Chapter 9 Time-Limited Group Therapy

Group psychotherapy is one of the most common modalities for treatment of substance abuse disorders. Group therapy is defined as a meeting of two or more people for a common therapeutic purpose or to achieve a common goal.

It differs from family therapy in that the therapist creates open- and closed-ended groups of people previously unknown to each other. The lessons learned in therapy are practiced in the normal social network. Although efficacy research on group therapy for substance abuse disorder clients has been limited, there is substantial anecdotal and clinical evidence that it can have a dramatic impact on participating clients.

In TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT, 1994a), group therapy is cited as the treatment modality of choice for a variety of reasons. In clinical practice, group psychotherapy offers individuals suffering from substance abuse disorders the opportunity to see the progression of abuse and dependency in themselves and in others; it also gives them an opportunity to experience their success and the success of other group members in an atmosphere of support and hopefulness.

The curative factors associated with group psychotherapy, defined by Yalom, specifically address such issues as the instillation of hope, the universality experienced by group members as they see themselves in others, the opportunity to develop insight through relationships, and a variety of other concerns specific to the support of substance-abusing clients and their recovery (Yalom, 1995).

For many years, Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have recognized the importance of breaking the isolation associated with substance abuse, while at the same time connecting individuals with others whose common purpose is to dramatically change their lives through connection and community. From these perspectives, time-limited group psychotherapy offers potent opportunities to maximize the treatment energies of both therapist and client.

Research suggests that most client improvement as a result of group therapy occurs within a brief span of time--typically, 2 or 3 months (Garvin et al., 1976). This research implies that short-term therapy can be as successful as long-term therapy in promoting change. Short-term group therapy should be more goal-oriented, more structured, and more directive than long-term group therapy. Some therapists also believe the experience should be intensified through the use of high-impact techniques such as psychodrama (see discussion later in this chapter).

Appropriateness of Group Therapy

Groups can be extremely beneficial to individuals with substance abuse problems. Levine and Gallogly have noted that groups for alcohol-dependent clients

Help reduce denial, process ambivalence, and facilitate acceptance of alcohol abuse

Increase motivation for sobriety and other changes
Treat the emotional conditions that often accompany drinking (e.g., anxiety, depression, hostility)

Increase the capacity to recognize, anticipate, and cope with situations that may precipitate drinking behavior

Meet the intense needs of alcohol-dependent clients for social acceptance and support (Levine and Gallogly, 1985)

Many beneficial effects happen more easily in groups than in one-on-one therapy. Group members confront each other, do "reality checks," practice reflective listening, mirror each other, and help each other reframe key issues.

Individuals in earlier stages of dependence can witness what later stage experiences are like (and by inference where they could progress if they do not reduce their use). Often, group members can be more effective than the therapist in confronting a participant who is not facing an important issue (e.g., the client who believes she can quit drinking and still smoke marijuana).

Group Effects

One Consensus Panelist recalls a therapy session in which a member arrived, furious and hostile, shouting, "How much longer do I have to do this stupid program? None of it works anyway!" Another group member immediately asked, "So, how does the anger keep things going for you?"

In the ensuing conversation, the group learned that the angry member's ex-wife had just sent him a bottle of expensive whiskey with the following note: "Dying to get together again." This revelation, and the supportive group listening that followed, occurred largely without verbal involvement from the therapist.

Group Therapy Approaches

Several kinds of groups fall under the spectrum of time-limited group therapy. In the broadest sense, two fundamental models help define categories of group interventions: the process-sensitive approach and the directive approach. The process-sensitive group approach finds its direction in the traditions of analytical theory and has a significant range of expression.

Depending on the theoretical base and leadership style of the facilitator, a process-sensitive group can examine the unconscious processes of the group as a whole, utilizing these energies to help individuals see themselves more clearly and therefore open up the opportunity for change. This "group-as-a-whole" approach is best exemplified by the work of Bion, who sees healing as an extension of the individuals within the group as the group comes to terms with a commonly shared anxiety (Bion, 1961).

Yalom offers a significant contrast to these group-as-a-whole interventions through his interactional group process model (Yalom, 1995). By attending to the relationships within the group and helping individuals understand themselves within the relational framework, an interactional group process provides individuals with significant information about how their behavior affects others and how they are in turn affected by other members.

In addition, focusing energy on the relationships within the context of group, the leader is careful not to assume a central role but, rather, recognizes that the group itself becomes the agent of change, with the leader supporting the process but not initiating it. Attention is focused on the nature and growth of the relationships manifested in the "here and now" as the group takes place.

The second approach, and one better known to alcohol and drug counselors, is a dramatically different form of group therapy, often referred to as a directive approach. It offers structured goals and therapist-directed interventions to enable individuals to change in desired ways.

