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 Socialising 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 generalisations 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 generalise 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.