Time-Limited Group Therapy
Use of Psychodrama Techniques in a Group Setting
Psychodrama has long been effectively used with the substance-abusing client population in a group setting. Wegscheider-Cruse effectively integrated psychodrama as a means to heal family-of-origin issues within the context of addictive behaviors (Wegscheider-Cruse, 1989). The utility of such an intervention seems to be clinically well established.
The techniques can help the group move more quickly in terms of self-understanding and relational awareness. The insights gained from the experience of family sculpting (illustrated below) can be worthwhile and potent. However, it is important to stress that psychodrama and other similar expressive therapeutic interventions bring with them a clinical potency that needs to be understood.
These interventions can raise anxiety and shame to the point where some clients may be pushed toward relapse or even feel the need to leave treatment to escape the internal conflicts encountered. As with any therapeutic technique, therapists should not utilize such techniques unless they are thoroughly trained and well supervised.
Any intervention that has a powerful potential for growth almost always has an equal potential for damage if poorly conducted. Training and appropriate supervision are particularly important with expressive techniques because of their clinical potency.
Psychodrama can be used with different models of group therapy. It offers persons with substance abuse disorders an opportunity to better understand past and present experiences--and how past experiences influence their present lives. This approach encourages clients to relearn forgotten skills, imaginatively change apparent problems that block progress, rehearse new behaviors, practice empathy, and expand their emotional range by confronting feelings that have never been properly dealt with.
As clients act, important concepts become real, internalized, and operational that might otherwise be purely theoretical. Changes experienced through acting become accessible to the psyche as part of the lived history of the individual.
Some therapists use psychodrama to help transform internal dynamics that maintain old patterns relevant to substance abuse. For example, one therapist invites group members to list "rules" in their family of origin. These rules may be related to substance abuse (e.g., "Don't ever say that Mother is drunk. She is taking a nap.").
After a client describes a situation in which the rule would be invoked, he assigns family roles to other participants, giving them instructions for how they would behave in this situation. The client is encouraged to break the rule--in the case of the "napping" mother, by insisting on bringing the truth into the open--with the verbal encouragement of all remaining group members who are not playing assigned roles.
The client's victory--which can be a transformative, powerful experience--is celebrated as the achievement it is. In this example, the individual experiences himself as a powerful truth-speaker rather than the powerless and voiceless participant he perceived himself to be in the past. This new experience can enhance his sense of self-efficacy and help foster change in his own pattern of substance abuse.
In another example of psychodrama, group participants explore "character defects" such as grandiosity or isolation associated with their pattern of substance abuse. The defects are dramatized, with half the group engaged in the dramatization and half sitting as an audience. For example, persons who experience themselves as isolated sit in the corner or under a table with a "sponsor."
The therapist gives them sentences to complete, such as, "I like this corner because..." or "The first time I remember isolating is..." Finally, they are asked to complete the sentence, "I have to get out of this corner because..." The sponsors then gather in a circle and invite the persons they have been supporting to join them, saying, "I want you to join this circle because..." This experience of connection often enhances participants' motivation and ability to change.
A common use of psychodrama in treatment for substance abuse disorders is "sculpting" family members in typical roles and enacting significant situations related to substance abuse patterns. In this process, developed by Papp, family members enact a scene to graphically depict the problem (Papp, 1977, 1983).
The physical arrangement of the family members illustrates emotional relationships and conflicts within the family. For example, a family may naturally break up into a triad of the mother, sister, and brother, and a dyad of the father and another sibling. In that case, the therapist might highlight the fact that the mother and father communicate through one of their children and never talk to each other directly.
In yet another form of psychodrama, one person in the group may be asked to give voice to different aspects of her own self that either help maintain dependency or speak for change (sometimes called the "disease" and "recovery" selves).
The client might speak from a different chair or position for each of these voices. The intensity of psychodrama often helps compensate for the shorter time span now commonly funded for treatment. Although many participants express concern about acting, the barrier of shyness often drops completely as they enter the process with the assistance of a dynamic and committed facilitator.
In his classic work, Theory and Practice of Group Psychotherapy, Irvin Yalom identified 11 primary "therapeutic factors" in group therapy (Yalom, 1995). Each of these factors has particular importance for clients with substance abuse disorders and can be used to help explain why a group works in a particular way for this client population. These curative factors are present in all group interventions and are listed below.
Instillation of Hope
Many clients come to a treatment setting feeling defeated by life and overwhelmed by their failure to control their use of substances. They feel they have nowhere to go and no possibility for a better outcome in life. When individuals with this life view join a group of people struggling with similar problems, they have the remarkable opportunity of witnessing change in others while at the same time having their own small victories acknowledged and celebrated by group members.
