Planned Group Counseling : An Alternative Group Method for Reluctant Chemically Dependent and Psychiatric Patients [1 ed.] 9780826122568, 9780826122551

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Planned Group Counseling An Alternative Group Method for Reluctant Chemically Dependent and Psychiatric Patients

Anthony N. Biancoviso, PhD, is certified psychologist in New York State. He spent 25 years at the Manhattan Veterans Affairs Medical Center, including 17 years as a Clinical Psychologist in the Mental Hygiene Clinic, and seven years as a Counseling Psychologist in their Substance Abuse Rehabilitation Program. He is currently Adjunct Associate Professor in the Graduate School of Education at Fordham University in New York. Dr. Biancoviso is the creator of the new group method Planned Group Counseling and is lead author of the most recent article, Planned Group Counseling: A Single-Session Intervention for Reluctant, Chemically Dependent Individuals, published in the December 2001 edition of The Journal for Specialists in Group Work. Wandajune Bishop-Towle, PhD, is a licensed psychologist in New Hampshire. She has been a practitioner of Planned Group Counseling for over ten years, using this method primarily with chronic psychiatric patients in both inpatient and outpatient settings. Her publications include original research on the use of questions as psychotherapeutic interventions. Dr. Bishop-Towle is currently a staff psychologist at New Hampshire Hospital in Concord, New Hampshire, and serves on the adjunct clinical faculty of Antioch New England Graduate School. Jairo N. Fuertes, PhD, is currently Associate Professor in the Graduate School of Education at Fordham University. He is a licensed psychologist in New York State, and is board certified in Counseling Psychology from the American Board of Professional Psychology. He is also listed in the National Register of Health Service Providers in Psychology. Dr. Fuertes has published 24 articles and chapters on various topics of counseling psychology, including process and outcome in counseling, counselor multicultural competency, and group counseling. Dr. Fuertes maintains a private practice focusing on group and individual therapy.

Planned Group Counseling An Alternative Group Method for Reluctant Chemically Dependent and Psychiatric Patients

Anthony N. Biancoviso, PhD Wandajune Bishop-Towle, PhD Jairo N. Fuertes, PhD, ABPP

SPRINGER PUBLISHING COMPANY

Copyright © 2004 by Springer Publishing Company, Inc. All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, Inc. Springer Publishing Company, Inc. 536 Broadway New York, NY 10012-3955 Acquisitions Editor: Sheri W. Sussman Production Editor: Sally Ahearn Cover design by Joanne Honigman 04 05 06 07 08 / 5 4 3 2 1

Biancoviso, Anthony N. Planned group counseling : an alternative group method for reluctant chemically dependent and psychiatric patients / Anthony N. Biancoviso, Wandajune Bishop-Towle, Jairo N. Fuertes. p. cm. Includes bibliographical references and index. ISBN 0-8261-2255-8 1. Mental health counseling—Methodology. 2. Drug abuse counseling—Methodology. 3. Group counseling—Methodology. 4. Mentally ill—Rehabilitation. 5. Drug addicts—Rehabilitation. 6. Patient compliance. I. Bishop-Towle, Wandajune. II. Fuertes, Jairo. III. Title. RC466.B53 2004 158'.35—dc22 2004002979 Printed in the United States of America by Sheridan Books.

Contents

Chapter 1

History and Overview

1

Chapter 2

Theoretical Framework

15

Chapter 3

The PGC Leadership Approach

33

Chapter 4

PGC Group Process

50

Chapter 5

Preparing for a PGC Session

65

Chapter 6

Detailed Description and Replicable Example of PGC

74

Chapter 7

Responding to Noncompliant Behavior, Suicidal and Homicidal Thoughts and Threats, and Requests for the Leader’s Self-Disclosure

