback, one or two more vocal members

26:24 tend to give this in a very critical way,

26:26 leaving the group feeling less connected to each other.

26:28 It’s unsurprising that group members

26:30 find it difficult to give each other direct interpersonal

26:32 feedback.

26:35 It isn’t normal in our society to do

26:37 this outside of very intimate relationships, or interactions

26:41 between people with different levels of social power,

26:44 such as schoolteachers or parents and children.

26:48 Receiving specific feedback from others

26:50 about how our behavior affects others,

26:52 or how we are perceived by others,

26:54 can make us feel childlike and stripped of power.

26:58 But when a group learns to do this

27:00 in a mutual direct and respectful way,

27:03 it engenders a depth of relationship that is energizing

27:06 and often experienced by members as quite new.

27:09 The therapist’s role in a group like this one

27:12 is to help the group to build cohesiveness.

27:15 This can be done in a number of ways–

27:18 by focusing on identification, on similarities between group

27:21 members, common goals, mutually supportive relationships,

27:25 and also by pointing out the sense of vibrancy

27:28 when the group are working in the here and now,

27:30 rather than wrestling with external or historical issues.

27:34 When the group is struggling, encouraging

27:36 feedback on each other’s strengths,

27:38 rather than an interpersonal challenge

27:40 or undermining a client’s defenses is more supportive

27:43 and tends to produce a more positive and hopeful

27:45 atmosphere.

27:47 Best evidence suggests that group cohesiveness

27:49 is a precondition of the trust and risk-taking required

27:52 for effective group therapy.

27:55 So it is important to help groups develop, maintain,

27:57 or recover this sense of cohesiveness.

28:01 In addiction treatment, there are

28:02 factors such as the common predicament,

28:04 which are conducive to group cohesiveness.

28:07 But the post-detoxification volatility, vulnerability,

28:10 and anxiety of members also tends to threaten it.

28:13

00:00 00:28:18,590 –> 00:28:21,690 The next scenario occurs a week after the first.

28:21 And new member, Sam, has joined the group.

28:25 Although new, he was a therapist in the field

28:27 himself before his alcoholism stopped him from working.

28:31 Now his detoxification is complete.

28:33 And after attending just three sessions, he is often quiet.

28:36 But when he does speak, he’s a very supportive group member.

28:39

00:00 00:28:49,590 –> 00:28:51,630 SABINA: Okay, yeah, I want to talk again.

28:51 It’s just my husband again.

28:52 I just– I’m at the end of my tether.

28:55 He’s saying, where am I?

28:57 Am I actually at the agency?

28:59 He’s checking my breath again.

29:00 What am I supposed to do?

29:01 It’s just driving me crazy.

29:03

00:00 00:29:05,860 –> 00:29:08,660 MARK: We’ve spoken about this last week.

29:08 We’re not here for your husband.

29:09 We’re here for you.

29:11 You need to start focusing on yourself.

29:13 Start taking responsibility.

29:15 SABINA: You don’t get it.

29:17 MARK: If it’s all your husband’s fault,

29:18 why isn’t he in treatment?

29:21 BRIAN: Sabina, it would be nice to hear something new from you,

29:24 something different.

29:25

00:00 00:29:34,025 –> 00:29:37,730 JIMMY: Yeah, I’ve got something I need to bring to the group.

29:37

00:00 00:29:46,010 –> 00:29:48,165 BEATTY: Jimmy, could you go on, please?

29:48

00:00 00:29:52,242 –> 00:30:03,025 JIMMY: It’s my mom, she died last year.

30:03

00:00 00:30:29,530 –> 00:30:30,725 I used to care for her.

30:30

00:00 00:30:49,290 –> 00:30:58,260 I used to have to give her her medication

30:58 to stop her from being in pain.

30:59

00:00 00:31:12,079 –> 00:31:13,120 But I used to steal them.

31:13

00:00 00:31:16,430 –> 00:31:20,380 I’d steal them just for a hit.

31:20

00:00 00:31:37,170 –> 00:31:39,530 NATHAN: Thanks for sharing that, Jimmy.

31:39 That’s pretty big stuff.

31:40

00:00 00:31:48,170 –> 00:31:51,220 BRIAN: We’ve all got secrets, mate.

31:51 AMBER: I’ve done stuff I’m not proud of.

31:55 HORACE: You’re still just you, Jimmy.

31:57

00:00 00:32:03,902 –> 00:32:06,640 When I was using, none of my family

32:06 wanted nothing to do with me, except for my granddad.

32:09

00:00 00:32:13,883 –> 00:32:15,591 He’s the only one I had any contact with.

32:15

00:00 00:32:18,960 –> 00:32:21,810 He was pretty old, though.

32:21 He used to send me down to the post office

32:23 to get his pension every week.

32:25

00:00 00:32:30,310 –> 00:32:35,584 And I used to nick the money because I needed to use.

32:35 JIMMY: That’s just money.

32:36 This is medication that actually stopped her from being in pain.

32:45

00:00 00:32:49,360 –> 00:32:51,033 MARK: I’ve stolen from my family.

32:51

00:00 00:32:54,210 –> 00:32:56,644 Might not be the same circumstances,

32:56 but I could certainly relate to the feelings

32:58 of shame and guilt.

33:04 NATHAN: How did you cope, Jimmy?

33:07 JIMMY: Drugs– heroin, meth, just anything.

33:14

00:00 00:33:18,540 –> 00:33:22,800 HORACE: That’s where our addiction takes us, brother.

33:22 LOUISE: Jimmy, this is really brave of you

33:24 to bring this to group.

33:27 AMBER: Yeah, I agree.

33:29 BEATTY: Jimmy, do you think you could let the group know

33:34 what it is about the group today that’s

33:35 allowed you to share this?

33:37

00:00 00:33:41,053 –> 00:33:55,701 JIMMY: The other day, Gemma, she got vulnerable, real

33:55 vulnerable.

33:56

00:00 00:34:00,458 –> 00:34:08,962 I just felt closer to her, really close.

34:08

00:00 00:34:12,746 –> 00:34:15,460 BEATTY: I’m wondering if you answered my question there.

34:15

00:00 00:34:18,418 –> 00:34:20,638 What was it, do you think, about this group

34:20 that let you share that?

34:22

00:00 00:34:26,254 –> 00:34:29,600 JIMMY: I don’t know, really.

34:29 Maybe it’s trust a lot.

34:33 I sort of trust them.

34:35

00:00 00:34:37,780 –> 00:34:39,549 Now you all know the real me.

34:39 LEIGHTON: Jimmy, it sounds like you’ve been holding this

34:41 in for quite a while.

34:46 What were you worried about?

34:47 What were you frightened about if you

34:49 told the group about this?

34:51 JIMMY: What was I afraid of?

34:53 Who’s going to respect someone like me?

34:54 Who’s going to respect someone that steals medication

34:57 off their mom?

34:59 NATHAN: It hasn’t changed the way I feel about you, Jimmy.

35:03 That took a lot of guts.

35:06 AMBER: Yeah, it did.

35:07 You’ve done really well to trust us.

35:11 GEMMA: What you’ve just done, I could never do that.

35:16 It’s really brave.

35:17

00:00 00:35:20,520 –> 00:35:22,382 MARK: Just remember, that wasn’t you, Jimmy.