Through this process, hope begins to emerge. The energy of hope and the focused attention on this curative factor receive specific attention in the MIGP model.
A variety of exercises can be utilized to further instill hope within substance-abusing clients. Clients can be asked to participate in a visualization exercise where they see themselves in a life without substance use, envisioning particularly how life would be different and better under such circumstances. The group energy fuels this experience and adds the intensity of other clients' support.
As with all "guided imagery exercises," the group leader must move with caution. Many substance-abusing clients may not have a picture of life without substances, and consequently such an exercise can be humiliating if not handled sensitively. If the client is unable to visualize, he once again perceives failure. To guard against such potential shaming, the group facilitator can take an active role in the creation of the image, monitoring it for issues of safety with all members of the group as the exercise develops.
Substance abuse disorders tend to impede relationships and force clients into increased isolation. In a brief group experience, the clients encounter other individuals who have faced similar problems. They become aware that they are not alone in life and can feel tremendous satisfaction in this connection. The sense that their pain is not exclusive or unique and that others with similar problems are willing to support them can be profoundly healing. It helps clients move beyond their isolation, and it gives further energy to hope, which helps to fuel the change process.
The inevitable exchange of information in a group setting helps members get from one day to the next. Particularly in conjunction with formal psychoeducational groups, MIGP affords group members the opportunity to reflect on what they have learned and at the same time apply that learning within the group setting.
The information shared is personal and tends to be experienced as motivational. The client struggling with issues of substance abuse can hear from others how they have dealt with difficult concerns and how they have experienced success. This mutually shared success gives positive energy to the group and encourages change.
Fundamental to the human condition is the desire to help others when they are in trouble. Clients struggling with substance abuse disorders tend to be focused on their own difficulties and have a hard time reaching out to help those in need. Group therapy offers the members opportunities to provide assistance and insight to one another.
Particularly within the model of MIGP, the facilitator pays great attention to altruistic moves on the part of members. They are celebrated and acknowledged. As individuals recognize that they have something of value to give their fellow group members, their self-esteem rises as change and self-efficacy are supported.
Corrective Recapitulation of the Primary Family Group
This therapeutic factor pertains to the importance of relationships within the client's family of origin, which invariably finds expression within the group experience. "Recapitulation of the family group" happens when a client--both consciously and unconsciously--relates to another group member as if that person is a member of his family of origin with whom he has struggled in the past.
This occurrence is clearly a projection, but it can be identified by the leader, and both group members involved can benefit as they investigate new ways of relating that break the old dysfunctional patterns of the family of origin. In a way, the group begins to serve as a substitute family.
The group members are the siblings, and the group facilitator is in a parental role. Even in a time-limited group, issues of transference and countertransference may require attention. However, MIGP tends to dilute the transference by "spreading it throughout the group" rather than concentrating it within the dyadic counseling relationship.
Development of Socializing Techniques
Many substance abusers are "field-sensitive" or "field-dependent" individuals who are keenly conscious of the network of specific relationships as opposed to principles or generalizations that apply regardless of context. Group therapy can take advantage of this trait and use the energy of the relationships to facilitate change. As participants engage in relationships, they learn new social skills that can help them break through their isolation and connect with others in more meaningful ways.
They also learn how to disconnect, which is equally important given the anxieties often associated with relational loss and grief. The group facilitator may at times deliberately focus on these social skills through role-playing or modeling exercises within the context of the group itself. The healing takes place as the clients take what they have learned and experienced in group and actively generalize it in their lives outside of the group.
Imitative behaviors are an important source of learning in group therapy. The process of modeling can be particularly important as clients learn new ways to handle difficult emotions without resorting to violence or drug use. Therapists must be acutely sensitive to the important role they play within this context; clients often look to the therapist to model new behaviors as they encounter new situations within the group context. Group members can also learn by imitating other members who are successfully dealing with difficult relational issues.
It is helpful for a new group member to witness an ongoing group where people are confronting their problems appropriately, moving beyond old dysfunctional patterns, and forming new relationships that support change. The group becomes a living demonstration of these new behaviors, which facilitates and supports insight and change.
Groups provide an opportunity for members to learn about relationships and intimacy. The group itself is a laboratory where group members can, perhaps for the first time, honestly communicate with individuals who will support them and provide them with respectful feedback. This interpersonal learning is facilitated by the MIGP model, in that special attention is given to relational issues within the context of group.
Often misunderstood, group cohesion is a sense of belonging that defines the individual not only in relation to herself but also to the group. It is a powerful feeling that one has meaning in relationships and that one is valued. Development of group cohesion is particularly important in the MIGP model, so that group members feel safe enough to take the risks of self-disclosure and change. The experience of belonging is both nurturing and empowering.
