Counselor's Manual for Relapse Prevention With Chemically Dependent Criminal Offenders
Technical Assistance Publication (TAP) Series 19

Part II: Relapse Prevention Treatment

Chapter 4—What Is Relapse Prevention Treatment?

Relapse prevention is a systematic method of teaching recovering patients to recognize and manage relapse warning signs. Relapse prevention becomes the primary focus for patients who are unable to maintain abstinence from alcohol or drugs despite primary treatment.

Recovery is defined as abstinence plus a full return to bio/psycho/social functioning. As previously noted, relapse is defined as the process of becoming dysfunctional in recovery, which leads to a return to chemical use, physical or emotional collapse, or suicide. Relapse episodes are usually preceded by a series of observable warning signs. Typically, relapse progresses from bio/psycho/social stability through a period of progressively increasing distress that leads to physical or emotional collapse. The symptoms intensify unless the individual turns to the use of alcohol or drugs for relief.

To understand the progression of warning signs, it is important to look at the dynamic interaction between the recovery and relapse processes. Recovery and relapse can be described as related processes that unfold in six stages:

When people who have had a stable recovery and have done well begin to relapse, they simply reverse this process. In other words, they

A number of basic principles and procedures underlie the CENAPS Model of Relapse Prevention Therapy. Each principle forms the basis of specific relapse prevention therapy procedures. Counselors can use the following principles and procedures to develop appropriate treatment plans for relapse-prone patients. Following a description of each principle is the relapse prevention procedure for that principle.

Principle 1: Self-Regulation

The risk of relapse will decrease as a patient's capacity to self-regulate thinking, feeling, memory, judgment, and behavior increases.

Relapse Prevention Procedure 1: Stabilization

An initial treatment plan is established that allows relapse-prone individuals to stabilize physically, psychologically, and socially. The level of stabilization is measured by the ability to perform the basic activities of daily living. Because the symptoms of withdrawal are stress-sensitive, it is important to evaluate the patient's level of stability under both high and low stress. Many people who appear stable in a low-stress environment become unstable when placed in a more stressful environment.

The stabilization process often includes

Because the risk of using alcohol or drugs is highest during the stabilization period, steps must be taken to prevent use during this time. The patient needs to be in a drug-free environment. Any irrational thoughts (thoughts that don't make sense to a healthy person) that are creating immediate justification for relapse need to be identified and discussed. The patient should then be helped to remember the consequences of past chemical use and to develop new coping strategies.

An early relapse intervention plan can be developed by the counselor and patient to decide what action to take if the patient begins to use alcohol or drugs. This early intervention plan motivates the patient to stay sober and provides a safety net should chemical use occur.

Principle 2: Integration

The risk of relapse will decrease as the level of conscious understanding and acceptance of situations and events that have led to past relapses increases.

Relapse Prevention Procedure 2: Self-Assessment

Self-assessment first involves a detailed reconstruction of the presenting problems (problems that caused the patient to seek treatment) and the alcohol and drug use history. A careful exploration of the presenting problems identifies critical issues that can trigger relapse. This allows the counselor to design intervention plans that help to solve crises that can be used for relapse justification in the early treatment stages. The next step is a reconstruction of the recovery and relapse history. This helps identify past causes of relapse.

In reconstructing the recovery/relapse history, it is important to identify the recovery tasks that were completed or ignored, and to find the sequence of warning signs that led back to drug or alcohol use. The assessment is most effective if the counselor reconstructs the relapse history using exercises (done as homework assignments), such as making a list of all relapse episodes and identifying the problems that led to relapse. These assignments should be reviewed in group and individual sessions.

Principle 3: Understanding

The risk of relapse will decrease as the understanding of the general factors that cause relapse increases.

Relapse Prevention Procedure 3: Relapse Education

Relapsers need accurate information about what causes relapse and what can be done to prevent it. This is typically provided in structured relapse education sessions and reading assignments, which provide specific information about recovery, relapse, and relapse prevention planning methods. This information should include, but not be limited to

The recommended format for a relapse education session is as follows:

It is important to test patients to determine their retention and understanding of the material. Many relapsers have severe memory problems associated with Post Acute Withdrawal that prevent them from comprehending or remembering educational information.

Principle 4: Self-Knowledge

The risk of relapse will decrease as the patient's ability to recognize personal relapse warning signs increases.