35:22 That was the addict.

35:23

00:00 00:35:26,650 –> 00:35:30,034 SAM: Jimmy, I just think it was great that you

35:30 managed to get it out there.

35:31

00:00 00:35:40,020 –> 00:35:42,700 ASHWOOD: We see at the start of this vignette, Sabina

35:42 bringing up the same issues she did last week.

35:44 Her peers have now become frustrated with her

35:47 and point out the pattern.

35:49 Mark suggests something that could be quite helpful.

35:52 But once again, his interpersonal style

35:54 comes across as attacking.

35:56 And the group quickly give up on offering any more support

35:58 to Sabina.

35:59

00:00 00:36:01,900 –> 00:36:03,400 During this process, Jimmy’s clearly

36:03 sitting in a lot of discomfort.

36:05 And when he finally speaks, the rest of the group

36:07 appear to detect this and give rapt attention.

36:11 It’s clear something different is going on now.

36:16 Disclosures such as Jimmy’s can be fairly common in addiction

36:18 support groups when there’s enough

36:20 cohesiveness in the group and readiness in the individual

36:23 to disclose.

36:25 They can be very powerful agents of change

36:27 for a number of reasons but should never be forced.

36:32 Some clients get the message from certain treatment

36:34 philosophies that you’re only as sick as your secrets,

36:37 or that unless you expose your shame,

36:39 it will eat you up and sabotage your recovery.

36:41 There’s actually no evidence to support either of these views.

36:45 However, if and when people are ready to disclose

36:47 shameful aspects of themselves, it

36:50 gives a clear message of trust, which almost always brings

36:53 the group members closer together by giving others

36:55 permission to take risks and make

36:57 further disclosures themselves.

36:58

00:00 00:37:01,387 –> 00:37:03,220 There are a number of benefits for the group

37:03 and for the individual in this.

37:05 As other group members identify with Jimmy,

37:07 they also are taking risks and exposing their vulnerability,

37:12 entering into the circle of trust with him.

37:14 However, Jimmy seems too wrapped up

37:16 in his remorse to receive the gifts offered to him at first.

37:19 But the communication clearly takes the group

37:22 to a much deeper and more involved level of interaction

37:24 than previously.

37:26 Even Mark shows some interpersonal sensitivity

37:29 with his identification.

37:31 Rather than focusing historically

37:33 on the content of the disclosure, as Nathan does,

37:36 Jax takes the opportunity to stimulate

37:39 the second stage of interpersonal learning

37:41 in the here and now.

37:44 After the first stage, a genuine, emotionally laden

37:47 interpersonal experience has occurred,

37:49 the therapist has the opportunity

37:51 to help the group illuminate the process.

37:55 In this case, Jax invites what we

37:57 might call a meta disclosure, a disclosure

38:00 about the disclosure, pointing the group into the here

38:03 and now, inviting them to explore what the event said

38:06 about the relationships between the people in the group.

38:11 By asking what allowed him to share his story,

38:13 Jimmy is able to highlight how another member of the group

38:16 has affected him, and how he feels towards them as a result.

38:20 Jax probes further, and Jimmy is able to highlight

38:24 how he’s developed trust with the members of the group.

38:26 This will have a tangible effect on the relationships

38:29 with the other members and on the group as a whole.

38:32 But by saying “Now you all know the real me,”

38:36 Jimmy portrays continued feelings of shame.

38:38 So Tim offers another classic intervention designed

38:41 to elicit further meta disclosure

38:43 by asking what he was afraid would happen if he shared this.

38:49 Jimmy is then able to identify the root of his shame

38:52 in the group, that people would reject him and disrespect him.

38:57 This reveals an even deeper level of intimacy,

38:59 as he shares his fears.

39:01 However, the feared catastrophe doesn’t occur.

39:04 People are quite clear that, on the contrary,

39:06 rather than looking down on him for his past actions,

39:09 they admire and respect his current honesty and courage.

39:13 When someone realizes that they are not

39:15 judged by others about historical actions

39:17 for which they judge themselves, it

39:19 can be a great help to that person

39:21 to give up their self-judgement and put

39:23 those events in the past.

39:24

00:00 00:39:29,160 –> 00:39:32,220 GEMMA: Thank you.

39:32 Jimmy, I really appreciate what you said.

39:36

00:00 00:39:41,870 –> 00:39:45,670 I just don’t get this group.

39:45 I just don’t see how it can help me.

39:48

00:00 00:39:51,294 –> 00:39:54,760 LOUISE: Gemma, my take is you don’t get anything

39:54 from group because you don’t give anything.

39:57

00:00 00:39:59,955 –> 00:40:01,660 NATHAN: I kind of agree with that.

40:01 You don’t participate.

40:04 MARK: How can we help you?

40:06 We don’t know anything about you?

40:09 BRIAN: Gemma, I don’t know anything about you either.

40:12 LEIGHTON: You know, I get something of the same feeling,

40:14 Gemma.

40:15 I find it very hard to have anything to offer you,

40:19 because I don’t think you really show yourself in the group.

40:24 BEATTY: Gemma, when you were out there

40:26 drinking, how was it for you?

40:28

00:00 00:40:33,778 –> 00:40:34,278 GEMMA: Fine.

40:34

00:00 00:40:40,077 –> 00:40:40,910 It made it bearable.

40:40

00:00 00:40:44,920 –> 00:40:48,167 It medicated the anxiety, matched the misery.

40:48

00:00 00:40:52,388 –> 00:40:56,470 I didn’t need anyone.

40:56 SABINA: Gemma, that’s how I kind of feel

40:58 you are in here, like you don’t really need us.

41:02

00:00 00:41:07,648 –> 00:41:11,310 BEATTY: Gemma, when you were out there drinking and keeping

41:11 people away, it’s as if that’s what you’re doing here

41:16 now with your group?

41:17

00:00 00:41:23,166 –> 00:41:24,100 BRIAN: That’s right.

41:24 It’s like you’re not even there.

41:25

00:00 00:41:28,079 –> 00:41:30,037 HORACE: I’d like to hear more from you as well.

41:30

00:00 00:41:33,520 –> 00:41:36,680 LOUISE: Gemma, I understand.

41:36 When I came in here, I could not say anything.

41:39

00:00 00:41:42,179 –> 00:41:43,470 JIMMY: Do you know what, Gemma?

41:43

00:00 00:41:46,250 –> 00:41:47,518 I found it hard to trust.

41:47

00:00 00:41:50,146 –> 00:41:53,255 I didn’t want anyone to see that I was scared.

41:53 Why would I?

41:54

00:00 00:41:57,760 –> 00:41:59,510 LEIGHTON: So how can the group help Gemma?

41:59

00:00 00:42:02,940 –> 00:42:08,706 AMBER: Gemma, we’ve spent a bit of time together now,

42:08 and I’ve gotten to know you.

42:12 And it means a lot that you’ve opened up.

42:16 I’ve got a friend, I’m going to have one

42:20 now for a very long time.

42:21

00:00 00:42:27,797 –> 00:42:29,630 LEIGHTON: So Gemma, how can you get the help

42:29 that you need in this group?

42:32 AMBER: Do what you do with me.

42:36 Just open up.

42:39 BEATTY: Can you do that?