A short-term directed group may be used to address major issues of concern for clients with substance abuse disorders and to facilitate self-discovery and growth through appropriately sequential activities. Because the therapist is "central" and in charge, this type of group depends less for success on group members and their ability to create a cohesive sense of belonging.

Compared with the process-sensitive group, which sees the cohesive power of the group as a primary curative factor, the directive approach addresses specific agenda items in a logical order with greater emphasis on content as the primary source of effective change. The directive approach, therefore, is perhaps more likely to be effective with those in early recovery.

A potent example of directive, time-limited group experience, developed by Maultsby and Ellis, is known as Rational Behavioral Training (RBT) (Maultsby, 1976). This cognitive-behavioral therapy takes place over 13 weeks, one session per week. It uses fundamental cognitive-behavioral interventions and the clients' growing awareness of their ability to control their own belief systems and self-talk and thus control their affective states.

Clients are asked to share homework assignments and bring real-life situations into the group for exploration and examination. There is little effort in this group modality to analyze or direct energy to the relationships within the room. RBT affords a short-term intervention to develop the client's skill in controlling emotions. The inference is that individuals who experience their emotional world as controllable will no longer need to use substances to exert "external" control.

It is important to note that in any kind of group therapy, relationships are formed and process issues experienced. Even within the context of a cognitive-behavioral approach such as RBT, which is more educational than therapeutic, issues of process invariably arise.

The experienced therapist can use the relationships within the group even in a psychoeducational framework to support and enhance the treatment experience. Whenever the opportunity arises, the group facilitator should help connect members to members.

When shared histories are acknowledged, the sense of belonging is increased, and greater cohesion takes place. Cohesion may seem less important in a directive psychoeducational group. However, because of the very nature of substance abuse disorders, a feeling of belonging to a group committed to its own health rather than its own destruction is an important motivator for many clients.

There has been significant debate within the field regarding the pros and cons of heterogeneous and homogeneous groups. The heterogeneous group, in which members have a variety of diagnoses, offers greater complexity and more opportunities for a wide range of relationships, which can be extremely helpful to many clients.

However, the homogeneous group, particularly when composed of clients with substance abuse disorders, tends to lend itself more quickly to issues of cohesion and safety. For this reason, homogeneity has particular utility in the time-limited group intervention.

An important issue within the context of the homogeneous substance abuse disorder group, whether time limited or not, is the group's tendency to bond around its history of substance abuse rather than its commitment to recovery. Although the general focus of substance abuse treatment is on the abuse itself, the focus also must include issues of living within the context of the group.

Through modeling and gentle persuasion, the group facilitator can broaden the scope of a substance abuse treatment group to include relationships, concerns about daily living, and newly discovered personal integrity. Such are the struggles of all people in all circumstances. The movement from "what is wrong with us" to "how do we build better lives?" is an important transition in the time-limited group, whether psychoeducational or process sensitive.

Group therapy can be conducted within the context of almost any theoretical framework familiar to the therapist and appropriate to group goals. Often the therapist will work with two or more models at the same time. The theoretical bases supporting both process-sensitive groups and a more directive style can be combined effectively to address substance-abusing clients.

Theories of Group Therapy

The following group therapy models are discussed in this section:

Brief cognitive group therapy
Cognitive-behavioral group therapy
Strategic/interactional therapy
Brief group humanistic and existential therapies
Group psychodynamic therapy
Modified dynamic group therapy (MDGT)
Modified interactional group process (MIGP)

The first five are summarized below and discussed at greater length in Chapters 4 though 7 of this TIP. MIGP, considered a highly effective type of brief group treatment for substance abusers, is discussed in detail in this section. The 11 therapeutic factors identified by Yalom as the basis of successful group therapy are presented at the end of this section (Yalom, 1995).

Brief Cognitive Group Therapy

Cognitive techniques work well in group therapy. The group is taught the basics of the cognitive approach, then individual members take turns presenting an event or situation that tempted them to abuse substances. Other members assist the therapist in asking for more information about the client's thoughts on the event and how it did or did not lead to substance abuse (or to negative feelings that might have led to use). Finally, the group members provide the client with alternative ways of viewing the situation. Chapter 4 discusses brief cognitive therapy in more depth.

Cognitive-Behavioral Group Therapy

The cognitive-behavioral approach focuses the group's attention on self-defeating beliefs, relying on group members to identify such beliefs in each other. The therapist encourages group members to apply behavioral techniques such as homework and visualization to help participants think, feel, and behave differently. Chapter 4 discusses brief cognitive-behavioral therapy in more depth.

Strategic/Interactional Therapies

The strategic therapist uses techniques similar to those used in family therapy to challenge each group member to examine ineffective attempted solutions. The therapist encourages group members to evaluate and process these attempted solutions and recognize when they are not working, then engages the group in generating alternative solutions.