Relapse Prevention Procedure 4: Warning Sign Identification

Warning sign identification is the process of teaching patients to identify the sequence of problems that has led from stable recovery to alcohol and drug use in the past and then recognizing how those steps could cause relapse in the future. The process of developing a personal relapse warning sign list is (1) reviewing warning signs, (2) making an initial warning sign list, (3) analyzing warning signs, and (4) making a final warning sign list.

The patient develops his or her own individualized warning sign list by thinking of irrational thoughts, unmanageable feelings, and self-defeating behaviors. Most final warning sign lists identify two different types of warning signs: those related to core psychological issues (problems from childhood) and those related to core addictive issues (problems from the addiction). Warning signs related to core psychological issues create pain and dysfunction, but they do not directly cause a person to relapse into chemical use. When patterns of addictive thinking that justify relapse are reactivated, a return to using alcohol and drugs occurs.

Principle 5: Coping Skills

The risk of relapse will decrease as the ability to manage relapse warning signs increases.

Relapse Prevention Procedure 5: Warning Sign Management

This involves teaching relapse-prone patients how to manage or cope with their warning signs as they occur. The better they are at coping with warning signs, the better their ability will be to stay in recovery.

Warning sign management should focus on three distinct levels. The first is the situational-behavioral level, where patients are taught to avoid situations that trigger warning signs. At this level, they are taught to modify their behavioral responses should these situations arise. The second level is the cognitiveBaffective (thoughts and feelings) level, where patients are taught to challenge their irrational thoughts and deal with their unmanageable feelings that emerge when a warning sign is activated. The third level is the core issue level, where patients are taught to identify the core addictive and psychological issues that initially create the warning signs.

Principle 6: Change

The risk of relapse will decrease as the relationship between relapse warning signs and recovery program recommendations increases.

Relapse Prevention Procedure 6: Recovery Planning

Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they develop in sobriety. This is done by reviewing each warning sign on the final warning sign list and ensuring that there is a scheduled recovery activity focused on each sign. Each critical warning sign needs to be linked to a specific recovery activity.

Principle 7: Awareness

The risk of relapse will decrease as the use of daily inventory techniques designed to identify relapse warning signs increases.

Relapse Prevention Procedure 7: Inventory Training

Inventory training involves teaching relapse-prone patients to complete daily inventories. These inventories monitor compliance with the recovery program and check for the emergence of relapse warning signs. A daily recovery plan sheet is used to plan the day, and an evening inventory sheet is used to review progress and problems that occurred during that day.

A typical morning inventory asks the patient to identify three primary goals for that day, create a to-do list, then schedule time for completion of each task on the to-do list on a daily calendar. During the evening review inventory, the patient should review his or her warning sign list and recovery plan to determine whether he or she completed the required activities and experienced any relapse warning signs.

Whenever possible, these inventories should be reviewed by someone who knows the patient and who can assist him or her in looking for emerging patterns of problems that could cause relapse.

Principle 8: Significant Others

The risk of relapse will decrease as the responsible involvement of significant others in recovery and in relapse prevention planning increases.

Relapse Prevention Procedure 8: Involvement of Others

Relapse-prone individuals cannot recover alone. They need the help of others. Family members, 12-step program sponsors, counselors, and peers are just a few of the many recovery resources available. A counselor should ensure that others are involved in the recovery process whenever possible. The more psychologically and emotionally healthy the significant others are, the more likely they are to help the relapse-prone patient remain abstinent. The more directly the significant others are involved in the relapse prevention planning process, the more likely they are to become productively involved in supporting positive efforts at recovery and intervening on relapse warning signs or initial chemical use.

Principle 9: Maintenance

The risk of relapse decreases if the relapse prevention plan is regularlyupdated during the first 3 years of sobriety.

Relapse Prevention Procedure 9: Relapse Prevention Plan Updating

The patient's relapse prevention plan needs to be updated on a monthly basis for the first 3 months, quarterly for the remainder of the first year, and twice a year for the next 2 years. Once a person has maintained 3 years of uninterrupted sobriety, the relapse prevention plan should be updated on a yearly basis.

Nearly two thirds of all relapses occur during the first 6 months of recovery. Less than one quarter of the variables that actually cause relapse can be predicted during the initial treatment phase. As a result, ongoing outpatient treatment is necessary for effective relapse prevention. Even the most effective short-term inpatient or primary outpatient programs will fail to interrupt long-term relapse cycles without the ongoing reinforcement of some type of outpatient therapy.

