Five `outside the box` strategies for your group

One of the most fundamental tasks of effective group leaders entails extending the group process toward therapeutic ends. A clear set of group agreements is needed, with life skill and recovery tool lessons carried out in a manner that strikes a tone of positive psychology. Additionally, clear-cut objectives drawn up on the whiteboard are essential to the group process, as this lays out a roadmap for both the facilitator and the group participants to chart a therapeutic course. Members need to be left with a strong sense that the facilitator is thoroughly prepared and means business, to ensure that by session’s end they come to think of the experience as worth their time.

What follows are five “outside the box” techniques, process strategies and interventions hewed from direct experience as a group facilitator, some of which have been sown into the group format.

Forgiveness circle

This one comes from a colleague, Michael J. Taleff, PhD, MAC, CSAC, who has 40-plus years of experience as an addictions clinician. In one of our monthly “coffee talk” meetings in which we discuss all things under the sun of addiction treatment and prevention, he shared his most memorable “outside the box” intervention. Mike offered the following explanation:

“Decades ago, while working in a classic 28-day treatment program, I managed to create an emotionally powerful group experience. As I recall, it often elicited significant member change, but I would only conduct it if the conditions of the group were right. As part of the standard treatment practice of the time, we asked participants to share some portion of their active addiction history, and do it within the confines of a group. It was a scary, but courageous, thing to do. Often as a member finished the wrenching task, they could not look the other group members in the eye. They voiced overwhelming guilt and shame, and kept their eyes closed or glued to the floor, often sobbing. It dawned on me that these participants could not leave the group with such exposed emotional wounds. To disclose all that pus and simply walk out of the group was wrong.

I would bend over and softly ask the member if they would be willing to do one small task. All said yes. At that point, I would ask the participant to stand in the middle of the group. Then I asked the group members to form a circle around him/her. Gently, I asked the participant to simply look at all the eyes of the group. Then I asked if the participant saw any judgment, any scorn. No one ever did, for there was none to be seen.

About this time, the emotional heat of the group was palpable, but the exercise was only half done. I then asked the group to take one half-step closer to the participant. Again, I asked the member to look at the eyes for any signs of negative judgment. Again, none was observed, but what became evident at this point was compassion and love from the circled group members. The heat was physical at this juncture.

One last time I asked the group members to step closer. Shoulder to shoulder, everyone sobbing or crying, I looked the member dead in the eye and said, “We made our move, what are you going to do?” Without fail the member reached out and grabbed the closest group member, while all the others crushed gently around that participant, all crying and sobbing.

It was always a moment beyond words, where the participant saw that they were not judged as a person, but more importantly learned they could reach out for help and succor even in the depths of their pain. And, if they could achieve this once, they could do it again and again.

I often observed following this little exercise that the bond between these people was extraordinarily strong. All seemed to know deep inside that forgiveness was possible and, despite the years of addiction, one could reach out and still touch, really touch another human.”

Musically cued

In understanding the spectrum of different personality types that make up a group, facilitators can build into the structure of some of their groups a check-in procedure with personal reflection time and space for introspection. For some members, merely attending group on time and being prepared is a challenging transition coming into group. Other members start the session preoccupied with feelings and thoughts that detract from being mindfully present, while others feel anxious or diverted by other emotional states. To ease members into the group process is to encourage them to settle in to a slower tempo and to gain composure, which essentially means devising time for self-reflection.

Some participants, especially those with an introverted disposition, may need an inwardly focused warm-up activity that affords personal headspace to compose thoughts and feelings before jumping into group. One way to do this is by harnessing the power of music in tandem with a “group process self-reflection check-in sheet” (a combination of open-ended and fill-in-the-blank questions, such as a three-to-five item gratitude list and “I am ________ , the world is___________, others are _______________”). The group is instructed that the check-in will be timed by one or two songs lasting several minutes and when the music stops, members still working on their sheet can set it aside and revisit it during break time.