Sometimes group participants will gain a sudden insight through interaction with others, which can cause a significant internal shift in the way they respond to life. Such insights may be accompanied by bursts of emotion that release pain or anger associated with old psychological wounds. This process happens more easily in a group where cohesion has been developed and where the therapist can facilitate a safe environment in which emotions can be freely shared. It is important to recognize, however, that although catharsis is a genuine expression, it is not seen as curative in and of itself.
High levels of emotional exchange not addressed in the group can become potential relapse triggers, which endanger the success of individual members. The therapist acknowledges the powerful emotions after the member has shared them but asks the group as well as the member to give those emotions meaning and context within the group. Thus, both the experience of the emotion and the understanding of how that emotion either interferes or supports relationships are healing.
Existential factors of loss and death are often issues of great discomfort in the substance-abusing population. The brevity of a time-limited group experience forces these issues to the surface and allows members to discuss them openly in a safe environment.
Time itself represents loss and also serves as a motivator, as the members face the ending of each group session and of the group treatment experience. As they become more aware of the frustrations of reality and the limits they face, clients can receive support from the group in accepting "life on life's terms" instead of their past patterns of escape.
Using Time-Limited Group Therapy
The focus of time-limited therapeutic groups varies a great deal according to the model chosen by the therapist. Yet some generalizations can be made about several dimensions of the manner in which brief group therapy is implemented.
Assessment and Preparation
Client preparation is particularly important in any time-limited group experience. Clients should be thoroughly assessed before their entry into a group for therapy. In terms of exclusionary issues, persons with severe disorders or those who cannot accept support may need to be given more individual time before a group experience. Also, persons with significant deficits in cognition may not benefit as much from a time-limited group.
Group participants should be given a thorough explanation of group expectations. For an MIGP group, for example, they need to understand their responsibility for speaking within the group and that the primary focus of the group is relationships. A brief explanation of a "here and now" encounter is helpful--the group can become a place where feedback takes place in the "here and now," as members learn how they are affected by the others and how they in turn affect other members.
This "here and now" focus brings clients into the present and allows them to deal with real issues within the group that they can then apply in their daily lives. It also distinguishes MIGP from self-help support groups, which traditionally discourage relational "here and now" interactions.
If time permits, it is particularly effective for group members as they are being assessed and prepared for group to either watch or participate in a practice group as a trial experience. A variety of group tapes are available; however, any program can videotape one of its own groups, with appropriate releases for client permission, to use for instructional purposes. This enables new clients to see what will happen in the group session and lowers anxiety.
This intentional effort to make the group safe and reduce its inherent anxiety distinguishes MIGP from a more traditionally interactive process group. Introductions to group can also be provided in a psychoeducational format. Clients learn not only what is going to take place in the group but also why and how the group process brings about healing. The importance of relationships and open communications through self-disclosure and support can be explained.
It is important to recognize that although a significant amount of client preparation takes place before the client ever enters a group, client preparation itself is also a process and not an event. Through continual references to the group agreements and group contracts, the therapist continues to prepare clients as they move into the experience.
Opening sessions for group therapy differ according to the type of group, its specific goals, and the personal style of the therapist. In homogeneous, problem-focused groups, for example, less time is needed to define what group members have in common. Opening sessions typically include the following:
New group members introduce themselves at the opening session, responding to a simple request such as, "Tell us what led you here." Research suggests that if groups do not explicitly address the reason for each member's participation, more members will drop out (Levine, 1967). In the context of substance abuse treatment, the therapist should therefore initially discuss with group members how substance abuse issues will be addressed so as to ensure that focus is maintained.
The "locus of control" for the group is clarified. Clients explore whether they believe they have the ability to choose effective actions or if they think of themselves as helpless victims of circumstance. For directive groups, in which the therapist exercises greater control, this process will be shorter than for group process groups, in which group members take turns as leaders.
Goals for the group (and often for individuals) are clarified.
The therapist seeks to establish a safe, warm, supportive environment. There may be a need to establish rules to increase safety--for example, that members will not engage in physical contact, will not discuss what was said outside the room, and will give feedback to each other in an agreed-upon manner.
The therapist helps group members establish connections with each other, pointing out common concerns and problems.
Some therapists ask the group to evaluate the opening session. This may be done orally or in writing. The group's success can be measured through the following questions:
Was substance abuse discussed?
Did group members listen to each other?
Did members cooperate and support each other?
Did they give feedback?
Often, to enhance continuity, the therapist will begin the next session by recalling the previous one and ensuring that "leftover" items are addressed. The therapist may ask group members how lessons learned in the group have affected their daily lives. Members may have tried to implement suggestions and found they did or did not work, or they may not have tried to do so at all, which is also an important topic of discussion.