42:40

00:00 00:42:45,150 –> 00:42:48,475 GEMMA: I don’t know how.

42:48 LEIGHTON: Well, you’ve got a lot of help here.

42:51 GEMMA: I guess I have to.

42:53

00:00 00:43:03,870 –> 00:43:06,835 LEIGHTON: Gemma returns to her previous week’s theme,

43:06 her confusion about how group therapy can possibly help her.

43:10 Louise offers what could be some quite challenging

43:13 interpersonal feedback.

43:15 However, the relationship she has

43:16 with Gemma and her tentative delivery

43:19 make it much easier for Gemma to hear.

43:21 The rest of the group pick up on this and echo Louise’s comment.

43:26 I decided to let Gemma know that I agreed with the group’s

43:29 perception and that I had some trouble finding a way

43:31 to help her.

43:33 I tried to be as gentle and respectful in tone as possible.

43:36 But I wanted to add the authority of a facilitator

43:39 to the idea that Gemma is to a great extent

43:42 responsible for her own experience in the group,

43:45 and that the answer to her question is in her own hands.

43:49 It is sometimes helpful for the therapist

43:51 to share his or her own perception or feeling about

43:53 what is happening in the group.

43:56 Although facilitators are not group members,

43:58 they are very much part of the process.

44:00 Members are relating to them too and vice versa.

44:04 They have the power to be good role models

44:07 and to teach the group how to be more effective.

44:09 But they must take great care not

44:11 to undermine the group’s responsibility

44:13 for its own functioning.

44:15 Sharing one’s own perceptions judiciously and with respect

44:19 also shows a human side.

44:21 However, much more rarely, if ever,

44:23 is it appropriate for therapists to regale the group

44:26 with anecdotes about their own past or current issues,

44:29 even if they are themselves recovered

44:31 addicts identifying with material

44:33 their clients are bringing,

44:35 Here, in fact, Gemma is showing some vulnerability,

44:37 but in a rather controlled way.

44:39 She’s avoiding acknowledging her feelings explicitly and not

44:43 giving any indication of why she’s in treatment,

44:46 and thereby appearing unavailable for help.

44:49 The group are unsatisfied with this

44:51 and try to highlight it to her.

44:54 Jax makes a practical intervention

44:56 by asking her how she was before coming into treatment.

45:00 This does allow Gemma to show something of herself

45:02 and deepen her relationship with the group

45:04 and also helps her to reveal the reason for being there.

45:09 Importantly, Gemma highlights the personal connection

45:11 between her alcohol misuse and her relational problems,

45:15 and how she has brought the avoidant relational style

45:17 she used to cope in addiction with her into the group.

45:22 This is a well-recognized process

45:24 where given a relatively unstructured group,

45:27 people inevitably bring their interpersonal style into group.

45:31 It’s an essential process for effective group therapy,

45:34 as there is no need for people to explain

45:36 their interpersonal problems.

45:37 They are manifest first-hand, right in the here

45:41 and now of the group.

45:44 Through feedback, clients can learn for themselves

45:46 how the way they have learned to relate interpersonally

45:49 isn’t working for them.

45:50 And in the group, they have an opportunity

45:52 to experiment with new styles of relating.

45:55 In the case of Gemma, the group clearly point out

45:58 to her how frustrating they find her not needing anyone attitude

46:03 but also let her know that they do want

46:05 to make a connection with her.

46:08 We also see here evidence of the increased cohesiveness

46:11 and trust that has developed in the group.

46:14 Members are able to offer feedback

46:16 in a much more gentle and supportive manner, many

46:20 focusing significantly more on identification,

46:23 speaking from their personal experience.

46:26 I ask how the group can help Gemma,

46:28 highlighting that therapy is a two-way process.

46:31 And it isn’t just Gemma’s responsibility

46:33 to make the process work.

46:36 This allows Amber to take a risk and offer

46:38 some uncharacteristic softness by expressing her appreciation

46:41 of Gemma’s friendship.

46:43 She highlights Gemma’s ability to open up

46:45 to her in one-to-one situations and encourages

46:48 her to show that same courage in the group.

46:52 While Gemma’s confusion and distress is clearly evident,

46:55 the support and cohesiveness of the group

46:59 allows her to tolerate this and express her willingness

47:02 to make an effort just the same.

47:03

00:00 00:47:08,910 –> 00:47:10,975 We join the group meeting a week later.

47:10

00:00 00:47:14,832 –> 00:47:16,540 LOUISE: I’ve got something I want to say.

47:16

00:00 00:47:19,669 –> 00:47:30,920 I feel really ashamed because I don’t

47:30 believe in hitting children.

47:35 But when I was drunk, I smacked my daughter.

47:43

00:00 00:47:48,262 –> 00:47:53,751 I hurt her, and it’s bad.

47:53

00:00 00:47:59,750 –> 00:48:02,754 GEMMA: Was it just the once?

48:02 LOUISE: No.

48:05 SABINA: Did you really hurt her?

48:07 LOUISE: I smacked her across the bedroom.

48:08

00:00 00:48:12,580 –> 00:48:16,590 SAM: Hey, Louise, I’ve got kids.

48:16 I know what it’s like.

48:19 Tempers just flare up and they get too much.

48:22 It all goes mad.

48:23 I don’t know anyone who’s got kids

48:24 and hasn’t hit them sometimes– sometimes in the wrong way.

48:30 LOUISE: Look, I was out of control.

48:33 And I was drunk.

48:36 It’s not okay.

48:39 I smacked my daughter across the bedroom.

48:42 It’s wrong.

48:44 LEIGHTON: Louise, when you bring this stuff today,

48:47 what are you hoping for?

48:49 What do you want from the group?

48:51

00:00 00:48:53,914 –> 00:48:55,330 LOUISE: I didn’t know what to say.

48:55 I didn’t know what they would say.

48:57 JIMMY: Well, do you know what, Louise?

48:59 It takes a lot of guts, so hat’s off to you.

49:01

00:00 00:49:05,000 –> 00:49:06,990 MARK: Yeah, people have done worse.

49:06

00:00 00:49:09,972 –> 00:49:11,960 SABINA: You’ve moved on.

49:11 You’re taking a risk.

49:12 You’re very honest.

49:13

00:00 00:49:16,940 –> 00:49:21,100 BRIAN: Yeah, we’ve all done stuff we’re not proud of.

49:21 LOUISE: Like what?

49:22 BRIAN: I’ve done stuff.

49:25 Me and my girlfriend, when we were drinking,

49:30 we used to get into arguments, heated debates.

49:34 And yeah, I hit her.

49:40 She even ended up in hospital And I

49:44 had to spend the night in the cells because of her.

49:46 I don’t believe it.

49:47

00:00 00:49:51,454 –> 00:49:55,841 HORACE: Boo-hoo, poor you.

49:55 BRIAN: What do you mean?

49:56 I was drinking.

49:57 I just said that.

49:59 HORACE: That’s no excuse, hitting a woman.

50:03 Look at the size of you.

50:04 BRIAN: Listen, you know what they’re like.

50:07 They push your buttons.

50:08 It’s what they do.

50:10 HORACE: That’s a bag out of order in my book.

50:12 SABINA: It’s what they do?

50:16 GEMMA: Brian, what you’ve just been saying

50:19 has made me really angry.