A relapse prevention plan update session involves the following:

Chapter 5—Basic Counseling Skills

Although the workbook is intended to be used in a group counseling session, occasionally you will need to do individual counseling. This chapter discusses some basic counseling skills that can be used in individual and group counseling. It also explains some of the concepts and terms used in relapse prevention counseling that you will need to help patients with the workbook.

Helping Traits

People who are effective at counseling have developed eight behaviors that they use during counseling sessions. It is important to develop these traits if you are to improve your ability to help others. The counselor is a role model (someone whom patients tend to imitate). Therefore, you want to model behaviors that will be helpful to patients' recovery. The following are some of these traits.

Empathy. Empathy is the ability to understand how another person sees and interprets an experience. It is different from sympathy (feeling sorry for someone). When you are empathetic, you can look at and understand a situation from another person's perspective. It does not mean you have to agree with that person.

Genuineness. Genuineness is the ability to be fully yourself and express yourself to others. It is the lack of phoniness, faking, and defensiveness. When you are genuine, the way you act on the outside matches your thoughts and feelings on the inside.

Respect. Respect is the ability to let another person know, through your words and actions, that you believe that he or she has the ability to make it in life, the right to make his or her own decisions, and the ability to learn from the outcome of those decisions.

Self-Disclosure. Self-disclosure is the ability to disclose information about yourselfCthe ways you think and feel, the things you believeCin order to help other people.

Warmth. Warmth is the ability to show another person you care about him or her. Behaviors that show warmth include touching someone, making eye contact, smiling, and having a caring, sincere tone of voice.

Immediacy. Immediacy is the ability to focus on the "here and now" relationship with another person. You can express immediacy by saying things like: "Right now I am feeling ________." "When you said that, I began to think _________." "As you were speaking, I sensed that you felt __________."

Concreteness. Concreteness is the ability to identify specific problems and the steps necessary to correct them. When a problem, situation, behavior, or set of actions is defined in concrete terms, you could draw a picture or make a movie about it if you were able.

Confrontation. Confrontation is the act of honestly telling another person your perception of what is going on without putting them down. Confronting someone can include:

Active Listening

When a patient is talking about a problem or presenting an assignment, it is important to listen actively. Active listening is a basic counseling skill that helps you clarify for yourself and the patient what is really going on. Patients in recovery are not always clear in their thinking. This lack of clarity can confuse them and those around them. Active listening will help them clarify their thinking.

Active thinking consists of several skills. These include the following:

Clear listening. When you are listening to a patient, it is important to just listen. The most common problem for new counselors is that they think while they listen. If you are thinking about what you are going to say, you will not accurately hear what the person is saying. It is important that you listen without judging what the patient is saying and without immediately trying to correct his or her thoughts.

Reflecting. When someone talks to you, reflecting is summarizing and repeating that person's thoughts andfeelings in a simple, clear manner. Reflecting helps clarify the issues for both of you. If you misunderstand the patient, he or she can correct you. When you repeat thoughts and feelings back to the patient, use statements instead of questions.

Example: Patient—"I try and try to stay straight but everything goes wrong and I end up using again."

Counselor-"You seem to feel hopeless about recovering." Reflecting gives a patient the sense that you are really listening. He or she will tend to open up more and talk about problems he or she hasn't talked about before.

Asking-open ended questions. Do not ask questions that can be answered with a "yes" or a "no." Instead, ask questions that require patients to explore the reasons they think, feel, and act the way they do.

Example: "What happens when you try to recover?" "What do you do when you feel hopeless?"

Not asking "Why?". Most new counselors make the mistake of asking "Why?" The patient does not know why, or else he or she would have changed. If you ask "Why?" the patient will give you an excuse. By asking "What?" you are getting the patient to focus on what he or she has done that can be changed.

Using effective body language. How you physically position yourself tells a patient a lot about how you feel about him or her. When you are working with patients, it is best to sit with your legs and arms uncrossed, to lean forward and to make eye contact. This body position shows that you are interested in what the patient has to say and that you are paying attention.

Watching for nonverbal cues. When you are working with a patient, listen and watch carefully. Does the person tense up, tap his or her foot, shift around, etc.? When you see these cues, make the patient aware of them and let him or her know what this might mean the patient is feeling.

Basic Relapse Prevention Techniques

There are a number of techniques that are used when doing relapse prevention counseling.

