by Hope Rehab Team
Group Therapy is Often Misunderstood
Jack Nicholson really did it! As Randy in the Hollywood block-buster “One Flew Over the Cuckoo’s Nest” he must have turned a whole generation of movie viewers off and away from group therapy. Domineering, belligerent, rebelling and at times aggressive during group sessions, neither he nor others benefit.
The movie won producers and Nicholson more than one Oscar, and left viewers with the unfortunate impression that group therapy is an emotionally unsafe process, in part orchestrated by group leaders that seem to have more issues than the patients. While most of us understand this is a rather unrealistic depiction of what actually takes place in group therapy today, lingering images and uncertainties may get in the way with seeking and experiencing the transformative and often life changing power group therapy really holds.
The Real Thing: What Happens in Group Therapy
At first glance, getting patients struggling with identical or at least similar problems together in groups seems a matter of logic, cost efficiency and practicality. Widely used in a multitude of health care settings, people are brought together to learn together about causes, course and coping strategies. Group sessions are typically available on an in- or outpatient basis.
In outpatient programs, group sessions are typically held once weekly for up to two hours over the course of 12-16 weeks, while inpatient, intensive or residential programs offer daily sessions in a shorter time frame. For example, residential alcohol or drug centers tend to offer treatment for a minimum of 30 days, often with the option to extent. A residential or inpatient program immersion allows patients to relinquish the responsibilities and distractions of everyday life, thereby allowing them to fully concentrate on the changes they wish to make.
Skills & Tools
During initial sessions in an addictions group, participants may learn about the cause and course of addiction, and the ups and downs of their recovery. Common topics can include stages of change, the nature of post-acute withdrawal or key factors in long-term recovery. Psycho-educational sessions may also teach group members about issues underlying or feeding an addiction, such as mental health issues or long-term stress.
As sessions progress, members are invited to learn skills and strategies necessary to support changes in unhelpful behavior. For example, cognitive-behavioral therapy (CBT), one of the most frequently utilized approaches in the treatment of addiction, focuses on identifying, challenging and changing negative thoughts as these typically translate into unhelpful behavior. Behavioral or emotional focused skills may aim at improving one’s ability to resist peer pressure, or observe rather than to act on urges to use or conquer high-risk situations.
Digging Deeper – Where the Healing Begins
Sharing with others is a crucial aspect for addictions or mental health group therapy, as struggling with addiction and/or mental health problems typically entails a range of difficult emotions, thoughts and behavior that are often not well understood by family or friends. Sometimes, divulging such difficult internal experiences can be outright scary for loved ones, as in the case with suicidal thoughts, urges to self-harm or cravings to use just after an overdose.
Group participants often voice an incredible sense of relief understanding that they are not alone with what is perhaps considered unacceptable or crazy, or what is frightening for themselves or others around them. There is instant and strong connection when we hear another human being express the same doubts, questions, dark thoughts, confusing emotions that have tormented us for months, sometimes years. Allowing ourselves to be vulnerable in this way, we learn very quickly that we are not alone in our difficulties.
You are not alone
Group therapy provides community, and is therefore the natural antidote to a range of human suffering, including addiction- the disease of loneliness. Addicts tend to check out of life, out of living and out of relationships. As addictive behaviors increase, meaning and purpose in life decreases. There is no longer a pursuit of goals and dreams, as addicts gradually let go of educational or occupational activities. More importantly, addicts check out of relationships, families and communities, unless others hold the promise of a next fix or high.
There is a painful absence of meaningful human connection, and this in turn constitutes a powerful fuel for continued and escalating despair and addictive behavior. Listening, supporting and encouraging each other week after week in group therapy sessions allows participants to connect with one another, and gradually back into the healing arms of human community. We begin to belong again.
A Safe Space to Connect with Self and Others
Our feel good society may convey that we should hide ‘negative emotions’ such as despair, grief and depression, forcing us to put on a mask pretending we are ok. This is not so much for our own sake, a ‘fake it until you make it’ endeavor, but instead prevents others from the discomfort of being exposed to our suffering. The show of life must on. In stark contrast to that, group therapy participants are encouraged to identify, express and stay with a range of emotions. This is important in more ways then one way: firstly, research shows that individuals struggling with addictions or mental health problems typically cannot endure difficult emotions, such as anger, sadness, fear or boredom.
Learning that all emotions are not only acceptable, but also necessary for our well-being is a crucial step towards health and healing. By extension, this allows for participants to connect with, and address sometimes deeply buried emotions and experiences. In doing so, or bearing witness to other participants doing so, can be powerful and sometimes life changing: we can finally stop drowning and numbing our soul’s and heart’s suffering with increasing levels of some sort of external and temporary fix.
Microcosm and laboratory
Fact is that no one comes to therapy because their life is fabulous and they are having such a good time. In contrast, we only tend to bare our souls and share our suffering when we are miserable, and when our typical ways of being in the world no longer work. Acceptance, support and safety in group therapy provide an ideal platform for experimentation with new ways of thinking, behaving and relating to others. For example, as unhelpful ways of relating to others emerge during group sessions, participants may start to explore unhelpful relationship patterns in their lives, thereby inviting baby steps towards change and perhaps healing with estranged loved ones.
The opportunity to observe fellow group participants making changes for the better, whether in regards to relationships or in other important aspects of their lives inspires others to do the same. Conversely, inspiring and supporting others to make changes for the better, we learn that we have something to offer -albeit or perhaps because of the challenges that brought us into group.