Introducing neutral music (e.g., classical) void of lyrics (e.g., instrumental, or nature sounds) works in the sense that it is not associated with group members’ drug use and at the same time can usher in a calming ambience to help ease members' segue into the group process. Members who finish the check-in ahead of other participants can self-direct themselves to artistic expression (drawing) and practicing Dialectical Behavior Therapy (DBT) skills such as square breathing or mindfulness meditation.

Imitation game

Every so often, cyclical periods (once every two or three months was the pattern I observed) recycle almost the entire group to an off-kilter orientation to the group process —overly bantered and sophomoric, or just distracted from the process. When the facilitator feels like he/she is at a game of tug-of-war with getting the group on track, a counterintuitive approach to rein in the group without a power struggle takes an attitude of, “If you can't beat 'em, join 'em.”

The group facilitator calls out the group to a challenge to see whether it can copy what the facilitator says and does. This might include tapping a rhythmic beat on the table and calling on the group for a response that reproduces the same sound, or verbally tracking the facilitator’s phrasing of nonsensical one-liners, quirky hand movements, and screwball facial expressions, all of which give permission to group members and the facilitator to cut loose together.

Because some group members may see the facilitator as one-dimensional (i.e., Mr. Too Serious, Ms. Perfect), this few-minute activity challenges such a view. The intentionality of the activity implores participants to pay attention to their behavior. I have found that mimicry draws members back into the fold at the direction of the facilitator, as members follow the cues of other members into a social contract of sorts that helps get the group running as usual. They come to understand that the time for fun and games is over, and any member continuing to act out is quick to find that most group members see this as inappropriate. The group facilitator shows how participation can be fun and engaging when done properly.

The blurt chair

When confronting an impulsively rambunctious participant and seeking not to kick him/her out of the group but to modify disruptive and generally attention-seeking behavior, the facilitator might first say, “As the facilitator I noticed how anxious you are to say something and how difficult it can be to wait and let it out at the appropriate time when it’s your turn. I’ll tell you what: If the group agrees, we’ll go ahead and let you blurt out whatever burning desire you’d like to get off your chest, as long as it’s relevant and appropriate to the topic.” Once an agreement is reached, the group enters into a social contract with the participant.

Rather than dread and resist the participant’s behavior, openly embrace it by entering into a contract with the member and permitting him/her to blurt out, without fear of consequences, as long as he/she is seated in a certain chair in the group room. This chair is branded with the vibrantly colored label “The Blurt Chair” and is placed a few feet from the participant. As the session proceeds, the distance is gradually increased. In some cases, the chair winds up clear across the room. What usually happens is, as the participant finds him/herself needlessly walking back and forth to say something, he/she decreases the impulsive blurting-out behavior, eventually stopping it altogether.

Another option to decrease this disruptive behavior involves handing the group member a piece of paper with the words “Blurt List” across the top and offering the following instructions: “When you feel the itch to blurt something out, go ahead and try to put it down on paper first, and then go ahead with saying it out loud.” The Blurt Chair is a bit more dramatic, and for that reason tends to be more compelling to the participant.

As the chair is moved farther and farther away from the participant, the distance is a visual representation of the member’s impulsiveness. The added distance it takes to get to the chair is an exercise in what is called an intentional shifting task. Gradually, the member’s attention shifts to the chair and how far away it is, rather than the act of blurting something out. Over time, this can short-circuit the urge to blurt.

The reinforcement from the group in showing interest, support and praise for when the participant finally manages to bring the impulse to blurt under enough control to walk over to the chair, sit down, and raise his/her hand before saying something is an incredibly powerful experience. This reinforcement helps to socialize the member to a more successful model of group interaction. And for all involved, this demonstration shows how behavior change can come about by thinking outside the box in a non-punitive, inclusive manner.

The magic ratio

Many group members are accustomed to hearing negative and unsupportive things about themselves. Unfortunately, some addiction treatment programs have a reputation for embracing punishment and paternalistic “program speak.” With heavy leanings toward a deficits-based approach (e.g., “I am disappointed in you”), program staff serve to undermine participants by replicating members' past painful experiences with disappointed family members, authority figures, etc.