Centering

When you begin a group or an individual session or when you want a patient to calm down and get in touch with thoughts and feelings, you can use a technique called centering. This is basically a relaxation technique. Instruct the patient to do the following:

Speak slowly as you give the instructions. This will help the patient calm down.

Sentence completion

Sentence completion is a technique used to help patients identify thoughts that they have that may not be true. These thoughts are called mistaken beliefs. Many times when a patient is acting in a self-defeating way, it is a result of mistaken beliefs he or she has about the world and himself or herself. When a patient is behaving in a way that hurts himself or herself and others, it is because the patient believes that this is the only choice he or she has. Sentence completion is a way to help a patient identify and correct mistaken beliefs. You do this by doing the following.

Sentence repetition

Sentence repetition is a way for a patient to become conscious of mistaken beliefs and the thoughts, feelings, and actions they cause. Identify the mistaken belief and ask the patient to write it down.

Mistaken belief—I can't tell others what I feel or they will look down on me.

Chapter 6—Group Counseling

Group counseling has proved to be the most effective way of treating chemical dependency. This chapter explains how to do group counseling. Patients in chemical dependency treatment programs learn best in group counseling, where patients learn about themselves by interacting with others. They also come to understand that they are not alone in their problems. In addition, they learn social and communication skills that allow them to make better use of self-help programs such as Alcoholics Anonymous and Narcotics Anonymous.

How Is Group Work Different From Individual Counseling?

Group counseling and individual counseling are both important tools for treating chemical dependency. Group counseling uses many of the same intervention strategies as individual counseling. There are, however, some important distinctions between the two modalities. A common mistake for beginning group counselors is to focus an entire group meeting on one patient, while the others in the group simply look on.

Group counseling is different from individual counseling in the following ways:

In group counseling, the counselor uses a peer group to influence individual patients and change behavior in a positive way.

Group Counseling Theory

Stages of Group Development

When a group first begins, counselors and group members alike will feel very uncomfortable. The members may not know the counselor or one another. As people become familiar with the group, feelings and behavior begin to change. These changes follow predictable patterns. In fact, groups have a clear developmental life cycle, that is, a group goes through different stages. As the group leader gains experience, he or she learns to anticipate these changes and work with them.

There are many models for the stages of group development. The following is a composite of several models:

In the preaffiliation stage, members feel uncomfortable, anxious, or fearful with the newness of the experience. In this stage, members look to the leader for direction. Initially, the group should be leader-focused, with the leader helping members adjust to the new experience.

Once group members are more comfortable, it is predictable that they will challenge the authority of the leader and will pursue power and control. It is important for the leader to remember that this is a normal style in the group's development, not unlike the challenges that face the parents of an adolescent. This phase may be uncomfortable, with group members expressing anger and frustration. The leader should be careful not to personalize these challenges to authority. The leader should be consistent, avoid fighting with the group, and allow the group to become more autonomous without sacrificing his or her position of authority.

In the next stage, some degree of intimacy is established. It is very important for the leader to move members to a common level of intimacy before allowing too much self-disclosure by the group members. The setting and type of the group will determine the overall level of intimacy. As members feel safer in the group, they can better engage in activities and take risks necessary for change. At this stage, the leader can give less direction, allowing the members to work together more spontaneously and more independently.

Differentiation is the stage at which members have a strong sense of identification with the group and feel trusting. This is the most productive stage of group development.

Finally, at the point of termination or separation, members experience a range of feelings and display a range of behaviors in anticipation of leaving the group. It is important to remember that chemically dependent people typically have experienced a lot of loss over their lifetimes. Many have lost family members and friends to violence and illness. They do not handle the ending of relationships well. Termination of the group or loss of a group member presents an important opportunity to deal with this problem. The leader should begin to prepare the group for ending well in advance and do so gradually. The leader can expect members to use denial or to regress. It is important to predict these behaviors and to identify them as they occur.

These stages of group development are very predictable. Virtually all groups go through them. However, depending upon the circumstances a group may regress to an earlier stage at any time. For example, if a group adds new members, the level of intimacy will decrease. The group may return to a stage of preaffiliation. It is hard to predict how long a group will stay in a particular stage of development. The type of group (i.e., mandatory or voluntary), the setting (i.e. institution or community), and other factors can all influence the process. With experience, the group leader develops the skills to promote the group developmental process or alter.