50:20

00:00 00:50:23,730 –> 00:50:25,399 SABINA: It’s really dismissive.

50:25 AMBER: You’re disgusting.

50:26

00:00 00:50:38,120 –> 00:50:39,377 I can’t do this anymore.

50:39 I’m just not getting this.

50:40 I’m really not getting this.

50:43 MARK: Here we go again, Amber, same old negativity.

50:47 You never bring anything positive to the group.

50:49 You’re just not getting this recovery, are you?

50:52 AMBER: I’m just saying how I feel.

50:55 MARK: Yeah, but it’s never constructive.

50:58 All you do is moan and criticize.

51:00 It’s about being positive.

51:02 You need to get with the program.

51:05 NATHAN: He’s got a point, Amber.

51:08 BRIAN: You’re just aggressive.

51:09

00:00 00:51:12,230 –> 00:51:15,394 AMBER: That’s rich, coming from you.

51:15 SABINA: I guess I think sometimes, Amber, it

51:17 is really hard to give you feedback,

51:20 I’m quite worried that you’ll attack me.

51:22 LOUISE: I agree.

51:24 MARK: You never bloody listen, Amber.

51:26 Do you know what I think you should do?

51:28 Take the cotton wool out of your ears

51:29 and stick it in your mouth.

51:30 AMBER: I can’t do this.

51:31 BEATTY: Amber, I think if you can stick with this,

51:34 there might be something really useful for you.

51:37 AMBER: Look, I really don’t feel safe in this group.

51:39 LOUISE: I agree.

51:40 SABINA: Yeah, you’re right.

51:42 It is like any time anyone brings anything important to–

51:45 into this group, there’s just this massive judgment.

51:48 SAM: That’s what I think.

51:49 I just think this has all become too judgmental.

51:53 This has all just been judgment.

51:56 LEIGHTON: So where do you think the judgment is coming from?

52:00 LOUISE: It’s coming from the guys.

52:03 SABINA: Yeah, I think it is.

52:05 HORACE: It’s not coming from me.

52:07 I mean, Brian, yeah, and Mark as well, and even Nathan a bit.

52:13 AMBER: Mark’s been judging.

52:15

00:00 00:52:18,711 –> 00:52:20,610 LEIGHTON: Mark, when you were giving feedback

52:20 to Amber just now, what were you trying to achieve for her?

52:26 MARK: I was trying to help her.

52:28 LEIGHTON: And what are the group saying

52:30 about the way you do give feedback?

52:33 MARK: They’re saying I’m being judgmental,

52:35 and I don’t believe it.

52:37 LEIGHTON: Mark, it seems as though, despite wanting

52:40 to be helpful, you’ve come across as judgmental

52:43 to quite a few of the group.

52:46 Are you satisfied with that?

52:47 MARK: No, of course not.

52:49 LEIGHTON: So why don’t you ask the group

52:50 to give you some explanation of how you’re coming across

52:54 in that way?

52:56 JIMMY: I’d hate to be running this group.

52:58 SABINA: I don’t think it’s just the women.

53:00 SAM: No.

53:01 No, it isn’t.

53:04 LEIGHTON: Can we tell Mark how he’s coming across?

53:06

00:00 00:53:09,266 –> 00:53:10,640 HORACE: Yeah, well, Mark, I mean,

53:10 you’re always telling other people what to do,

53:12 like you should do this, you should do that.

53:16 It just be better if you speak for yourself,

53:18 just talk about your own feelings.

53:19

00:00 00:53:22,710 –> 00:53:23,270 NATHAN: Yeah.

53:23 Mark, you’re always just full of 12-step cliches.

53:27 You’re quoting from the book, always giving lip service.

53:29

00:00 00:53:33,010 –> 00:53:36,290 SAM: Mark, I just feel it’s disrespectful.

53:36 You’re always telling people what to think.

53:39 LEIGHTON: Mark, it sounds like several people

53:41 are saying that the way you give feedback is not very effective.

53:46 How can Mark be more effective?

53:48 How can you be more effective when you give your feedback?

53:51 JIMMY: Well, Mark, you actually have quite a lot

53:53 of talk for the group.

53:54 People are getting in touch with their vulnerability here,

53:57 and you should do the same.

53:59 Don’t be Mr. Recovery all the time, man.

54:01

00:00 00:54:04,500 –> 00:54:05,800 HORACE: Yeah, I like you, Mark.

54:05 You’re a good guy.

54:06 And just speak for yourself, just how they

54:09 keep saying use “I” statements.

54:10 NATHAN: Yeah, stop quoting from the book.

54:13 Start to identify.

54:13

00:00 00:54:17,260 –> 00:54:19,510 LEIGHTON: So it sounds like people

54:19 are saying that you’ve got a lot to give the group,

54:22 that you often have some sensible ideas,

54:25 but that you need to speak from your own position

54:29 and talk more about yourself.

54:31 How do you feel you could do with that?

54:33 I mean, do you feel that’s a doable thing?

54:36 MARK: Well, it’s lots to take onboard.

54:38 And I had no idea, really, how I came across.

54:42 But yeah, it’s a lot to think about.

54:45 LOUISE: I really do hope you take

54:46 it onboard, Mark, because you have a lot to offer.

54:48

00:00 00:54:56,020 –> 00:54:57,520 ASHWOOD: The group cohesiveness that

54:57 has built up through particular individuals

54:59 taking some risks– sharing, identifying, supporting

55:02 one another, and beginning to offer interpersonal feedback–

55:06 seems to have set up an adaptive spiral which

55:09 has begun to allow some of the more reserved clients

55:12 to share aspects of themselves that previously

55:14 didn’t feel safe to expose.

55:18 At the beginning of this session,

55:19 Louise follows Jimmy’s example and discloses things

55:22 that she did whilst in active addiction.

55:26 While this is external material or content,

55:29 there’s still an interpersonal process occurring.

55:31 She’s showing a level of trust and openness

55:34 to the group that she hadn’t before.

55:36 However, in response to this, many of the group

55:38 are still struggling to go beyond focusing

55:41 on the content of the disclosure.

55:42 And this doesn’t seem to offer much support

55:45 for learning or change.

55:47 Sam chose a deeper level of interpersonal sensitivity

55:50 by trying to normalize Louise’s behavior and hints that maybe

55:54 he’s done similar but doesn’t quite

55:56 go as far as admitting this.

55:58 It isn’t entirely clear what Louise is wanting for the group

56:02 in making her disclosure.

56:04 To highlight the asking for detail about the event

56:06 isn’t what she’s looking for.

56:08 Tim makes the question of her intention explicit.

56:12 She doesn’t seem sure, but by saying,

56:14 I didn’t know what they’d say, it

56:16 hints there’s some interpersonal anxiety about the group’s

56:19 response.

56:21 Jimmy appears to pick up on this and offers support

56:24 by affirming her courage in bringing this to the group.

56:27 Other group members follow this lead,

56:29 but Louise doesn’t seem to want to let it in.

56:32 Finally, she chooses to challenge Brian’s rather

56:35 generalized comment, “We’ve all done stuff we’re not proud of.”

56:39 and this changes the dynamic of the group significantly.