When program staff lack the necessary training and fall into being more responsive to negative behavior in the group, members are reminded of what they can’t do right. Instead of invalidating participants, program staff can develop the old “gotcha” syndrome for catching members engaged in pro-social behavior, and highlight such behavior. This isn’t to say that behavior considered the opposite of whatever is deemed good ought to go unaddressed. Rather, a more balanced perspective can be a more effective means of deepening the therapeutic intent and impact of group work.

Facilitators can keep in mind the “magic ratio” to counteract the human tendency to focus too greatly on bad behavior. Gottman’s 5-to-1 ratio of positive to negative interactions, deemed “the magic relationship ratio” for its ability to predict healthy relationships, is instructive. The gist of Gottman’s magic ratio is that healthy, supportive and successful married couples are characterized by five times as many positive interactions (praise, compliment, recognition of something good done by one's partner) as negative ones (criticism, annoyance, hostility, hurt feelings, complaints). The take-home point involves reinforcing what one desires more of, so that it is more likely to happen again.

Facilitators are positioned to deepen the therapeutic process by recognizing healthy risks, accomplishments and myriad contributions made by each member of the group. The facilitator could decide to spend a solid minute after the standard check-in procedure is complete, or to hold off until the end of the session, and offer each member genuine and authentic praiseworthy feedback that keys in on what he/she does well and what makes him/her a good person. The facilitator is in an ideal position to model how to give compliments, normalizing this for group members who in many cases aren’t used to hearing much of anything positive about who they are. Members eventually teach one another how to offer and accept genuine and sincere compliments, and this generalizes to how they interact in their relationships outside of group.

Applicable to various stages

From a developmental standpoint, the therapeutic evolution of a group can be thought of in distinct stages. Note that there are a handful of developmental stage models to choose from,1 and the stages outlined here do not take into account closed and open group settings. As a brief summary, in the inchoate phase (“pre-affiliation”), the meaning of group membership is discussed with members, who adjust to the group structure, agreements, and the facilitator’s leadership style. Generally in this beginning stage, participants put their best foot forward as they situate themselves to the group. Members start to show their true colors in the “development” stage and relate to one another on a more authentic level. As they grow accustomed to the group and the facilitator, members tend to jockey to claim the highest spot on the totem pole. Despite power struggles, trust and cohesion start to percolate as more members show personal investment in wanting to do serious group work. In the “working” stage, members pretty much have their own individual/group identity carved out and know where they are cast in terms of trust, cohesiveness, interdependence and group interaction. Finally, the “separation” stage marks the formal ending of each member’s relationship with the treatment setting or group. A sense of personal friendship and bond with the group facilitator evokes a sense of impending loss as group membership expires. Relapse, attrition, and administrative discharge for non-compliance are aspects of separation to which members are especially vulnerable.

Irrespective of the stage of the group process, the interventions discussed above can be employed by facilitators to make the group process more productive. There are some caveats to consider, however. For example, one of the trickier parts of the magic ratio involves whether to make this a predictable constant of the group process or more of a variable feature. If the reinforcement schedule is too inconsistent, group members may be inclined to read into it the wrong way. For instance, a member might feel uncomfortable hearing something good about him/herself in an open forum and may believe the facilitator has ulterior motives for offering positive feedback. I know of one group facilitator who was openly called out by several group members for acting “funny,” “abnormal” and “weird” after saying positive things to spotlight group member behavior, simply because she did it only when she was in a good mood.

Generally, with the exception of the “magic ratio” and “musically cued” approaches, only when group conditions are right should the thought of employing the other interventions occur. To simply try out some of the interventions with a group of participants who are not in the right mode to experience them would be a treatment blunder. The outside-the-box intervention process can be powerful and effective, but if used badly will result in harm. This is a warning to be heeded.

Izaak L. Williams, a Hawaii state-certified substance abuse counselor, was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment's (CSAT's) Behavioral Health Leadership Development Program. His e-mail address is izaakw@hawaii.edu.

References

1. Loughran H. Group work in the context of alcohol treatment. J Teach Addict 2009;8:125-41.