Communication in Groups: Content and Interactive Process

The terms "content" and "interactive process" refer to the patterns of communication among group members. "Content" refers to the substance of a communication. The content is the subject matter, including issues, questions, or problems on which the group is focused. "Interactive process" refers to how members communicate and act with one another. The process includes not only the spoken words, but also the nonverbal messages expressed by tone of voice, posture, and facial expression. Process provides the "present focus" or "here and now" raw material for group treatment.

The content of a group meeting sometimes symbolizes the group process. In the same way a client might talk about "a friend who has a problem," group members may talk about prior events and issues that reflect current experiences. Often as group leaders, we get caught up in the content. We are very interested in the what, when, where, who, how, and why. In group counseling, this content has relevance in a way that can be different from its relevance in individual counseling.

The Counselor as Group Leader

Many techniques used in group counseling are similar to those used in individual counseling. The general approach of the group leader, however, must work to create a group culture that focuses on the Ahere and now" behavior. An active and dynamic approach along with an empathic style are needed to do this.

The group leader's focus should:

The group leader's approach should:

The group leader should:

Planning for Group Work

Logistics

All logistical arrangements should be planned well in advance of beginning the group. In order for the preplanning to go smoothly, group counselors should seek the support of appropriate administrative and support staff. Establish the following before getting started.

Group Size

Groups typically range in size from 6 to 12 people. The size should be determined by such factors as the type of group and the capacity of the patients. "Capacity" refers to the level of individual functioning. Can the patient concentrate, focus, and pay attention? Some substance abusers, particularly those in the early stages of recovery, cannot make use of all their mental functions. Others may have mental/emotional problems that interfere with these abilities. Low-functioning individuals will need a smaller group. Educational groups can handle more members, whereas process oriented-groups should be smaller.

Time

Time is an important boundary. The length of group sessions should be preplanned if the group is to be time limited. A schedule of sessions should be established that considers holidays and other commitments.

Sessions should be of equal length. The ideal length depends on the capacity of the patients, the setting, and the type of group. More functional patients can handle longer sessions than less functional or younger patients. The materials presented in this manual are intended for two-hour group sessions.

Once the time boundaries have been established, it is very important to begin and end group sessions on time.

Space

The space chosen for group meetings will make a statement about the importance given to this activity. The space should be psychologically positive and provide a safe environment for the emotional risks that go with treatment. The space should be well lighted, well ventilated, and an appropriate size for the size of the group. A private location that is accessible, free from interruptions, and physically safe should be chosen.

Types of Groups

Different types of groups serve different purposes. The following is a review of some options to help you decide what type of group is most practical and useful for the setting.

Mandatory or Voluntary Group?

You might assume that voluntary groups are best, but research and practice indicate that both voluntary and mandatory groups have their advantages and disadvantages.

Mandatory groups ensure that members will attend. With regular attendance the group process can develop with little disruption. Unfortunately, mandatory requirements often increase hostility and resistance and intensify denial. No one likes to be told they must go to a counseling group, and few counselors like being confronted with such hostility, particularly by a group of eight or more people.

When the counselor is well prepared, the situation can be managed. Patients will attempt to engage you in battle. The best tactic is to avoid these battles. One way to do so is to join with the group by saying something like, "You have to be here and I have to be here. I understand and appreciate your anger but it is not my fault. How can we both make the best of things?" Offering concrete rewards for cooperation may also help. Setting rules for attendance can eliminate overt resistance but seldom reduces passive resistance.

The disadvantages of the mandatory group become the advantages of the voluntary group. Members of voluntary groups identify with one another, denial is less potent, there is less hostility, and one can move on more quickly to group goals. However, the voluntary group does not have some major disadvantages. When participation is voluntary, members often find excuses to be absent when there is pressure on them to face problems. Without a "captive" audience, leaders find that it is hard to ensure member attendance and that it is difficult for the group process to evolve with absent members.

Which type of group is best? Research indicates that mandatory treatment works as well as voluntary treatment with substance abusers. In a criminal justice setting, required attendance can be useful for all.

Open or Closed Group Membership?

One issue to be decided in advance is whether or not to add members after the group has started. The terms Aopen membership" and "closed membership" are used to describe the two options.

Open membership can reach more clients and is easier to keep going over time because lost members can be replaced. However, adding new members can cause a loss of group intimacy and cohesiveness. Development may regress. Although this may not be ideal, depending on the goals of group, adaptations can be made. Closed membership allows for greater individual progress but is impractical in some settings.

Time-Limited or Open-Ended Group?