The therapist also works, where appropriate, to change group members' perceptions of problems and help them understand what is happening to them. Typically, the therapist guides the process, while members offer suggestions and encouragement to each other as they identify and implement effective solutions. To address the problem of substance abuse, the group will often be directed to examine problems that might result in substance abuse and reframe their perceptions of these problems.

The principles of solution-focused therapy are the same for group treatment as for individual therapy. These include client goal-setting through the use of the "miracle" question, use of scaling questions to monitor progress, and identification of successful strategies that work for each client. (These techniques are defined in Chapter 5 of this TIP.)

The therapist works to create a group culture and dynamic that encourages and supports group members by affirming their successes. At the same time, the therapist works to restrain client digressions ("war stories") and personal attacks. The therapist tries to challenge group members--all of whom, unlike in family therapy, are seen as "customers"--to take action to create positive change. Chapter 5 discusses brief strategic/interactional therapies in more depth.

Brief Group Humanistic and Existential Therapies

Several approaches fall within this category. The transpersonal approach is useful in meditation, stress reduction, and relaxation therapy groups and can be adapted for clients who have substance abuse disorders. In dealing with issues of religion or spirituality, it is helpful to have other people talk about their perspectives. In this way, past degrading or punitive experiences related to organized religion can be redefined in a more meaningful and useful context.

Gestalt therapy in groups allows for more comprehensive integration in that each group member can provide a piece of shared personal experience. Each group member plays a role in creating the group, and all of their perceptions must be taken into account in making a change. Role-playing and dream analysis in groups are practical and relevant exercises that can help clients come to terms with themselves.

One of the most influential contemporary experts on group therapy, Irvin D. Yalom, considers himself an existentialist because he is not concerned with past behavior except as it influences the "here and now." A summary of his existential approach is presented in The Yalom Reader (Yalom, 1997) and consists of three sections: (1) therapeutic factors in group therapy, (2) a description of the "here and now" core concept, and (3) therapy with specialized groups, including a chapter on group therapy and alcoholism.

This last chapter details specific techniques to diminish anxiety but still permit the group to maintain an interactional focus--for example, writing a candid summary of the session and mailing it to members before the next meeting. Yalom has worked closely with the National Institute on Alcohol Abuse and Alcoholism to apply basic principles of group therapy to alcohol abusers, and his ideas are applicable to those with other substance abuse disorders as well. See Chapter 6 for more discussion of humanistic and existential therapies.

Group Psychodynamic Therapy

Group psychodynamic therapy enables the group itself to become both the context and means of change through which its members stimulate each other to support, strengthen, or change attitudes, feelings, relationships, thinking, and behavior--with the assistance of the therapist.

The context sought is one in which the group becomes an influential reference group for the individual. Participation of members according to their abilities leads to some degree of involvement of each in pursuing individual and group goals. The process of goal-setting and clarification for expectation provides an agreed upon framework for meeting of mutual needs. This, in turn, contributes to the building of cohesive forces (Roberts and Northen, 1976, p. 141).

Chapter 7 discusses psychodynamic therapy in more depth.

Modified Dynamic Group Therapy

On the basis of psychodynamic theory, a modified dynamic group therapy approach was defined for substance-abusing clients (Khantzian et al., 1990). Viewing substance abuse disorders as an expression of ego dysfunction, affect dysregulation, failure of self-care, and dysfunctional interpersonal relationships, MDGT falls in the intermediate length of time-limited group psychotherapy, with its basic structure defined by two meetings per week over a 26-week format.

Based primarily on interventions to address cocaine addicts, MDGT focuses energy on the individuals within the group and conceptualizes the basic origins of substance abuse disorders as expressions of vulnerabilities within the characterological makeup of the client (Khantzian et al., 1990).

As a supportive, expressive group experience, MDGT provides substance-abusing clients the opportunity to evaluate and change their vulnerabilities in four primary areas: (1) accessing, tolerating, and regulating feelings; (2) problems with relationships; (3) self-care failures; and (4) self-esteem deficits. Congruent with this understanding of the origins of substance abuse, MDGP emphasizes safety, comfort, and control within the group context.

Group facilitation is defined primarily by the therapist's ability to engage and retain substance abusers in treatment by providing structure, continuity, and activity in an empathic atmosphere.

This supportive approach creates an atmosphere of safety, allowing the client to move away from the safety of the known behavior associated with substance abuse and into the less known world of recovery. As in other group experiences, this group theory encourages issues of universality as a means of overcoming isolation, while at the same time dealing with a common shame so often encountered in the substance-abusing client.

Unlike interpersonally focused process groups, which look more at relational concerns, MDGT places greater emphasis on the clients' growing understanding of their characterological difficulties and/or deficits, not entirely dissimilar to issues identified in self-help groups such as AA and NA.