145

Chapter 8

PGC Plans

174

Chapter 9

Using PGC in Psychiatric Settings

219

Chapter 10

Using PGC in Educational Settings

236

Epilogue

241

References

245

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Acknowledgments

Dr. Anthony N. Biancoviso I wish to thank my parents Anna and Nick with all my heart for all the love they have given me in the past and in the now, and for showing me how to be accepting, kind, respectful, and thoughtful of all people, both physically and psychologically. I attribute all of my basic constructive relationship skills to my observing how my parents relate to all people who have the good fortune to know them. I also wish to thank my brother Natty who served our country as a combat army soldier in Vietnam, which helped make it possible for me and most of the professionals of my generation to learn and study in the safety of the academic world while he and his comrades struggled to survive. Sixty years ago, New York City was racially and ethnically segregated while New York City Public Housing was not! I had the unique experience to live and grow up in an integrated community in the Queensbridge public housing project, where I learned that our human differences are minor compared with our shared basic humanity. I am forever grateful to all the dedicated faculty of the Baruch College of the City of New York, the City University of New York, Graduate School of Education, and the University of Kansas Counseling Psychology Department who provided me with both an outstanding education and superior role models. I am thankful for the Veterans Affairs psychology training and internship program which provided me with sufficient stipends to obtain and enjoy my graduate education, and where I met and was supervised by Dr. George V. Mascia, who became my colleague and dear lifelong supportive friend, and who served as the Chief of Psychology Service for many years at the Brooklyn Veterans Affairs Medical Center. vii

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Acknowledgments

I wish to thank all of those Manhattan VAMC patients whose honesty and trust made it possible for me to develop the Planned Group Counseling method. As well, all of the supportive professional staff deserve recognition for providing me with a unique professional opportunity, enabling me to refine the method. Paul Casadonte, M.D., director of the Substance Abuser Rehabilitation Program deserves special recognition for doing all he could to support my efforts. Thanks also to the many psychology interns whom I have had the pleasure of teaching. The two former interns—now colleagues— who deserve the most recognition and gratitude are Drs. Wandajune BishopTowle and Jairo N. Fuertes; I am very pleased to have them as contributing authors and extremely appreciative of their unique contributions: Dr. Fuertes, who has always so generously encouraged me, given his time, and helped me transition from the clinical to the academic world, and Dr. Bishop-Towle, who not only quickly learned the method, but who effectively adapted it to meet the specific needs of day-treatment and inpatient psychiatric patients. I am very grateful for her support and friendship, and I deeply respect her sensitivity, humanity, and professional ideals. Special thanks also to Dr. James J. Hennessy, Professor of Education, Graduate School of Education, Fordham University, for his generosity, encouragement, and very helpful comments and suggestions. This book would not exist if it weren’t for the total commitment and all the contributions provided by my loving wife Sally—and this book is dedicated to her. Sally’s generous spirit, her tenaciousness, and her appreciation and absolute belief in the value of this book sustained my motivation and made it possible for me to complete the manuscript. I am greatly indebted to her for all the creative comments, criticisms, and skillful editorial work she so generously provided, at all times. Dr. Wandajune Bishop-Towle I would first like to express my gratitude to Anthony Biancoviso—for the opportunity to contribute to this book, for teaching me the group method described in it, and for showing and reminding me how to maintain my curiosity and compassion. It is difficult for me to imagine what kind of therapist I would have become without his guidance and friendship. I am similarly indebted to my academic mentor and friend Jefferson Fish, and to all the psychology faculty of St. John’s University, for a first-class education in this diverse and challenging field. To my parents Herman and Eunice Bishop, my deepest thanks. They and their respective clans have always sustained me with their love and faith.

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And to my husband Jonathan, whose delight in my accomplishments is one of many expressions of a love most worth waiting for. There are numerous individuals—including my former colleagues and supervisors at Maimonides Medical Center, the many creative supervisees I have been privileged to teach, and my teammates on the treatment team at New Hampshire Hospital—who have supported my efforts to provide Planned Group Counseling to people with severe and persistent mental illness. I would like to particularly thank my cotherapist Barbara Maccrae, OT-R, whose gentle compassion and personal integrity have made a deep impression on me, and on our patients. Finally, immeasurable thanks to my former patients in the Continuing Day Treatment Services program at Maimonides Medical Center in Brooklyn, New York, a truly extraordinary therapeutic community. Your humanity, your struggles, and your humor continue to inspire me. Dr. Jairo N. Fuertes I would like to acknowledge the generosity of my teachers and patients, who continue to teach me about perseverance, the human condition, and counseling.