It may be practical to place a time limit on a group depending on the patients' stage of recovery. This way patients graduate together to another group with another specified goal. If the setting allows, an open-ended, closed membership group can be ideal. Such a group can achieve high levels of intimacy and differentiation that allow for greater risk taking. The goals can advance while the membership remains the same.

Educational Groups?

For patients to succeed in recovery, they must learn certain things about chemical dependency. This information helps them to cope with the challenges of recovery and avoid relapse. Educational groups also help engage the client in treatment and recovery. The overt or covert expectation of individual or group therapy is "change." People find this threatening. An educational group is much less threatening because it is easier to Alearn" than to Achange."

Educational sessions can be offered in 60- to 90-minute blocks. The educational sessions should offer basic information on

These sessions should consist of a lecture and an exercise, presented with media supplements. Some programs have an educational curriculum available, and such programs may be available through your State Alcohol and Drug Abuse Agency. One prepackaged educational program that can be ordered is the Staying Sober Educational Modules (see the bibliography).

Group Goals and Principles

It is important for the group leader to be clear about what is to be accomplished in the group. It is best to have a written goal with a step-by-step plan for reaching the goal. Having both a written goal and a plan will help to keep the group on track.

The goals of group treatment with addicted patients should be:

Self-assessment. The patients should be able to talk about and understand the meaning of different exercises to their recovery.

Communication training. The group leader should teach patients basic techniques for talking about their thoughts, feelings, and reports of life events. This training should focus on teaching patients how to reveal things about themselves and how to give and receive feedback.

Cognitive restructuring. Patients should relearn how to think so that they can accurately examine and report information and understand how it pertains to their recovery.

Effective counseling. Group treatment should teach patients how to identify, express and self-regulate their emotions and moods.

Memory retraining. Treatment should help patients restore short-term and long-term memory.

Treatment monitoring. Group sessions should provide a vehicle for monitoring and holding the patient accountable for progress and problems encountered when pursuing treatment goals.

Support. The group leader should provide peer and professional support throughout the recovery process.

Opportunity for dialogue. Group sessions should give the patient a chance to talk about recovery issues in a supportive environment where feedback from and discussion with people both more and less advanced in the recovery are available.

Involvement of others in problem solving. The group process should involve the patient in problem solving with other recovering people. The group leader can tell patients that others can and will help in problem solving if they are allowed to, that they too are capable of helping others, and that they can help themselves by helping others.

The principles of group counseling for patients recovering from addictions should be:

Addiction groups. In order to be successful, groups must consist of only recovering alcoholics and drug addicts.

Group treatment goals with addicted patients. The addicted patient is suffering from chemical dependency. This is an illness causing specific physical, mental and social impairments. Group treatment must be directed at helping the patient with these impairments.

Structured and directive group process. The group process should be structured rather than free-floating. Patients must focus on concrete, specific problem solving relating to accepting their addiction and achieving a comfortable recovery. Feelings should be dealt with in the context of these concrete problems. All problems dealt with in the group must be related to recovery from chemical dependency.

The role of the group counselor. The group counselor should be directive, yet permissive and supportive. The counselor is responsible for establishing and maintaining direction for each patient and for the group as a whole. The group counselor gives direction and supervision to the group. He or she must provide a consistent group format; set the pace of the group and see that it is maintained; assign, follow, and review assignments; and manage group problems as they develop.

The abstinence goal. The first focus of group treatment should be for each patient to establish and maintain abstinence from alcohol and mood-altering drugs. This goal of recovery involves the identification of concrete problems and situations that could jeopardize abstinence, the development of specific plans for managing these problems, and the completion of skills training and assignments designed to develop skills in coping with these problems and situations.

Reliance on group support. Patients need to develop a strong substitute dependency to replace their old dependency on alcohol and drugs. Patients will tend to develop a strong dependency on the counselor as this substitute dependency. Group treatment should be used to transfer this dependency from the counselor to the group. Group counseling for addicted patients should be designed to support the patient's ongoing involvement in AA, NA, and other support groups. It should also focus on building strong, positive, supportive relationships among the group members.

Admission and discharge criteria. There should be specific admission criteria that describe the type of patient that is appropriate for treatment in group counseling. There should also be specific discharge criteria that describe when a patient is ready to responsibly Agraduate" from the group.

Issues that are inappropriate for group treatment. There are certain issues that are best dealt with individually. This is due to the need for extreme confidentiality or a patient's inability to deal with the issues in a group setting. Care needs to be taken, however, not to support a patient's continuing denial by allowing him or her to avoid talking about routine recovery issues in group sessions.

