Groupwork
No kidding: group therapy for addiction Twelve-step group therapy aims to create a safe space where people with addictions can learn to reconnect with others and create the foundations for recovery, as Rachel Young reports
Imagine a group of 12 recovering addicts/ alcoholics, one peer supporter and two facilitators, sitting in a circle. Most of the clients have been in contact with the criminal justice system at some point, with convictions ranging from drink driving to GBH and attempted murder; some have served time. About half have had a social services caseworker at some point. More than half are divorced; most of the others are single; some are also estranged from their children. These are people who have demonstrated extreme anti-social behaviour and seem unable to conform to social norms. Their self-destructive behaviours, their constant failure to face their responsibilities and the waste of their gifts and talents frustrate their loved ones. They have, between them, a number of failed suicide attempts; half also have another mental disorder. Professionals agree that, as a client group, addicts/alcoholics are the least likely to respond to their advice, that they are unpredictable, unreliable and uncooperative. People who know the individuals in this group would probably describe them as ‘lost souls’. This group has been together for 12 weeks, meeting five times a week for intensive drug and alcohol treatment and group psychotherapy. They have shared intimate details of their lives and have built up a deep understanding and trust. They have learned how to give each other constructive feedback and can recognise their own and each other’s defensive patterns of behaviour. They know the difference between support
and collusion, and between challenge and aggression. In short, during the last three months these group members have formed a cohesive social structure; they are supportive, accountable and responsive to each other. And they have remained clean and sober. It has not always been a comfortable group to attend. There have been storms. They have battled with each other and the facilitators, and in the process learned how to manage conflict in a productive way. They have experienced deep tenderness and emotional support, and have also been helpless with laughter. They would all agree that the last 12 weeks have been an emotional roller coaster. They are approaching the end of their time together, preparing for graduation. This is an imaginary group based on many with which I have had the privilege to work in an addiction treatment setting. I was trained to deliver this type of group therapy while working for RAPt (Rehabilitation of Addicted Prisoners Trust) in Bullingdon Prison. RAPt have rolled out 12-step drug and alcohol treatment programmes in many UK prisons and their results are impressive. Twelve-step treatment
As many readers will know, the 12-step philosophy evolved from the inspiration of 100 alcoholics in America back in the 1940s.1 They developed a way of staying sober by meeting up with others who also suffered from alcoholism and sharing their experience, strength and hope. They discovered that they had a
higher success rate when they helped other people than if they tried it alone. Their manual, Alcoholics Anonymous,1 sets out the principles of the 12-step philosophy. This includes the belief that, in order to recover, addicts and alcoholics must change their selfishness and self-centred behaviour to consideration and service to others. Alcoholics Anonymous (AA) members believe that group involvement is essential for recovery from drug and alcohol addiction, and that group membership changes an individual’s perspective from being egocentric, isolationist and introverted to welcoming connections between individuals and understanding the significance of accountability to the group. Many UK drug and alcohol rehabilitation institutions use the 12-step model, and it has proved consistently successful. Twelve-step treatment is not to be confused with the self-help fellowships of groups like Alcoholics Anonymous and Narcotics Anonymous (NA). These fellowships provide a consistent support network that addicts can incorporate into their lives to help them maintain their recovery indefinitely. Twelve-step treatment is typically three to six months of intensive rehabilitation therapy at the beginning of the recovery process. Participants move quickly through the Stages of Change,2 from Contemplation to Action and Maintenance. It is a powerful combination of therapeutic interventions that allows the client to explore historical issues as well May 2012 /www.therapytoday.net/Therapy Today 27
Groupwork
‘The 12-step method strips away denial by encouraging clients to look at their own process and witness that of the other group members’
as work in the here-and-now to address problematic behaviours and relationships. It uses therapeutic devices such as homework assignments, role play (drama therapy) and group therapy. The group is an experimental space where clients can try out new ways of relating and new behaviours and attitudes before using them in the wider community to achieve fundamental life changes. Group facilitation
In my time as a group facilitator I have become convinced of the importance of a consistent structure. As long as the group knows the structure, the participants will feel safe to take risks and learn to trust each other. I generally work with 10–12 group members in 90– minute sessions. I find that this number allows group members to engage, identify with and receive support from the others. Any fewer than eight and people become less willing to take risks and give little feedback. In larger groups I have struggled to hold my awareness of all the participants’ processes, even with a co-facilitator present, and I find that most of the group members simply watch each other perform. Holding the time boundaries is vital to the safety of each session, so I avoid the temptation to run on longer if the session becomes intense. It can be challenging to interrupt a client in the middle of some difficult work, but I calmly signpost the work as important to return to at the next session, and complete the finishing ritual. The group routine takes priority. 28 Therapy Today/www.therapytoday.net/May 2012