56:42 As Brian discloses his violence while under the influence–

56:47 BEATTY: How the group respond to Brian’s disclosure

56:49 is starkly different to any of the previous sharings.

56:53 He blames his violence on drink and on his partner.

56:56 Some of the group make efforts to try

56:58 to explain their reaction to him, essentially,

57:00 that he’s not taking responsibility

57:02 for his actions, which is a treasured group norm.

57:06 The attacks escalate.

57:08 But Brian’s lack of response leaves

57:10 an uncomfortable silence.

57:12 There was a useful opportunity here for the therapist

57:15 to invite the group to explore the difference between the way

57:18 Brian’s disclosure was received and that of Jimmy and Louise’s.

57:22 This could have addressed what happened

57:24 in a way that allowed Brian to take part

57:26 in an exploration of the process from an observer’s stance,

57:29 and so be less defensive.

57:32 This might have offered him a better opportunity

57:35 to understand what it was about his manner that left him

57:38 outside the group.

57:39 Also, other members in observing the process this way

57:43 might have been able to see whether they came across

57:45 in a way that was congruent with their intentions

57:48 when giving feedback.

57:50 However, in this instance, Tim and I

57:52 choose to stay with the discomfort that

57:54 is evident in the room and give the group an opportunity

57:58 to find its own way.

57:59

00:00 00:58:02,400 –> 00:58:04,530 LEIGHTON: When Amber expresses her frustration,

58:04 Mark attacks her with what might have been helpful feedback,

58:07 if it had been delivered more appropriately.

58:11 Other group members try to pick up on the point

58:13 that Mark is making.

58:14 But the attack has left her defensive.

58:17 Mark’s final assault is too much for Amber,

58:19 and she gets up to leave.

58:22 Jax’s quick and careful verbal and gestural intervention

58:25 supports her in staying.

58:27 But I would point out, this doesn’t always happen.

58:30 If group members leave in situations like this,

58:32 it’s useful to have an arrangement about how

58:34 it’s dealt with.

58:36 This might mean one of the therapists present

58:38 leaving, or asking a senior member of the group

58:40 to encourage them back in, or alert staff elsewhere

58:44 in the building to do this.

58:46 While we do what we can to moderate the anxiety

58:49 levels in this personal group therapy,

58:51 they can become emotionally charged.

58:53 And this is a high-risk situation

58:55 for people in early recovery.

58:57 Getting people back into a group they couldn’t tolerate

59:00 is almost always the most therapeutic outcome.

59:03 A skillful exploration of the process right at that person’s

59:06 growing edge helps them to understand what occurred,

59:10 what was theirs, and what were other people’s parts in it,

59:13 and also to realize that they can

59:15 tolerate tension and conflict.

59:17 ASHWOOD: The group dynamic shifts,

59:20 and Gemma, Sabina, and Sam start to identify

59:22 what they see as unhelpful, the things that are undermining

59:26 the cohesiveness of the group.

59:28 They highlight in general terms how they’re feeling judgment.

59:33 Generalized comments like this can often

59:35 be turned into opportunities for interpersonal learning

59:38 by asking people to be more specific.

59:41 Till now, Mark’s way of communicating

59:43 has gone unchallenged.

59:44 And in early recovery, it’s often better

59:46 to help people to use their defenses constructively

59:49 than to confront them head-on in an attempt to eradicate them.

59:52 However, Mark’s relational style has

59:55 experienced a somewhat aggressive and undermining

59:57 of group cohesiveness.

59:59 But something needs to be done to help

01:00:01 him work as part of the group.

01:00:03 Tim asks for people to give more specific feedback.

01:00:07 And they then begin to focus their comments on individuals.

01:00:11 Amber, staying in the room, begins to bear fruit,

01:00:14 as she’s able to name Mark.

01:00:16 This is the start of an important process for him,

01:00:19 and one that illustrates how interpersonal learning can

01:00:22 be so effective of facilitating character change.

01:00:26 Tim’s first intervention helps Mark to understand and state

01:00:29 his intention in giving Amber feedback.

01:00:32 Then he asked him how he’s hearing

01:00:33 he comes across to others.

01:00:35 This highlights the dissonance between his intentions

01:00:38 and the reality of the situation.

01:00:41 Initially, Mark characteristically

01:00:42 denies he is this way.

01:00:44 This is reasonable.

01:00:45 He doesn’t see himself as judgmental.

01:00:47 But the power of Tim’s next intervention

01:00:49 isn’t in challenging Mark’s perception of himself.

01:00:52 Instead, it’s in asking him if he’s content

01:00:55 that he comes across to others quite differently

01:00:57 to how he sees himself.

01:00:58 The fact that Mark wants others to see him as he does

01:01:01 offers the therapeutic leverage to ask him to invite feedback

01:01:04 on how he’s perceived and how he might do things differently.

01:01:07

00:00 01:01:13,230 –> 01:01:16,071 AMBER: I want some help from this group.

01:01:16 I’m not getting it.

01:01:17

00:00 01:01:19,890 –> 01:01:22,376 Can somebody help me?

01:01:22 MARK: People have tried to help you, Amber.

01:01:24 I don’t think you can be helped.

01:01:27 NATHAN: You just ooze negativity, Amber.

01:01:30 LOUISE: So angry.

01:01:31

00:00 01:01:35,215 –> 01:01:36,930 MARK: It’s hard to help somebody who

01:01:36 looks like they don’t want it.

01:01:40 SAM: Amber, do you want to be helped?

01:01:42

00:00 01:01:45,979 –> 01:01:47,520 BEATTY: Amber, you know this struggle

01:01:47 that you’ve got into with the group, is this familiar?

01:01:54 AMBER: I don’t know.

01:01:55 BEATTY: You’ve been here before?

01:01:57

00:00 01:01:59,770 –> 01:02:03,120 AMBER: I don’t understand.

01:02:03 BEATTY: When you came to me, and we had an assessment,

01:02:07 and you asked for help, what were you feeling like then?

01:02:11

00:00 01:02:15,120 –> 01:02:16,100 AMBER: I was weak.

01:02:16

00:00 01:02:19,040 –> 01:02:20,217 I’ve reached my rock bottom.

01:02:20

00:00 01:02:24,193 –> 01:02:25,187 I left my flat.

01:02:25

00:00 01:02:28,700 –> 01:02:31,030 I’m no one.

01:02:31 LEIGHTON: So how is Amber in the group?

01:02:33 Do we see that side of her?

01:02:35

00:00 01:02:38,990 –> 01:02:41,377 BRIAN: She’s angry.

01:02:41 MARK: Yeah, I’d say angry.

01:02:42 GEMMA: She’s supportive to me.

01:02:46 SABINA: A bit dismissive, bit like she doesn’t really

01:02:50 care about us.

01:02:52 HORACE: Look how she puts up a shield.

01:02:56 SAM: Amber, you come across like you don’t want help,

01:02:59 or need anyone, or anything.

01:03:03 JIMMY:I think you actually come across as quite a hard person.

01:03:05

00:00 01:03:09,450 –> 01:03:11,650 LEIGHTON: Is that how you see yourself, Amber?

01:03:11 Do you think you are a hard person?

01:03:13

00:00 01:03:16,639 –> 01:03:17,430 AMBER: Life’s hard.

01:03:17

00:00 01:03:19,960 –> 01:03:21,930 It’s how I have to be.