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Chapter

One History And Overview

Imagine that you have been asked to lead a one-hour, open-ended group for 15–20 patients in any of the following clinical settings: inpatient chemically dependent detoxification, 28-day inpatient rehabilitation, a 1- to 2-year outpatient program, or a day-treatment psychiatric program. The patients are both voluntary and involuntary (court ordered). Although these patients have been screened for the programs, they are strangers to you. Some patients know each other, some are new to the group, and others may be returning after weeks of absence. Some will arrive late, and a few will leave early. The patients’ characteristics are as follows: • Mostly male, age 18–70 • Approximately equally divided between African-American, Hispanic, and Caucasian • Wide range of psychopathology (many chronic) • Chemical dependency problems (many chronic) • Physical ailments (war injuries, diabetes, heart disease, HIV positive/ AIDS, etc.) • Diverse past treatment histories for psychiatric and chemical dependency problems • Varying levels of participation in, and compliance and commitment to, treatment • Very defensive, usually relying upon denial, projection, and somatization • A range of intellectual abilities, and educational and occupational achievements 1

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• • • •

Differences in socioeconomic class, culture, and ethnic backgrounds Many are very distrustful and some are very angry Many are alienated from family and friends Varying levels of social skills

What you were just asked to imagine, was what I was asked to do in the mid-1970s at the Manhattan Veterans Affairs Medical Center (VAMC): provide supplementary group treatment from the counseling perspective to complement the other group treatments offered in these interdisciplinary programs in the clinical settings described above. I asked and received permission to observe the leadership styles, group process, structure, and tasks of the other existing professional group treatments in the programs. What I observed was that compliant patients attended regularly, actively participated, and followed the group norms. However, patients who were often late, attended irregularly, were disruptive, and did not follow group norms were labeled partially to noncompliant, and were eventually discharged from the treatment program. What I also observed, and which intrigued me, was that some of those patients who were either discharged or who terminated treatment prematurely continued to attend self-help groups, while complaining that they did not offer much psychological help. The question I asked myself was this: Why did some of these noncompliant and premature terminators continue to accept self-help group experiences after rejecting professional group treatments? In seeking an answer, I consulted with the more experienced staff of addiction counselors, social workers, psychiatric nurses, psychiatrists, and psychologists. I was told not to expect to retain all patients in treatment because not all patients requesting professional help were ready to accept treatment. They said that self-help groups were the treatment of choice for these patients, because they were better able to tolerate and accept this kind of group experience, and those who also stopped attending self-help groups were not ready to change. The “answer” was: Noncompliant and prematurely terminating patients were not ready to accept existing professional group treatments. This answer disturbed me. I took comfort in knowing that some could potentially benefit from the self-help movement’s group experiences. But for them to reject and deny themselves the benefits of professional treatment was unacceptable. Attending a self-help group was a demonstration of a person’s ability to expose themselves to the positive influence of others and, for some, we could interpret this behavior as representing some desire and capacity to change. Rather than questioning the person’s readiness to

History and Overview

3

“change,” a better question to ask was what kind of group treatment could they accept now. If they were not accepting existing professional group treatments, then a new group treatment method was needed. I concluded that existing group methods did not match the noncompliant and prematurely terminating patients’ needs. I began to analyze what professionals required of group members: • • • •