Our groups all have ground rules that are kept in a visible place at each session and adhered to. We give the group time to discuss and understand the rules and agree what the penalty will be if we don’t abide by them. In this way we help our clients to invest in the structure that keeps the group secure. This type of group therapy is most effective when there are two facilitators: one leading and one supporting. These are trained professionals with an awareness of their own process as well as group process. They are responsible for the safety of the group as a whole, including the facilitators themselves. They work together to hold the boundaries. Having two minimises the chances of a facilitator being unconsciously drawn into the dynamic of one or more members. Working as a team is considerably less stressful and creates a more holding environment for the group. To do this work, the facilitators must have a thorough understanding of group dynamics. They need to recognise the stage of the group in order to play a supportive role. For example, at the start, when participants are developing their relationships and their understanding of each other, the group leaders will do much of the work, inviting individuals to take their space and modelling effective feedback techniques. As the group matures there will be some jostling for power and control. This is normal and the group leaders must allow the safe expression of conflict, again modelling how to express emotion in a way that
is not abusive to others or damaging or overwhelming for the individual. Holding conflict
There will also be conflict with the group leaders from some of the group members, as they begin to rebel and stretch their own muscles of responsibility. This can be alarming for the novice facilitator, but it is often a sign that the group is working effectively and that the members can now conceive of challenging the status quo and being responsible participants. Towards the end of the group’s life, the facilitators will be playing much more of a witnessing role. They will still hold the boundaries, but the group will largely organise itself. It is impossible for a facilitator not to become emotionally involved when working in this way. I am also a member of the group and, while I have my professional boundaries and understanding, I am also a human being and witness the struggles and triumphs of my fellow humans. I form relationships. I feel my soul respond to a group member exploring his fear, guilt or anger. I am touched to tears by someone expressing their vulnerability to others for the first time. I am frustrated beyond belief by the obtuseness of an individual, or scared when she or he lashes out at me. Without supervision it would be too much for me and I would burn out and retire to my potting shed. Worse, I might act out my frustrations within the group. With the support of my peers and a supervisor to challenge, encourage and
‘The group is an experimental space where clients can try out new ways of relating and new behaviours and attitudes before using them in the wider community’
direct me, I can continue to be a useful part of the process. It is important to constantly remind myself that I am one small part of the process – not the all-knowing, all-seeing professional. I am a facilitator, and what I facilitate is the natural, curative effect of the group. Treatment and recovery
Three factors are intrinsic to the success of this type of treatment. The first is trust: the nature of the work allows the participants to become vulnerable to each other quickly and so to trust one another with very personal material. They learn how to give constructive feedback to each other and so learn in an experiential way how their behaviour impacts on people around them. The second essential factor is peer support. A peer supporter is a vital component of the group. This is a person who has graduated from a previous programme and is living proof that recovery is achievable. A peer supporter can model recovery, identify with the participants and share their experience in a way that the facilitators cannot. The third and last factor is honesty. The 12-step method strips away denial by encouraging clients to look at their own process and witness that of the other group members. They are encouraged to look for aspects of each other’s story with which they can identify. The mantra ‘You can’t kid a kidder’ is central to 12-step treatment: it says you can’t get away with the habitual manipulation and dishonesty that can characterise addictive behaviours.
When individuals go into 12-step treatment, they are quickly introduced to a culture of recovery. Many people become isolated when using drugs and alcohol; if they were part of a group, their peers may have reinforced their addictive behaviours. During treatment, clients are introduced to a new language, a new philosophy and a new set of values. Peer pressure becomes a positive factor in encouraging individuals to conform to recovery. Meaningful relationships are developed that nurture the individuals, sometimes in ways that they have never before experienced. This culture extends to their lives in the community as they attend 12step fellowship meetings where they encounter the same language and recovery culture. Slogans that emphasise the importance of social cohesion can frequently be found in AA and NA meetings: ‘Give it away to keep it’; ‘Stick with the winners’; ‘12-step programmes are a school in which we are all learners and all teachers’; ‘If I serve, I will be served’; ‘You are not alone.’3 This treatment works. In a recent study RAPt analysed data for almost 400 prisoners who had completed an intensive, abstinence-based programme between November 2004 and April 20094 and compared the results with a control group of prisoners identified as having substance misuse problems who had undergone shorter, less intensive programmes. Just 26 per cent of the RAPt group received custodial sentences after release, compared with 49 per cent of the control group. Less than half the
prisoners (44 per cent) with substance misuse problems who completed a RAPt intensive 12-step long-term programme went on to reoffend on release. This compares with a reoffending rate of two thirds (73 per cent) for drugaddicted prisoners who did not go through the programme. Twelve-step group therapy treatment kick-starts the recovery process by introducing clients to the dynamics of working in groups. It provides them with an experimental space in which to learn how to inter-relate in new and rewarding ways, and so achieve lasting change. Without this treatment, the odds of premature death or ending up in prison are extremely high. With the treatment they have a fighting chance of building a new life. Rachel Young is Clinical Director of Special & Different Addiction Services at the Rehabilitation of Addicted Prisoners Trust. References
1. Bill W, Dr Bob. Alcoholics Anonymous: the story of how many thousands of men and women have recovered from alcoholism. New York: Alcoholics Anonymous World Services, Inc; 1939. 2. Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: W Miller, N Heather (eds). Addictive behaviors: processes of change. New York: Plenum Press; 1986 (pp3–28). 3. Alcoholics Anonymous Great Britain. About AA meetings. Online information. [Accessed on 11 April 2012.] http://www.alcoholics-anonymous. org.uk/newcomers/?PageID=71 4. Rehabilitation of Addicted Prisoners Trust. Treatment works: RAPt addiction programme cuts crime by more than a quarter. Press release. London: RAPt; May 2011. May 2012/www.therapytoday.net/Therapy Today 29