01:03:21 Life’s made me like that.

01:03:24 LEIGHTON: But is it how you would like to be seen?

01:03:27 AMBER: No.

01:03:29 BEATTY: Amber, you know when you were giving Gemma feedback,

01:03:33 where were you coming from?

01:03:35 Which part of Amber was that?

01:03:39 AMBER: She’s my friend.

01:03:40

00:00 01:03:44,371 –> 01:03:44,870 NATHAN: See?

01:03:44 You’re showing your vulnerability now, Amber.

01:03:47 I feel a bit more closer to you.

01:03:49 JIMMY: Yeah, I mean, why can’t we see more of that?

01:03:52 BEATTY: So is this an Amber the group hasn’t seen before?

01:03:56 JIMMY: Definitely.

01:03:59 LEIGHTON: So when you come to group,

01:04:00 and you are this hard, aggressive person,

01:04:03 how do the group experience you?

01:04:04 What are you hearing that they– how you come across to them?

01:04:10 AMBER: I don’t listen, then I’m aggressive.

01:04:14 LEIGHTON: Is that true?

01:04:15

00:00 01:04:19,415 –> 01:04:21,250 AMBER: No.

01:04:21 LEIGHTON: So in order to survive,

01:04:23 you’ve had to put up, as what Jax

01:04:26 calls it, a shield– a hard, aggressive shield.

01:04:29 But when you present this in the group,

01:04:32 they can’t really get through to you.

01:04:36 I mean, is it all right for Amber to be angry?

01:04:41 ALL: Yeah.

01:04:42 SAM: Yeah, sure.

01:04:43 LEIGHTON: Is it okay for her to be frustrated some of the time?

01:04:45 ALL: Yeah, of course.

01:04:46 LEIGHTON: So what would you like Amber to be showing the group?

01:04:49 What would you like her to be bringing to you?

01:04:54 NATHAN: How she’s feeling.

01:04:56 MARK: If you have honesty, it would be good.

01:04:59 SABINA: Yeah, maybe let down some barriers.

01:05:02 JIMMY: When you start trusting the group,

01:05:04 Amber, that’s when you’re going to get more of it.

01:05:09 LEIGHTON: Amber, do you trust anyone in the group?

01:05:13 AMBER: No.

01:05:14

00:00 01:05:16,379 –> 01:05:17,920 LEIGHTON: Is there anyone you admire?

01:05:17

00:00 01:05:24,440 –> 01:05:26,760 AMBER: Gemma and Jimmy.

01:05:26 LEIGHTON: So what is it about the way that they’re

01:05:28 doing, presenting themselves, that makes you admire them?

01:05:32 AMBER: How Jimmy spoke about his mom.

01:05:34

00:00 01:05:44,140 –> 01:05:45,592 It must have been really hard.

01:05:45

00:00 01:05:48,980 –> 01:05:54,060 LEIGHTON: How is Amber coming across right now?

01:05:54 SABINA: I feel like she’s listening.

01:05:56 MARK: And I feel like it’s the first time she’s actually

01:05:58 getting real.

01:06:00 NATHAN: I’m actually seeing a much softer side to you, Amber.

01:06:04 JIMMY: I feel more willing to work with you now.

01:06:08 GEMMA: Much different.

01:06:09

00:00 01:06:15,500 –> 01:06:18,266 BEATTY: How are you right now, Amber?

01:06:18 AMBER: It feels uncomfortable.

01:06:21 It feels weird.

01:06:22

00:00 01:06:32,200 –> 01:06:34,800 LEIGHTON: Dealing with Mark’s part in this process

01:06:34 appears to have allowed Amber to come back

01:06:37 to her confusion and frustration as to how

01:06:39 the group might help her.

01:06:41 They try to offer her interpersonal feedback

01:06:44 with varying degrees of skill.

01:06:46 Jax attempts to ratchet up the therapeutic leverage for Amber

01:06:50 to take responsibility for her situation

01:06:52 by connecting Amber’s present struggle in the group

01:06:55 with previous observations.

01:06:57 However, this isn’t something she can engage with.

01:07:01 So Jax takes a different tack and invites

01:07:02 her to show a different aspect of herself

01:07:05 by reminding her of her vulnerability

01:07:07 before coming into treatment.

01:07:10 I then highlight the difference between the vulnerable Amber

01:07:13 and how she normally presents herself in the therapy group

01:07:16 by asking the members to say how they usually see her.

01:07:21 I pick up on Jimmy’s suggestion that she appears hard

01:07:24 and ask Amber how she sees herself.

01:07:28 Amber initially justifies her presentation

01:07:30 by pointing out why she needs to be hard.

01:07:33 However, when asked if she wants to be seen this way,

01:07:36 it appears she doesn’t, once again

01:07:38 illuminating the dissonance between how

01:07:40 someone wants to appear and how they actually do.

01:07:44 Jax once again invites Amber to show a different side

01:07:47 of herself by drawing her attention

01:07:49 to the softness with Gemma, and the group appreciate the shift.

01:07:54 I underline this learning by summarizing

01:07:56 the process in collaboration with Amber

01:07:58 and go on to validate her emotions,

01:08:01 as it’s important that she and the rest of the group

01:08:03 realize it isn’t the emotions themselves

01:08:05 that are problematic, but the way they are expressed.

01:08:09 I then invite the group to suggest

01:08:10 how she might relate to these feelings in a way

01:08:12 they can better connect with.

01:08:15 After this, I go on to invite further interpersonal learning

01:08:18 for Amber by asking if she trusts anyone in the group.

01:08:21 She honestly replies that she doesn’t.

01:08:24 But since I am confident that she has some attraction to some

01:08:27 of the group members, I ask if there’s anyone

01:08:29 in the group she admires.

01:08:32 The exploration of her admiration of Gemma and Jimmy

01:08:35 warms the bonds between these people and develops group

01:08:37 cohesiveness, as well as giving them

01:08:39 affirmation of the qualities that are appreciated in them.

01:08:43 In doing so, it also helps Amber to think

01:08:46 about how she might be different and act differently

01:08:49 in relationship with others.

01:08:50 The warm and affirming feedback she receives

01:08:52 is quite different to the way she’s

01:08:54 been related to in the past.

01:08:56 And although she is somewhat uncomfortable with it,

01:08:58 she clearly likes this new found intimacy.

01:09:02 ASHWOOD: Brian received quite an attack

01:09:03 from the majority of the members of the group

01:09:05 at the beginning of this vignette.

01:09:07 And the session didn’t give much opportunity

01:09:09 to resolve his rejection by the group.

01:09:11

00:00 01:09:13,841 –> 01:09:15,840 After this, he discharged himself from treatment

01:09:15 and did not return.

01:09:17 Sadly, not an uncommon event when working with substance

01:09:20 misuse.

01:09:22 Whether the therapists might have

01:09:23 been able to deal with the situation in a way that

01:09:26 made it more likely he would stay

01:09:27 is a question they’re left with and something

01:09:30 they could pick up in clinical supervision.

01:09:32 But apart from this, in many ways,

01:09:34 it’s an example of a good and hardworking

01:09:36 interpersonal group.

