Treatment of Addiction and Coexisting Disorders Claire Aitken

Treatment of Addiction and Coexisting Disorders Claire Aitken October 2020

GROUP WORK AND ADDICTION TREATMENT “The lives of individuals are shaped, for better, for worse, by their experiences in groups. People are born into groups. Throughout life, they join groups. They will influence and be influenced by family, religious, social and cultural groups that shape behaviour, self-image, physical and mental health. ” TIP 41 samhsa/csat treatment improvement protocols p 1.

Some of the most comforting words in the universe are “me too. ” That moment when you find out that your struggle is also someone else's struggle that you’re not alone, and that others have been down the same road.

INTRODUCTION Ø Group work in healing and addiction is not new. Ø Indigenous cultures have had healing cultures of groups as part of their traditions. Diminished acceptance over time led to less use of these. Ø Less used as our services changed shape e. g. less residential where groups were a mainstay. Ø Evidence of group efficacy. (Scheidlinger 2000; Toseland Siporin 1986) Ø Related to reducing isolation and ability to witness recovery of others.

Many treatments occur in a group setting but not all are considered group therapy. Tseng 1999 and Montgomery 2002 defined group therapy as: “A treatment where one or more therapists treat a small group of tangata whaiora together and where learning through exploration of the interpersonal relationships within the group experience and group process is utilised as a major mechanism of change. ”

Ø Now- increased waiting lists. Cost effective and often cheaper. Ø Confusion between therapeutic intent and cost effectiveness. Ø Discussion re “what constitutes a group, and what makes them effective as all are not equal. ” Ø Very few experienced group workers provide significant workforce development issues.

Group Therapy properly conducted is difficult. Ø What makes it so? Ø What are challenges of group work? Ø What are advantages of group work?

Group vs. Individual Ø More difficult (demanding, staying in control) Ø More Complex (many participants) Ø More work (focus/alert/balance/feedback) Ø More challenging e. g. more pressure for some participants. Ø More opportunity for transference/counter transference issues due to increased numbers.

Ø Different skills-need to know defensive processes and character dynamics present and why present. Ø Need to manage each other if co-leading. Ø More supportive (multiple change agents) Ø More rewarding Ø More opportunity to practice new behaviours Ø Group is agent of change. Ø Interpersonal processes critical for group cohesion.

Ø More feedback (from others as well as therapist) Ø Learn problems not unique, others similar concerns Reduce isolation, witness recovery Ø Positive peer support, pressure to abstain. Ø Wider range of information available. Ø Can provide whanau/family type experiences.

Ø Encouragement, coaching, support and reinforcement to undertake difficult tasks. Ø Learn/relearn social skills. Ø Group can challenge difficult, harmful behaviours. Ø Can add needed structure, discipline into often chaotic lives. Ø Interpersonal processes critical for group cohesion. Ø Installation of HOPE. “If he/she can do it so can I. ”

Primary Therapeutic Factors 1. Instillation of hope This applies to both faith in the treatment to keep a person in therapy as well as on-going inspiration from those who have been participating longer. 2. Universality Relates to the recognition of shared experiences and feelings among group members which may be universal This reduces feelings of isolation and can help validate the individual’s experience. 3. Imparting Information Gaining factual information from others is very important as is advice, suggestions and general guidance 4. Altruism Helping others through giving, lifting self-esteem and increasing positive coping styles and interpersonal skills

Primary Therapeutic factors 5. Corrective recapitulation of the primary family experience Many who attend group therapy have had a primary negative experience in their own families. The transference that occurs in relation to this can be healing in a way that one-to-one therapy does not allow 6. Development of socialising techniques Development of social skills and positive interpersonal behavior 7. Imitative behavior This often occurs via modelling, self-disclosure and observation. The benefits are often short-lived, but this may be a key factor in sparking initial change.

Primary Therapeutic Factors 8. Interpersonal learning With accurate feedback, group members can gain insight and learn to differentiate the negative and positive aspects of themselves, taking responsibility for lessening or developing them 9. Cohesiveness A cohesive group vital in all forms of therapy 10. Catharsis The relief from emotional distress, which is achieved by free expression of emotion, can be freeing of shame and guilt, though is insufficient unless accompanied by other learning process. 11. Existential factors Learning to take responsibility for their own life and the consequences of decisions and actions

How do you make them work? Ø Who is group for, what are their needs, why is it being established? Ø How much do you know about the world view/values of your participants? Ø What is Therapeutic Intent? Ø What kind of group will best fit this? Ø Resource, training and orientation of leaders?