Arrive on time Stay for the entire session Attend regularly Comply with essential therapeutic directives determined by the leader, based upon a specific theory of group treatment • Make some measure of commitment to psychological change or development My analysis of professional group treatments, specifically didactic, themeoriented, cognitive and/or behavioral, and modified psychodynamic/interpersonal/person-centered, was that they all relied on and required punctuality and continuous attendance, while expecting that most patients were committed and ready to change and would comply with the leader’s therapeutic directives. Where they differed most was in their dependence upon group members verbalizing thoughts and feelings freely to each other to create the group process, and in how much honest self-disclosure (and the techniques used for eliciting it) was necessary to comply with each model’s therapeutic tasks. The group’s cohesion was disturbed by a reluctant patient’s lateness, irregular attendance, and early departures. Psychodynamic/interpersonal/person-centered group treatment methods, even when purposely highly modified to treat reluctant patients, encouraged group members to verbalize freely to each other and the group leader. This assumed the patient was ready and able to honestly express their thoughts and feelings, cope with some unwanted emotions, and tolerate conflicts that arose in groups due to differences and miscommunications. This could be a very potent interpersonal learning experience for patients who met the method’s assumptions. Unfortunately, many patients were not capable of meeting these assumptions, even though they would like to believe, and have others believe, that they could. Huey (1991) noted that relapse prevention programs are based upon learning theories that are designed for mildly to moderately impaired patients, while in some treatment programs the majority of patients are severely impaired.

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What did noncompliant patients do? • • • • •

Arrive late Leave sessions early Attend irregularly Often not comply with essential therapeutic directives Avoid any measure of commitment to psychological change or development

Noncompliant patients are frequently ambivalent about changing, not ready and/or unable to commit themselves to regular attendance patterns, and unable to cope with the confrontations, conflicts, and intimacy demands inherent in many psychological group treatments. They are afraid, distrustful, and even hostile towards existing professional group treatments and frequently terminate their treatments prematurely. Skinner and Drake (1997) noted that chemically dependent patients’ past experiences with dealers, drug-using peers, and the legal system have taught them to be secretive, and that they have been living in a social environment where dishonesty and manipulation have been the norm. Noncompliance with professional group treatment requirements leads ultimately to the patients’ rejection of or discharge from the treatment programs. Everybody loses: the patients do not get the help they need, and the professionals’ efforts to be helpful fail. According to Yalom (1995) “the very patients who most badly need what group (therapy) has to offer are most likely to fail.” It has also been noted by others in the group counseling literature (Sciarra, 1999; Vasquez & Han, 1995) that some culturally diverse groups are not as “pressed” to keep their appointments as scheduled, and some display their resistance and ambivalence to psychological work by intentionally not arriving on time. What did self-help group experiences ask patients to do? • • • •

To attend To stay as long as they wish Attend as often as possible and/or as needed Comply with the leader’s directives

Self-help experiences permitted the patient to have more control and responsibility over when and how much help they were willing to expose themselves to on a given day, and did not require or ask patients to make a commitment to psychological change or development. A pattern of erratic

History and Overview

5

attendance, lateness, leaving early, and minimal participation did not lead to rejection from self-help groups. The members were not labeled noncompliant. The person was always welcomed back. A very troubled person who needs psychological help but who is fearful and very conflicted about receiving such help may find it easier to attend a self-help group because membership requirements are more accepting and accommodating. In self-help groups, group experiences are offered every day, including weekends and holidays, and lifetime membership and attendance is encouraged. These groups promote eternal hopefulness, and provide perpetual care, both enthusiastically and generously. Relapses are expected, tolerated, and accepted. Their voluntary efforts have helped many chemically dependent people live their lives without depending upon chemicals, thus preventing further physical, social, and psychological destruction. The term “self-help” is a misnomer, however. The fact of the matter is that when chemically dependent people attend self-help groups, they are reaching out to others, hoping to benefit from caring others who are themselves in the process of becoming free of chemicals, or who may no longer be relying upon chemicals to live their lives. These individuals are not increasing their self-reliance when they enter self-help groups; they are actually choosing to increase their dependency upon strangers who suffer from similar problems, which is a very constructive and adaptive response to their chemical dependency problems.