01:09:37 Although the cohesiveness is still fragile, there

01:09:40 is enough trust and value in the group for people

01:09:43 to remain and to tolerate tension,

01:09:45 to give and receive interpersonal feedback,

01:09:48 even when it’s difficult. With the guidance of the therapists,

01:09:51 Mark and Amber come away with significantly different

01:09:54 experiences as a result of their peers’ abilities

01:09:56 and willingness to offer more skilled feedback.

01:09:58

00:00 01:10:01,840 –> 01:10:04,880 We join our final vignette with Brian absent from the circle.

01:10:04

00:00 01:10:13,245 –> 01:10:14,620 HORACE: We wound up sitting here.

01:10:14

00:00 01:10:17,300 –> 01:10:21,830 We sit in these groups day in, day out, just

01:10:21 talking, talking, talking.

01:10:24 And I just want to read like navel-gazing.

01:10:27 This ain’t what recovery’s about.

01:10:29 Recovery’s out there, man.

01:10:30 I should be living my life, getting a job, earn some money,

01:10:33 or something.

01:10:34 GEMMA: Horace, therapy’s just so self-indulgent.

01:10:37 We’re all going to be out on our own anyway, so

01:10:39 why don’t we just get on with it.

01:10:42 MARK: Well, this isn’t how we keep clean.

01:10:44 We keep clean by going to meetings, getting a sponsor,

01:10:47 and working the steps.

01:10:49 It’s working a program.

01:10:51 NATHAN: You’re still carrying on like the other day, Mark,

01:10:53 full of cliches.

01:10:56 MARK: They’re not cliches.

01:10:57 It’s life or death.

01:10:58

00:00 01:11:00,760 –> 01:11:04,139 NATHAN: Not everybody gets recovery the way that you do.

01:11:04 MARK: That’s what I know.

01:11:05 SAM: This is all a diversion.

01:11:07 I’ve said it before.

01:11:08 It’s a waste of time.

01:11:10 Can’t we just focus on what’s important?

01:11:12 JIMMY: Do you know what, Mark?

01:11:14 We never get to hear about you– the real you.

01:11:17 LOUISE: What’s going on for me is, where is Brian?

01:11:20 I’ve heard he’s using.

01:11:21

00:00 01:11:23,740 –> 01:11:27,595 BEATTY: So what do we think is going on in the group?

01:11:27 LOUISE: I’m scared.

01:11:29 Brian’s out there, and I’m thinking about it.

01:11:32 He’s been in treatment three times,

01:11:36 and he still doesn’t get it.

01:11:39 SAM: I’m scared too.

01:11:41 This is for me.

01:11:41 This is my last chance to learn.

01:11:43 This is the last chance I get.

01:11:46 SABINA: Yeah, I’m scared too.

01:11:48 It’s fear.

01:11:49 I think I don’t have enough time left here.

01:11:52 I need more time here.

01:11:54 You’ve been in recovery a few times, haven’t you, Mark?

01:11:57 MARK: Yeah, three times.

01:11:58 And relapses got lower and lower.

01:12:01 But I had two years clean time last time

01:12:04 and determined to get it back.

01:12:05 I’ll do it right this time.

01:12:06

00:00 01:12:10,210 –> 01:12:13,796 NATHAN: I’m sorry about Brian using, but I’m here for myself.

01:12:13 You come in on your own.

01:12:14 You’re going to leave here on your own.

01:12:18 HORACE: Well, it’s easy for you to say, Nathan.

01:12:20 But tell you, I’m worried as well.

01:12:23 I mean, look, Brian’s out there using.

01:12:25 Mark said he’s relapsed before.

01:12:26 There’s no guarantees, is there?

01:12:29 AMBER: We’ve had something to do with this, with Brian.

01:12:33 We were really harsh on him.

01:12:37 LEIGHTON: So what’s bothering you, Amber?

01:12:41 AMBER: When Brian opened up about his girlfriend,

01:12:45 I judged him.

01:12:47 There was no empathy in the room.

01:12:51 GEMMA: Yeah, but he didn’t exactly open up, did he?

01:12:54 NATHAN: He just made a statement about his girlfriend

01:12:56 and just left it open.

01:12:58 SABINA: Yeah, but I’m wondering if we could’ve

01:13:00 given him more support.

01:13:02 GEMMA: I mean, it wasn’t what he shared.

01:13:03 It was, well, he just had no remorse.

01:13:06 LOUISE: Do you know what?

01:13:07 I don’t think it was that last group, though.

01:13:10 Maybe he wasn’t serious from the start.

01:13:13 JIMMY: Yeah, I mean, Brian is out there using,

01:13:15 and I’m gutted.

01:13:18 But Brian knows what he has to do if he wants recovery.

01:13:20 We’re all still here.

01:13:24 Nathan, we are here for ourselves.

01:13:26 But at the same time, we’re here for each other.

01:13:28 And I’ve seen this group getting stronger and stronger.

01:13:31 SABINA: Wow, just listening to you,

01:13:34 it’s like I know I’ve got so much respect for so

01:13:37 many people in this room.

01:13:38

00:00 01:13:41,430 –> 01:13:42,430 BEATTY: Can you say who?

01:13:42

00:00 01:13:45,250 –> 01:13:48,112 SABINA: Amber, actually.

01:13:48 She’s really changed.

01:13:49

00:00 01:13:52,537 –> 01:13:54,120 LEIGHTON: Well, who’d have thought it?

01:13:54

00:00 01:13:57,060 –> 01:13:59,270 LOUISE: Yeah, you’re really changing.

01:13:59 MARK: Yeah, even I could see a change in you.

01:14:01 JIMMY: Now I really feel like you’re one of us now.

01:14:03

00:00 01:14:05,740 –> 01:14:08,910 BEATTY: It’s a bit of a special day today.

01:14:08 It’s Jimmy’s last group.

01:14:12 LEIGHTON: Yep.

01:14:13 You finished the program, Jimmy.

01:14:15 You know the drill.

01:14:16 I’m going to ask you to say a few words to your group

01:14:21 about how treatment’s been for you.

01:14:22

00:00 01:14:28,830 –> 01:14:33,052 JIMMY: First of all, I just want to thank Tim and Jax, really,

01:14:33 for your support.

01:14:33 And you’ve been amazing.

01:14:35

00:00 01:14:39,150 –> 01:14:45,950 I’ve been here 12 weeks now, and it’s been a struggle,

01:14:45 I’ve got to admit.

01:14:48 But at the same time, in a weird sort of way,

01:14:50 I’ve really enjoyed it.

01:14:51 I’ve learned a lot.

01:14:54 I just want to, I suppose, take this opportunity to just say

01:14:58 to a few people a few things.

01:15:02 Gemma, for one, you’ve learned to trust the group.

01:15:07 And trust is really important in this environment.

01:15:10 In order for the group to work, there’s got to be trust in it.

01:15:13 And I’ve seen that in you a lot.

01:15:14

00:00 01:15:18,694 –> 01:15:21,970 Amber, I mean the change in you is amazing.

01:15:21 You came in here, and I didn’t even want to speak to you.

01:15:26 And now I feel I can have some sort of connection with you.

01:15:29 I can have a conversation with you.

01:15:33 And Sam, you’re the newest member in this group.

01:15:38 And I can see you’re a clever bloke.

01:15:42 I can see you’re going to be good for this group.