Effective Components of Group Therapy. Yalom and Leszcz 2005 -11 primary therapeutic factors that act independently and are key to effective change. Thygesen 1992 -accomodation of Diversity imp. Salvendy 1999, Yalom et al 2005 -group confession and testimony. Tseng 1999 -ethnic and cultural backgrounds of participants and therapist imp eg communication style, relational patterns and interaction with group therapist. Connection between process and content.

Ø Several choices known to be effective as long as principles followed. – Skilled leadership – Model matched with needs of particular population. – Goals determine model. – Assessment and screening to ensure appropriate match, including Stage of Change.

READINESS FOR GROUPS ― Assess ― Ability to participate. ― Needs and desires re treatment/healing. ― Experience/knowledge of groups and processes. ― Types been in before, their experience and their roles.

― Ability to engage with others ― Personality makeup and issues so as not to disadvantage either. Ø Impulse control ability. Ø Motivation to abstain. Ø Stability-is group at stage of managing a less stable member?

Ø Stage of Recovery. Ø Expectation of success- place in group where most likely to succeed. Ø Cultural/Ethnic considerations-any clash between group and cultural norms likely.

Adaptations for Specific Populations. CEP-Drake et al 2008 found 8 studies were consistent re effectiveness regardless of type as were long term residential. Justice pop-CBT targetting offending behaviour, criminal thinking, offender culture, and treatment targetting severity of problems with intensity of treatment.

Minority Groups and Subcultures. Youth-group as effective as indiv for AOD, CEP, esp associated with offending (Kaminer et al 1999, Dennis et al 2004, Morral et al 2006) Group treatment assoc with better engagement and retention esp when combined with external motivators (Pagey et al 2010) Christie 2009 - inc substance use as a result of group setting overstated esp when directly addressed. Some Ethnic minorities prefer group settings.

Gender Women do better in women only groups (Stevens 1989), more likely to complete (Grella 1999), use more services and more likely to feel they are doing well (Nelson-Zlupko 1996) Ethnic minority women-often issues are related to immigration, loss of support and resources and are gender specific.

Women less likely to disclose and discuss victimisation in mixed gender groups. Cowan et al 2003 -”Placing women in women only groups in male orientated environment inadequate”

Sexual Orientation Mac. Ewan 1994 -neg perception of group therapy due to homophobia, threats of violence, seen in terms of sexual orientation rather than people. Lesbian women less successful in mixed gender groups. Perez et al 2000 -group therapy more effective when most of group are from sexual minorites. Pega, Mac. Ewen 2009 - group therapy useful during and after “coming out process” esp to address family relationships.

Mac. Ewan 1994 -neg perception of group therapy due to homophobia, threats of violence, seen in terms of sexual orientation rather than people. Lesbian women less successful in mixed gender groups. Perez et al 2000 -group therapy more effective when most of group are from sexual minorites. Pega, Mac. Ewen 2009 - group therapy useful during and after “coming out process” esp to address family relationships.

Dickey, Loewy 2010 -Transgender most isolated and stigmatised so group work esp helpful in dealing with difference and isolation. Holahan and Gibson, 1994 -groups chosen to accommodate sexual minorites may be treatment of choice.

Ethnicity Ethno-Cultural differences impact on the experience of those in group treatment due to different histories, levels of acculturation, attitudes and how people function in relationships (tip 41 2005). Hall (1997), Sue 1998 -cultural competence of therapist more important than matching tangata whaiora/therapist ethnicity.

Smith, Rodriguez (2011)-programmes targetting specific cultural groups more effective than multicultural groups. Most effective were those with cultural adaptations. More important is ability of therapist to provide flexible, tolerant environment where cultural needs can be identified and accomodated.

Group Therapy in New Zealand Little research but use widespread. MAORI Durie and Hermansson 1990 - “relationships at heart of Maori Health” so expert opinion believes group approaches very useful.