IMPORTANCE OF PROFESSIONAL GROUP TREATMENT There are many chemically dependent people needing psychological help. In the United States, 18 million people are chemically dependent upon alcohol, 5.5 million are chemically dependent upon other drugs, and between 15% and 30% of hospitalized clients have a chemical dependency problem (Geller, 1996). These numbers are staggering. Yet, Harris (1995), after citing a few full-length works (Collins, 1969; Harris & Watkins, 1987; Meloy, Haroun, & Schiller, 1990; Rooney, 1992), and some examples of well-focused articles on counseling reluctant patients (Arcaya, 1978; Berman & Segal, 1982; Dyer & Vriend, 1973; Larke, 1985) concluded that during the last 20 years, little comprehensive attention has been paid to the problem of working with involuntary and resistant clients. Thombs (1999) maintained that researchers have ignored studying patients who demonstrate little or no commitment to recovery, and that some relapse prevention strategies assume that all patients are equally motivated to change.

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Ideally, all chemically dependent individuals should have the opportunity to benefit from the combined advantages that both self-help group experiences and professional group treatments offer. To increase the probability of freeing themselves of their harmful chemical dependency problems, chronically dependent individuals need all the professional treatment that they can get. Seriously troubled people who have been identified as needing help should not stop receiving professional group treatment because they are unwilling or not capable of meeting all existing professional expectations and assumptions. Professional care is frequently necessary to help prevent relapse, psychological regression, incarceration, and reliance upon hospital emergency room services. Spitz and Spitz (1999) and Monti, Abrams, Kadden, and Cooney (1989) accurately point out that making a commitment to professional group treatment is an essential goal for chemically dependent clients, and that drugfree methods of coping with life issues and the development of problemsolving skills is an essential component of all chemical dependency treatment groups. Especially for potentially high-risk suicidal and homicidal patients, it is always better to have late and irregular attendance than no attendance. Ideally, high-risk patients should have easy access to ongoing professional group treatment that could provide an indirect, global assessment opportunity regarding their need for immediate care, as well as other psychological, psychiatric, and medical treatment. If patients reject professional group treatment and accept self-help groups, then existing professional group methods can be conceptualized as inadequate and “too exclusive.” Conclusion: Existing group methods did not match the needs of very reluctant patients. Very ambivalent, conflicted, and uncommitted patients needed an alternative group treatment. How could professionals engage and better retain such people in treatment, without abandoning important traditional psychotherapeutic goals? The solution was to create a group method that better matched reluctant clients’ needs. Miller, Zweben, DiClemente, and Rychtarik (1992) noted that chemically dependent patients who are very ambivalent about change need counseling methods that enhance their readiness to change. Prochaska (1997) believed health professionals “need to match the needs of people in each stage of change rather than expect their clients to match their favorite treatment modality.”

PLANNED GROUP COUNSELING: AN ALTERNATIVE GROUP METHOD The PGC method is based upon my clinical experience in the day psychiatric hospital and chemical dependency programs at the Manhattan VAMC for

History and Overview

7

more than 20 years, where this specialized group method was used in several thousand group sessions, and has been taught to interns in its psychology internship training program. The patients in these programs were primarily male, World War II, Korean War, and Vietnam War veterans. Many suffered from Axis I and Axis II disorders, post-traumatic stress disorder, physical ailments (diabetes, heart conditions, HIV positive/AIDS), and physical disabilities as a result of combat. Many were also unemployed, homeless, in debt, estranged from their families, had pending criminal charges/past incarcerations, and were either not ready, conflicted, or only partially committed to change—“contemplators” in Prochaska and Norcross’s (1994) taxonomy. They were frequently highly defended, emotionally underdeveloped, fearful and distrustful of others, and had severe time management and intimacy problems characteristic of the socalled drug lifestyle, regardless of their drug of abuse (Walters, 1994). In addition, a number of these patients suffered from poorly developed social skills. Monti, Abrams, Kadden, and Cooney (1989) believe that social skill deficits undermine these patients’ ability to change maladaptive addictive behaviors, and that chemical dependency may serve an adaptive function, namely, helping patients cope with intolerable emotional experiences. My initial intention for the PGC method was to use it as a supplemental treatment to all existing treatment modalities, including individual treatment, and to provide a more accepting and protective group treatment for those patients who seemed unable to tolerate or meet the assumptions of the more potent existing group treatments. The method was “born of necessity” as a response to my frustration and disappointment that existing professional methods were based upon expectations and assumptions that too many reluctant patients could not or would not totally meet. For people to admit to others that they are chemically dependent and that they need to make major psychological and behavioral changes is often very difficult. Asking patients to make a commitment to conform to existing group treatment requirements should be viewed by professionals as a goal rather than a requirement. Treating patients as if they are ready and able to make major behavioral changes when they are not can inadvertently create added failure experiences. Additional failure experiences can potentially lead to patients rejecting or not requesting or relying upon professional help. Although a percentage of the patients in these programs are frequently labeled “not ready” and “noncompliant,” and are ultimately discharged from the program or self-terminate their treatment prematurely, they nonetheless demonstrate some capacity to meet some of the requirements of existing professional group treatments, some of the time. What is needed is a profes-