Mirror, Mirror on the Wall …
Addictions group therapy can work like holding up a mirror. Group members inevitably identify with others’ accounts of lying, deceiving or stealing from those who deserve so much better. This invites taking a hard long look at our behaviors and our lives, and in doing so, counters denial. No longer can we tell ourselves our substance or alcohol use was ‘not that bad’, or ‘not as bad as that of others’. It brings about stark awareness to those things we previously drugged, drowned or otherwise pushed down.
Such awareness demands we take ownership of the wreckage our addiction has left behind. It calls for honesty with self and others, and builds the basis for making amends and repairing relationship with hurt and alienated family and friends. With guidance and support from group facilitators and other group participants alike, we can develop the courage to face addiction-related shame and guilt, rather than take these emotions as yet another convenient justifications to use. Although painful and uncomfortable, this proves a wonderful opportunity to consider our values as to what and who is important so we can gradually re-build a life worth living
No Such Thing as ‘One Fits All’ When it Comes to Healing
Albeit vast benefits, group therapy is not for everyone. Compared to individual therapy sessions, groups bear some disadvantages that make it counterproductive, perhaps even to some degree harmful to some of us seeking help.
Group therapy is usually focused on a specific problem area, such as depression, anxiety or addiction. The skills and tools participants learn typically reflect research and clinical experience as to what is helpful to most individuals struggling with the identified issue or condition. While this makes sense, this ‘one fits all’ approach may fail to address specific individual circumstances underlying individuals’ struggles. While all group participants in an addictions focused group struggle with some form of addiction, for example, individual participants may suffer from additional issues such as mental health problems, or longstanding interpersonal difficulties. Studies have shown that failure to address such challenges often makes for a short-lived sobriety, as these unresolved issues tend to resurface and threaten participants’ fragile recovery. This does not necessarily mean addictions group therapy is not going to be helpful at all for individuals with specific concerns, but it may call for additional one to one sessions to address unique needs.
When Group Therapy Becomes Unhelpful
Group participation may become unhelpful, either for the individual or other group members, if prospective participants suffer from certain mental health problems.
Social Anxiety: Individuals with social anxiety fear anticipated judgment, ridicule or embarrassment by others. They are often consumed by anxiously anticipating future social interactions they are sure will go horribly wrong, or they think incessantly about past social interactions, berating themselves for all the supposed stupid things they have said. Rather than concentrating on group discussions and activities, such individuals tend to be intensively occupied with what to possibly say or do that will not result into the feared embarrassment when called upon by the facilitator or a fellow group member. While group therapy sessions may offer opportunity to counter such negative beliefs and fears in a best case scenario, highly socially anxious individuals may be so riled up about upcoming or past group therapy that they are unable to sleep before or after sessions. Under such circumstances, potential group participants would be much better off addressing their social anxiety one to one therapy sessions, perhaps adding group sessions at a later point.
Severe personality disorders: While there is frequent overlap between addiction and some of the personality disorders such as Narcissistic, Antisocial or Borderline Personality Disorder, these do not usually constitute an obstacle to participation in addictions group therapy. However, individuals with personality disorders so severe that they are unable to relate to, or emphasize with fellow group members, and who remain exclusively concerned about their own experiences and needs, may not be able to participate in the give and take that is vital to any group process. Such individuals may be benefit more from long-term individual therapy.
Trauma: Many individuals struggling with addiction have a history of physical or sexual violence, often perpetrated by those they felt close to and trusted. Among other things, this translates into a paramount need for emotional and physical safety, and for clear boundaries. Group therapy sessions that offer little structure, and facilitators who lack the skill to provide solid containment as to acceptable behaviors and language, can easily be triggering. For example, although spontaneous touching of another group participant to convey sympathy and support may be well intentioned, doing so may propel trauma survivor into memories of other uninvited intrusions and boundary violations. For this population, group therapy offering structure and content that is trauma specific, or at least trauma sensitive, may be a much gentler and more helpful option as compared to programs focusing solely on addiction-related topics and skills.
One-on-one sessions can also be advisable for the caretakers among us: those of us who tend to focus more on others’ needs rather than on our own. After all, group therapy provides a formidable opportunity to concern ourselves with others’ problems in order to avoid our own uncomfortable work.
Thou Shall Not Confuse: Group Therapy versus Peer Support Groups
Group therapy is not to be confused with the many forms of self-help, peer support groups and recovery communities. Like group therapy, such groups offer inspiration, hope and support to anyone in addictions recovery. They allow those new in recovery to learn from the experiences and mistakes of seasoned attendees. Over time, and with commitment, fellowships also offer an opportunity to give back, for example by sponsoring someone new to recovery, thereby further cementing one’s commitment to a sober lifestyle.
Research has shown that the support and regular contact with others who are as committed to an addicts’ recovery as the addict herself, is crucial for long-term sobriety. Needless to say, such recovery communities are therefore important. However, self-help groups do not provide a structured group environment in which individuals can safely address deep-seated and often complex issues underlying their addiction. This requires skilled facilitation and therapeutic guidance by a highly trained and experienced professional, usually only found in accredited addictions or mental health programs. Self-help or peer support groups such as AA/ NA, SMART RECOVERY or Refuge Recovery are therefore no substitute for therapy, but instead and ideally lend additional and/or ongoing support long after group therapy has ended.
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