Maori contd. To be successful significant adaptations necessary. eg CBT adapted to Maori World view, cultural linkage (Sellman et al 1997), Huriwai et al 2001 refer to whanaungatanga as vital part of healing; Huriwai 2002 includes customary values, beliefs and practices; Cargo 2007 -use of metaphor eg waka; Cherrington 2002 -use of purakau and narrative stories.

Pasifika Little research as many studies do not collect ethnic, cultural, spiritual data (Miranda et al 2005) Te Pou o te Whakaaro Nui 2010 - great emphasis by Pasifika on a holistic and collective approach to life so group likely to be appropriate. However must consider nature of inter-relationships esp those involving age and gender.

Negotiated space-(Mila-Schaaf and Hudson 2009)-room needs to be provided for exploring the relationship between different cultural understandings of health and illness. Refer : Seitapu (Polotu Endemann et al 2007) Talking Therapies for Pasifika Peoples (Te Pou o te Whakaaro Nui 2010) “I AM”-A guide for nurturing hope, resilience and happiness Pasifika style” Siataga 2010. Le Va Website- many resources ijn different languages and formats.

What will you offer? Ø What is the kaupapa, values, traditions of what you are offering? Ø What rituals are part of your group or you are willing to develop? Ø Have you attended to spiritual components, acknowledgements? Ø What are your bottom lines - are they clear on information provided and throughout process? Ø Have you addressed purpose, values, power issues, leadership issues and style before group commences?

Ø Are you adequately trained/supported for task? Ø What supervision/mentoring arrangements do you have in place? Ø Is your material current, relevant, culturally appropriate and do you know it thoroughly? Ø Are you prepared for transference/counter transference issues when they arise? Ø Are you committed to the process and seeing it through?

Ø Do you have a conflict management plan in place for leadership, or participant issues or a combination of both? Ø Are resources available - kai, drinks, first aid, Interpreters, written material, paper, pens etc. Ø Confidentiality, privacy issues clarified e. g. who you need to report to or not.

Personal development of Group Leaders Experiential learning involves affective as well as cognitive levels Focus on interaction between self and material vs focus on material self-help and team building involve personal change as it’s own end It’s the way we learn in therapy: combination of affect and cognition - it’s what we are training people to do with others emphasis on the integration of knowledge, application of skills, and use of self awareness

Ideal Training Teaching components ideally have Didactic learning: structured coursework based on theory, research Experiential: group process experiences off campus, confidentiality maintained Supervision: ongoing individual and group supervision of group work Electives: in the clinical community

Some caution is needed. “Do not mistake the appearance of efficiency for true effectiveness. ” ― Irvin D. Yalom, Theory and Practice of Group Psychotherapy “While in principle groups for survivors are a good idea, in practice it soon becomes apparent that to organize a successful group is no simple matter. Groups that start out with hope and promise can dissolve acrimoniously, causing pain and disappointment to all involved. The destructive potential of groups is equal to their therapeutic promise. The role of the group leader carries with it a risk of the irresponsible exercise of authority. ” Judith Lewis Herman

References Ø http: //www. samhsa. gov/centers/csat 2002 Ø TIP 44 “Substance Abuse Treatment for Adults in CJ System. Ø TIP 41 “S. A. T. and Group Therapy” Ø TIP 39 “S. A. T. and Family Therapy”. Ø Linda Sobell www. nova. edu/-gsc Ø “The Zen of Groups” Hunter, Bailey, Taylor. Fisher Books 1995. Ø “The Art of Facilitation” Hunter 2007, Random House.

References Ø “Chemical Dependency & Anti-Social Personality Disorder”Psychotherapy & Assessment Strategies. Forrest, 1994, Haworth Press Ø “Group Therapy and Addictions”Claire Aitken, Dissertation as part of Masters of Health Sciences, University of Otago, Dec 2011. Ø “Te Ari O Te Oranga”Dr Fraser Todd 2010 Ø ‘The Theory and Practice of Group Psychotherapy”Yalom, Irvin. D 2005 Ø Trauma and Recovery: The Aftermath of Violence - From Domestic Abuse to Political Terror Judith Lewis Herman

EVALUATION Ø My learning from this session is…. Ø I can use this to…… Ø I will talk about this with…. . Ø I will increase my ability in this area by…. . Claire Aitken October 2020.