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sional group treatment that respects and builds upon whatever very reluctant patients bring to the treatment session. Planned Group Counseling (PGC) is a new, more inclusive, and accepting group treatment method, whose objective is to achieve limited but significant social, educational and therapeutic goals (Biancoviso, Fuertes, & BishopTowle, 2001). The method integrates theoretical concepts and techniques derived from a wide variety of theories: humanistic, interpersonal, psychoanalytic, person-centered, gestalt and cognitive/behavioral. PGC is designed to treat very reluctant, chemically dependent and/or psychiatric patients in day treatment psychiatric programs, and in voluntary and involuntary (court ordered) interdisciplinary substance abuse rehabilitation programs as a conjoint, orientation, and maintenance group treatment method. It accommodates patients who present a wide range of intellectual abilities, and educational and occupational achievements, and who come from different socioeconomic classes and cultural backgrounds. Distrustful patients who cannot tolerate conflict, criticism, ambiguity, anxiety, rejection, or anger expressed toward them, and who are very conflicted about self-disclosing, fearful of intimacy, have secrets, need to limit their emotional experiences, are threatened by the intense emotional expression of others, and fear losing their precious individuality are patients who might benefit from PGC.

BASIC PGC STRUCTURE PGC is based upon a planned, single-session, highly structured workshop model. Each session is conceived as a self-contained social, educational, and therapeutic learning experience, and contains a series of psychological exercises. On a large blackboard, or something comparable, the leader writes all of PGC group’s general goals, and then reads them to the group, for example: Dr. Biancoviso, Counseling Psychologist Welcome to Planned Group Counseling, a group method to help you: • become more aware of your perceptions, emotions, thoughts, actions • identify those that are helpful and harmful • change those that are harmful to you and others Also written on the blackboard and read to the group is the selected general goal for the day:

History and Overview

9

Today’s Topic: Anger Towards the Self Part I.

Mini-Lecture (me)

Psychological Exercises 1. Word Association (me) 2. Psychological Question (me) Part III. Final Questions/Comments

questions and comments (YOU)

Part II.

response (YOU), analysis (me) response (YOU), analysis (me) (YOU)

The general goals are always written on the blackboard. However, each session also has a specific goal, which is presented as the topic for the day. For example, if the leader selects “identifying harmful emotions” (general goal) and “learning about anger towards yourself” was the specific goal, the Mini-Lecture would be used to introduce and explain concepts about the self, and emotional reactions to oneself. In the Word Association exercise, group members would be asked to respond to the word “anger”; and for the psychological question, the leader would ask each member “when do you become angry at yourself?” To help the leader achieve both the general and specific goals selected for each session, the PGC leader uses the “going around technique” (GAT), where every member is systematically invited to respond to psychological questions. PGC relies upon this technique because it is democratic and highly inclusive, and every member is guaranteed a turn to speak. GAT ensures that every group member is properly acknowledged in the group and respectfully called on for a response, which is written on the blackboard. This format prevents the “invisibility syndrome,” where shy, reclusive, or minority members fade from the group and are prevented from actively participating, particularly when they are intimidated by other extroverted group members or subgroups. By using GAT, every patient in PGC is empowered and given an equal opportunity to participate, no one is marginalized or discounted, the formation of alliances is discouraged (at least during the treatment hour), and the leader is less likely to favor certain verbal and socially skilled group members. The leader focuses on what patients are able and willing to do in the group on the day they attend. The group leader is always very active, directive, supportive, and protective. Although highly structured within sessions, the PGC model is very flexible in terms of sequencing of sessions, degree of member participation, and attendance. Members have the freedom and responsibility to determine when they come and go. Lateness, leaving sessions early, and irregular attendance, although never preferred, is always accepted.