Role modeling by the counselor. The counselor should model the behaviors that he or she expects from the patients.

Supportive counseling. The early efforts of the group counselor should be directed toward allying himself or herself with the addicted patient's needs rather than with attacking defenses. Addicted patients need basic support, education, communication training, and direction in recovery. These should be provided with support rather than harsh confrontation.

Group involvement. Eighty percent of the benefits of group treatment comes from becoming actively involved in utilizing the group process to help other group members to recover. This involvement interrupts chemically dependent self-centered behavior and provides training in the processes of problem solving and recovery. Many patients will automatically identify and discover solutions to problems in their lives by helping other patients cope with similar problems. Only 20 percent of the benefits of group counseling comes from working on personal problems.

Note taking and tape recording in group. Addicted patients suffer from severe memory impairments. It is recommended that all patients take notes on important issues. Patients can also tape record portions of the group sessions where they work on an issue and receive feedback. Listening to these tapes later often speeds up the counseling process.

The intoxicated patient in group treatment. It is unproductive to allow a patient to attend group sessions while actively intoxicated with alcohol or drugs. The patient should be asked to leave the group and an individual appointment should be made to motivate the patient to enter appropriate detoxification treatment.

Rules and Contracting

Contracting is a tool that many groups use to help get members to attend meetings and follow rules. Because it is very important that all members agree to the requirements and rules of the group, a document can be written up and copied for each member and the group leader. Each member and the leader will sign this contract. The contract sets forth the day or dates of meetings, time, location and group rules.

Clearly stated and enforced rules are critical for a successful group. They can free members to deal with recovery issues. For example, when a rule of no violence is clearly stated and enforced, it allows the patient to feel and express anger, knowing that the group will not allow any one person to get out of control. Rules also offer limits to patients who have very few internal controls and who cannot set their own limits. Many substance abusers grew up in situations that did not teach them controls and limits. Establishing and enforcing group rules can help correct this.

Use the following guidelines in setting group rules.

Group Rules

The following rules are designed to be used as part of the problem-solving group process.

Responsibilities of patients in the group include the following:

Problem-Solving Group Counseling Format

The Preparation Session

Before the group session begins, the counselors must prepare. Counselors meet as a group. A brief written description of each patient (a Athumbnail" sketch) is presented, and the patient's progress is reviewed. An attempt is made to predict the assignments and problems that patients will present.

The Opening Procedure (5 Minutes)

During the opening procedure, the counselor sets the climate for the group, establishes leadership, and helps patients warm up to the group process.

Reactions to Last Session (15 Minutes)

A reaction is a brief description of (1) what each group member thought during the last group session, (2) how the group member felt during the last group session, and (3) identification of the three persons who stood out from the last session and why they were remembered.

All group members are required to give a reaction to the last session. This accomplishes a variety of goals:

It is important to remember that a reaction is a one-way communication. Other group members are not permitted to comment on the reactions. If someone is upset by what another group member says, it is that person's responsibility to volunteer to work on the issue when the agenda is set.

A reaction is also a no-fault communication. There are no right or wrong reactions. The only feedback the counselor and other group members generally give is on the format and completeness of the reaction. In other words, the group member is reporting on his or her thoughts, feelings, and at least three persons who stood out to them in the last session.

A typical reaction should have three parts:

A counselor must help patients by coaching their responses.

Typical problems that patients will have are

Examples of Good Responses. A typical reaction made by a group member to the last group might be as follows:

Learning To Give Good Reactions

It takes time for the average person to learn how to give good reactions in group session. This learning takes place as a result of instruction and imitation. The counselor and other group members should explain the components of a good reaction to each new group member. A written handout should be provided that describes the components of a reaction and gives examples.

The group member will also learn by observing and imitating the reactions of other group members. Counselors can speed up this progress by acknowledging good reactions. This is done by saying, "Good" or another positive response to encourage and reward the person. The counselor gives positive feedback for doing the reaction correctly, not based on agreement with the content of what the person says.

Report on Assignments (10 minutes)

Assignments are exercises that patients are working on in their workbook or in addition to their workbook. Additional assignments are often given to help a group member solve a problem that is being worked on in the group. Some of these assignments will be completed in group, and others will need to be completed in between group sessions. Immediately following reactions, the counselor will ask all group members who have received assignments to briefly answer six questions.