01:15:45 You just make sure you keep putting in,

01:15:47 and you’ll definitely get what you’re putting out.

01:15:51 And last for Mark, my best mate in here.

01:15:55

00:00 01:15:58,450 –> 01:16:00,370 God, we’ve been through a lot.

01:16:00 You’ve helped me through some hard times.

01:16:04 The only thing I say to you, mate,

01:16:06 is ease up on the recovery talk.

01:16:10 Open up a little bit more, and I feel you’ll do fine.

01:16:13 MARK: Thanks, man.

01:16:13

00:00 01:16:18,260 –> 01:16:23,270 JIMMY: Anything I say or advice I’ll give is just trust each

01:16:23 other.

01:16:25 Work with each other.

01:16:26 You’re not here to fight.

01:16:27 You’re here to get better.

01:16:29 You’re here to help each other.

01:16:30 And the thing, if you carry on going

01:16:33 the way you’re going at the moment,

01:16:35 I think you’re all going to have a brilliant recovery.

01:16:37 I think you’re going to do really well.

01:16:40 I just want to thank you all.

01:16:41

00:00 01:16:44,124 –> 01:16:44,665 MARK: Cheers.

01:16:44 NATHAN: Cheers, Jimmy.

01:16:45

00:00 01:16:52,310 –> 01:16:53,620 LEIGHTON: Well done, Jimmy.

01:16:53 And we’ll see you at Aftercare on Thursday.

01:16:55

00:00 01:17:00,730 –> 01:17:03,030 This group starts with a demonstration

01:17:03 of many of the signs of an uncohesive group.

01:17:06 People who till now have been dedicated group members,

01:17:08 are devaluing therapy and the group,

01:17:11 as well as looking forward to other activities

01:17:14 external to the group for the support they need.

01:17:17 This is an indication for attention and action

01:17:19 on the part of therapists.

01:17:22 As if members continue to mistrust the group, at best,

01:17:25 it is unlikely they will invest in or learn anything from it.

01:17:28 At worst, people will leave.

01:17:31 Nathan makes some attempt to highlight how people aren’t

01:17:33 helping the group process.

01:17:35 But his style is rather over-confrontational.

01:17:38 Sam is able to step back from the process

01:17:41 and suggest that the group could be more helpfully directed.

01:17:44 But it isn’t until Louise names the elephant in the room–

01:17:48 Brian’s absence– and Jax picks up on this,

01:17:51 that the unspoken tensions become explicit.

01:17:54 It’s an axiom of interpersonal group therapy

01:17:57 that when something important isn’t being acknowledged

01:17:59 in a group, then very little meaningful work

01:18:02 can be done in it.

01:18:03 Once the clients start to express their real fears,

01:18:06 the cohesiveness in the group builds again rapidly.

01:18:10 Amber’s newfound willingness to show a little vulnerability

01:18:13 is evidenced as she begins to worry

01:18:15 about the group’s and indeed her own part in Brian leaving.

01:18:19 This leads onto a useful and material exploration

01:18:22 of how the members of the group may have played

01:18:24 a role in Brian’s leaving.

01:18:26 Some individuals focus more on their own part in it,

01:18:29 and others focus on Brian’s, each

01:18:31 expressing their individual tendencies

01:18:33 for responsibility attribution.

01:18:36 This might have been a useful opportunity

01:18:38 to highlight people’s different reactions to Brian’s absence.

01:18:41 However, the importance dealing with the anxiety

01:18:44 his leaving and relapse have engendered rightly

01:18:47 takes precedence.

01:18:49 The result was that the group were

01:18:51 able to agree that Brian was primarily

01:18:54 responsible for his own mistakes,

01:18:56 that they still cared about him, and that his leaving did not

01:18:59 mean that their own treatment was doomed to failure.

01:19:01 The more experienced members come out

01:19:03 of it reaffirming their commitment

01:19:04 to and the value of the therapy group.

01:19:07 And with the support of Jax, their valuing of each other.

01:19:12 BEATTY: This is Jimmy’s last group,

01:19:14 so it ends with a somewhat formulized ritual for him,

01:19:18 as he’s graduating from the treatment program.

01:19:21 Giving senior clients an opportunity

01:19:23 to say something to individual group members

01:19:25 at the end of their last group, and to summarize

01:19:28 their own journey, can help the other participants

01:19:31 see how far a person has come during treatment.

01:19:35 This has the important therapeutic effect

01:19:38 of instilling hope for change.

01:19:41 It’s also a chance for that person

01:19:43 to offer specific interpersonal feedback to members

01:19:46 they are concerned about, as he does with Mark.

01:19:50 This ritual process can be done in different ways

01:19:53 according to the traditions of the treatment setting.

01:19:57 But some kind of empathic acknowledgement

01:19:59 of the milestone they have achieved

01:20:01 is an important part of the transition when

01:20:04 an experienced person leaves the group,

01:20:07 for the group as a whole, as well as the person leaving.

01:20:10

00:00 01:20:13,000 –> 01:20:16,040 At the end, Tim mentions the Aftercare program

01:20:16 that Jimmy will be moving onto.

01:20:18 This is a much less intensive support system

01:20:21 than the one Jimmy has been using till now in his recovery

01:20:25 but an important next stage to ease his move

01:20:28 into an independent life.

01:20:31 LEIGHTON: Working therapeutically

01:20:33 in the field of substance misuse is at least as challenging

01:20:36 and complex as working with other mental or physical health

01:20:39 problems for which regulated bodies ensure

01:20:41 minimum standards of training for clinical practitioners.

01:20:45 An absence of regulation in addiction work

01:20:47 is not an excuse for an absence of standards.

01:20:50 For this reason, although these vignettes and commentary

01:20:53 offer a glimpse into the theory and practice

01:20:55 of interpersonal group therapy and addiction treatment,

01:20:59 they’re clearly not sufficient in themselves

01:21:02 as a clinical training in the model.

01:21:04 It’s essential that those wishing

01:21:06 to lead therapeutic groups of individuals recovering

01:21:09 from substance misuse seek out robust, accredited training

01:21:12 programs, such as those offered currently

01:21:15 and being developed by Action on Addiction.

01:21:18 Other ways of developing good practice

01:21:20 involve forming special interest groups,

01:21:23 peer supervision groups, and seeking

01:21:25 competent external supervisors who

01:21:28 understand and are experienced in using this model.

01:21:31 It would be marvelous to be able to tell you

01:21:33 about a robust body of research evidence

01:21:36 supporting this model for addiction treatment.

01:21:39 Unfortunately, at this time, we can only

01:21:41 rely on a clear and convincing rationale–

01:21:44 clinical experience, some promising unpublished research,

01:21:48 and the experience of clients of well-run treatment programs

01:21:51 who tell us with great consistency

01:21:53 that group therapy was the most valuable component

01:21:56 of their own treatment.

01:21:58 One of the reasons why such research is lacking

01:22:01 is the lack of well-trained, well-supervised practitioners

01:22:05 who can conduct this model of group therapy and addiction

01:22:07 treatment in a well-specified, consistent,

01:22:11 and faithful way in order that meaningful research can

01:22:14 be done.

01:22:15 We are hoping that these materials may play a small part

01:22:18 in encouraging the development of such

01:22:20 a group of practitioners.