Modified Interactional Group Process

Time-limited MIGP is a synthesis of the work of several theorists (Flores, 1988; Khantzian et al., 1990; MacKenzie, 1990; Yalom, 1995). MIGP is distinguished in a variety of ways from the psychoeducational groups so important in substance abuse treatment. As referenced in TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT, 1994a), both process-sensitive and psychoeducational group learning experiences are often necessary for the substance-abusing client.

Even in a short-term, intensive treatment experience, combining a psychoeducational group and a process group has significant clinical impact. The psychoeducational group is more directive, with the therapist as the central figure. However, as will be explained, it is important to utilize the energy of group process itself, even in a psychoeducational format, to enable clients to make connections and build relationships that will support their recovery.

The features that distinguish MIGP from a more traditional interactive process are the greater activity of the leader and the sensitivity to the development of a safe atmosphere that allows group members to examine relational issues without excessive emotional contagion. The atmosphere of safety is greatly enhanced by the therapist's adherence to group agreements or group norms and by the continued reinforcement of these agreements throughout the group process.

The importance of confidentiality, the group's accepting responsibility for itself, and self-disclosure are all supported by the facilitator. Procedural agreements, including beginning and ending the group session on time and ensuring that each member has a place within the circle, with any absences addressed, are part of the development of the safe environment.

In this process, the therapist helps the clients recognize that they are the primary change agents. The group becomes a safe place both to give and to receive support. Although traditionally substance abuse groups tend to be confrontative, MIGP is far more supportive.

This stems from the belief that denial and other defense mechanisms become more rigid when a person is attacked. Consequently, group members are encouraged to support one another and look for areas of commonality rather than use more shame-based interactive styles that attempt to "break through denial."

Intellectualization and MIGP

Many therapists are told that clients should get in touch with their feelings and experience "what is in their gut." Although awareness of the affective life is important to everyone, it is precisely the regulation of emotions that many substance-abusing clients have difficulty addressing. Consequently, although emotional exploration is encouraged within the context of MIGP, the facilitator is constantly monitoring the affective energy within the group, taking steps to break emotional contagion should it begin.

In a particularly intense group experience, the therapist may ask the group as a whole to take a step back and look at what just took place. In this way, the group not only learns from its shared life but also experiences its ability to control intense emotional responses. This consistent effort to reduce high levels of anxiety or emotional catharsis and to prevent them from dominating the group is another hallmark of MIGP.

General issues in MIGP

Following the insights of Flores and Mahon, MIGP focuses special attention in four areas of the client's life: gratification and support, vulnerability of self, regulation of affect, and self-care (Flores and Mahon, 1993). These four areas receive particular attention because they represent areas of vulnerability within the substance-abusing client that can easily lead to relapse and undermine recovery.

Gratification and support

Many clients come to treatment with profound issues of guilt and shame. Therefore, they lack the ability to give themselves gratification and support in the face of change. The active leadership style of MIGP allows group members to openly support one another and at the same time provides each group member with attention from the leader that leads to higher levels of gratification. Affirming group members' willingness to share and support one another is an essential ingredient in time-limited group work. It creates a positive atmosphere and increases levels of safety and cohesiveness, which further supports the change process.

Vulnerability of self

Substance-abusing clients often enter treatment with shattered self-esteem. Defending against this internal vulnerability can become damaging, because clients project their fears onto others. They may try to hide internal vulnerability by appearing hostile and overly self-confident. An atmosphere of safety and empathy enables clients with profound vulnerabilities to enter the process of self-disclosure, through which they become accessible not only to the group but also to themselves.

The group facilitator actively encourages such self-disclosure but at the same time emphasizes that individual members need not disclose any issue they are not yet ready to discuss. Clear boundaries and clear group agreements further support the possibility for self-disclosure.

Regulation of affect

Substance abuse disorders can be perceived as the consequences of trying to control one's emotional life with external substances. This points to a failure of internal regulation that makes the client uncomfortable when feeling emotions that others might consider commonplace. Issues of grief, loss, sadness, and joy can be so affectively charged and linked to the client's past alcohol and drug use that they threaten the client's continued recovery.

As mentioned above, the leader's sensitivity to the levels of affective energy in the group is particularly important. Supporting group members to both feel what they are experiencing and at the same time move to a safer and more objective viewpoint regarding those feelings is inherent in MIGP.

Self-care

Substance-abusing clients often present to treatment unaware of internal stresses and pain, having lost sensitivity to physical cues that lead others to the normal self-care functions of daily living. These functions may be as simple as basic hygiene or more complex in terms of boundary setting and relational definitions. Setting boundaries within the group and encouraging heightened sensitivity to self-care are ways in which MIGP addresses this issue.

Clients must hear a consistent message that they are worthy of the group's support and, therefore, worthy of their own attention in regard to self-care. All of the above can comfortably be addressed within the context of MIGP, with the leader actively connecting members to members, who support one another on the importance of self-monitoring and care.