Patients should be asked to rate how important their assignment or problems are in the group session by labeling them with a number from 1 to 10, with 1 being not very important and 10 being extremely important.

Setting the Agenda (3 Minutes)

After all assignments have been reported on, the group counselor will identify all persons who want to work, and announce who will work and in what order. Group members who do not have time to present their work in this group session will be first on the agenda in the following group session. It is best to not plan on over three patients working in any group session.

The Problem-Solving Group Process (70 Minutes)

The problem solving group process is designed to allow patients to present issues to the group, clarify these issues through group questioning, receive feedback from the group, receive feedback from the counselor (if appropriate), and develop assignments for continued progress.

The problem solving process is guided in two ways. A series of exercises are assigned and then processed in group. Special problems that come up are discussed by the group. One goal of group counseling is to teach problem solving skills that will enable the recovering patient to handle difficult situations when they arise.

When dealing with problems that are not assignments, a standard problem solving process is recommended. This process consists of the following steps:

Step 1: Problem Identification.

First, have the members ask questions to identify what is causing difficulty. What is the problem?

Step 2: Problem Clarification.

Encourage them to be specific and complete. Is this the real problem or is there a more fundamental problem?

Step 3: Identification of Alternatives.

What are some options for dealing with the problem? Ask the patient to list them on paper so they can readily see them. Try to have the group come up with a list of at least five possible solutions. This will give them more of a chance of choosing the best solution and give them some alternatives if their first choice doesn't work.

Step 4: Projected Consequences of Each Alternative.

What are the probable outcomes of each option? Have the group ask the person the following questions:

Step 5: Decision.

Have the group ask the person which option offers the best outcomes and seems to have the best chance for success. Ask them to make a decision based upon the alternatives they have.

Step 6: Action.

Once they have decided on a solution to the problem, they need to plan how they will carry it out. Making a plan answers the question, "What are you going to do about it?" A plan is a road map to achieve a goal. There are long range goals and short range goals. Long range goals are achieved along with short range goals. One step at a time.

Step 7: Followup.

Ask the person to carry out his or her plan and report on how it is working.

Most problems will not be solved by presenting them one time in group session. Personal problem solving is a process that requires time. It may require three to six presentations of a problem, accompanied by specific assignments completed between group sessions to bring a problem to full resolution. Patients should be given a limited time to present a problem or the summary of an assignment. As a general rule, patients should not work in group for more than 20 minutes.

Not every person will work on a problem during each session. There is an 80/20 rule for group treatment. Eighty percent of the benefit of group treatment occurs from learning how to become responsibly involved in helping others to solve their problems. Only 20 percent of the benefit is derived from working on personal problem issues.

Feedback

When you reach a point where part of the problem solving process is completed or an assignment is presented, group members and the counselor should give feedback. The counselor should go last. Feedback should be given by having the members complete the following:

The purpose of this feedback exercise is to practice communication skills, learn to give and take feedback, and use the group for problem solving. The counselor may give an assignment to the patient if it would be helpful to continue to learn more about how to solve this issue.

The Closure Exercise (15 minutes)

When there is approximately 15 minutes left in the group session, the counselor will ask the members the following:

Each participant will then briefly review his or her answers to those questions with the group. The counselor then adjourns the group.

The Debriefing Session

The debriefing session is designed to review the patient's problems and progress, prevent counselor burnout, and improve the group skills of the counselor. If this can be done with other counselors running similar groups, it is especially helpful. A brief review of each patient is completed, outstanding group members and events are identified, progress and problems are discussed, and the personal feelings and reactions of the counselor are reviewed.

Outline for Group Counseling Sessions

Opening Procedure—Format (5 minutes)

Opening Procedure—Purpose

Reactions to Last Sessions—Format (15 minutes)

Reactions to Last Session—Purpose

Report on Assignments—Format (10 minutes)

Report on Assignments—Purpose

Setting the Agenda—Format (3 minutes)

Setting the Agenda—Purpose

Problem Solving Process—Format (70 minutes)

Problem Solving Process—Purpose

Presenting a Problem in Group

Goals of Group Questioning

Types of Questions

The "EIAG" Method.of Questioning

Addiction-Focused Questions

Giving Feedback in Group

The Timing of Change

The Problem Solving Process

The Closure Exercise—Format (15 minutes)

The Closure Exercise—Purpose

Adjournment

The Debriefing Session—Format

The Debriefing Session—Purpose


<< Back | Table of Content | Next >>

Back to Top