On an inpatient unit with clients going through withdrawal or struggling with coexisting psychiatric disorders, instilling hope is particularly important. For the newest clients on the unit, connecting with others who have just been through a similar difficult experience can be inspirational. Such a therapeutic encounter can also reduce issues of shame, as clients connect with others who both share and understand their journey.
In addition, the inpatient group can serve as an example of what treatment will be like after discharge and allow the client to "practice" being in a group. Clients can experience the supportive nature of the group, which will reduce their anxiety about future group involvement. Underscoring the impact of brief group interventions, the inpatient process treatment group remains one of the cornerstones of continued change.
Duration of Therapy and Frequency of Sessions
The preferred timeline for time-limited group therapy is not more than two sessions per week (except in the residential settings), with as few as six sessions in all, or as many as 12, depending on the purpose and goals of the group. Sessions are typically 1 1/2 to 2 hours in length. Residential programs usually have more frequent sessions.
Given the dramatically shortened inpatient and residential stays available under managed health care, some have questioned the utility of a process-sensitive treatment group and are focusing on directive educational groups. Even though clients often do not stay more than 3 to 5 days on an inpatient unit, much can be accomplished in this brief timeframe.
As mentioned before, directive educational groups are necessary but not always sufficient. Groups with active facilitation, but adhering to process sensitivity, can build cohesion quickly and act as powerful motivators for clients to follow through with the next level of care.
Group process therapy is most effective if participants have had time to find their roles in a group, to "act" these roles, and to learn from them. The group needs time to define its identity, develop cohesion, and become a safe environment in which there is enough trust for participants to reveal themselves. (The exception is an educational group, which relies less on group process factors.)
Consequently, prematurely terminated groups relying on group process may be less effective than they could be in promoting long-term change. Furthermore, participants may have to clear their systems of the most serious effects of substances before they can fully participate. Because of such factors, arbitrary time limits for groups, as opposed to timelines set according to the therapeutic goals of the particular group, can be ill advised.
Gender and Cultural Issues Within Groups
Researchers at Cornell University found that social contact with persons who have gone through the same crisis is highly beneficial (Manisses Communications Group, 1997a). Therefore, a common gender, culture and/or sexual preference will help clients in group therapy share difficulties they may have encountered because of that common background.
Participation in group therapy may be less effective for women than men, perhaps because groups are often dominated by men and reflect their issues and style of interaction (Jarvis, 1992). At this time, however, little research is available on the relative efficacy of women-only rather than mixed-gender groups. Weitz argues that women may have to be empowered in order to remain abstinent (Weitz, 1982).
Group cognitive-behavioral therapy has been found to be an effective treatment for women with posttraumatic stress disorder and a substance abuse disorder (Najavits et al., 1996) as well as for women with both a substance abuse disorder and a history of physical or sexual abuse (Manisses Communication Group, 1997).
Covington has written extensively about the importance of women-specific groups, particularly in early recovery. She accurately pointed out that the powerful role definitions within our culture tend to be played out in group and are often oppressive to women (Covington, 1997). In a mixed group, the women quickly become the "emotional containers" for the group and take care of the men.
Although such activity is not defined as pathological, it expresses cultural norms wherein women's needs become secondary to those of men, with the women primarily defined as caretakers. They are uncomfortable about bringing up issues of sexuality, particularly sexual abuse, given that men have generally been the abusers (Covington, 1997).
The creation of gender-specific groups, particularly in small agencies or private practice, may pose logistical difficulties. However, there is growing consensus among therapists that, whenever possible, women need to have their own groups, particularly during early recovery (Byington, 1997). This does not suggest that women should be fully segregated from men. Participation in mutually shared psychoeducational experiences and multifamily groups is a therapeutic way of addressing gender issues (Byington, 1997).
Concerns of ethnicity and race should be handled with sensitivity. This is not to suggest that in a time-limited group, the potency of homogeneity is such that each and every ethnic or racial subgroup should be segregated in order to reap the benefits of this intervention. However, cultural issues need to be addressed openly and with sensitivity.
The clinical utility of time-limited groups has clearly been demonstrated, but the cost factor is not irrelevant to a consideration of the value of these groups. Although individual work and family work will likely always remain a part of even the briefest time-limited treatment experience, acceptance and use of group interventions are slowly growing.
From a cost-management perspective, the benefits are obvious. Not only can the therapist use the power of the group to support change within all group members, but one well-trained group therapist can meet the clinical needs of 8 to 12 clients in roughly the same amount of time as an individual session.
When these numbers are enlarged to include more directive approaches such as cognitive-behavioral or psychoeducational groups, the cost-benefit ratio increases.
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 34: Brief Interventions and Brief Therapies for Substance Abuse