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GROUP PROCESS To maximize the safety of the PGC learning experience, and to minimize the creation of potentially harmful and destructive confrontations and interpersonal conflicts, the leader limits the group process by requesting members to refrain from verbalizing thoughts and feelings to each other, while regularly inviting members to freely and briefly verbalize their honest thoughts and feelings to the leader in response to the leader’s questions and comments. Members’ compliance or noncompliance with these directives provides the leader with a limited degree of valuable, therapeutic “grist for the mill” (Yalom, 1995), providing the here-and-now behavior to be analyzed and changed. The potency of the PGC method depends upon the leader’s ability to engage all members in the group’s tasks, challenging them to give something without asking them to give what they are not capable of giving. The PGC leader is responsible for creating a stimulating and protective group structure for each session, and members are held responsible for whether or not they reveal their thoughts and/or feelings to the group. Members’ benefit most when they all verbally contribute. The PGC leader treats all members’ verbal responses as a “gift” to the group. The leader also shows equanimity by writing all the responses to the Word Association and Psychological Question verbatim (or as close as possible) on the blackboard, ensuring that roughly everyone has about the same length of time to speak. The leader is always accepting and affirming of group members’ equal participation and the content of their responses.

PGC’S RELEVANCE WITH MULTICULTURAL ISSUES Since PGC is a more inclusive, accepting, protective, and accommodating group treatment method, its features are naturally supportive of patients who come from diverse cultural backgrounds. Many of these patients may lack proper language skills (speaking or reading), and equally important, their overall cultural values may come in direct conflict with certain aspects of psychological group treatment, such as self-disclosing personal thoughts and feelings to strangers, or trusting others. For example, certain cultural groups such as Hispanics and Asians are very concerned about breaking family loyalty, or displaying moral weakness by seeking psychological help (Ivey, Ivey, & Simek-Morgan, 1997; Ponterotto, Casa, Suzuki, & Alexander, 2001), and are threatened by speaking to mental health professionals and sharing personal information with others apart from the family.

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Practical People from different cultures do not always share the same time orientations, and commitments to family and friends can come into conflict with their commitment to receiving psychological treatments. The PGC method has been created to accept, accommodate, and assimilate patients into the group treatment process whenever they arrive. Since PGC is based upon a single session workshop model, patients who—for motivational and/or situational reasons—are unwilling or unable to attend sessions regularly, come on time, or stay for the entire session can still be group members and participate in professional group treatment. PGC is based upon the belief that some psychological treatment is better and preferred than no psychological treatment, especially when the treatment is carefully designed to be harmless to helpful, and is accepting of limited but significant psychological therapeutic goals.

Simple In PGC, the leader writes the day’s Plan and other significant psychological terms on the blackboard, and explains all psychological exercises. The leader also reads whatever is written on the blackboard out loud to the group. This is to help those group members who may lack language skills and/or have visual problems, and to empower all group members by simplifying and “demystifying” the group treatment process. Group members learn immediately what the leader plans to do and what behavior is expected of them. This is ideal for those minority and immigrant members who may not be accustomed to individual or group therapy and the process of engaging in psychological exercises, which may be as foreign to some populations as speaking or hearing a new language.

Student vs. Patient/Client Role To many people throughout the world, the role of a student is usually a more positive and acceptable one than the role of a patient or client. PGC appears more like a teaching experience, and therefore is more user-friendly because it is more readily understandable to people from varied backgrounds and cultures. Since attending a regularly scheduled PGC session is similar to attending a weekly class, it may help reduce the stigmatization of being a

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patient or client and increase acceptance of needed counseling and psychological services.

Interpersonal Safety The PGC leader is committed to providing a harmless to helpful group experience for all group members, at all times. Group members are asked to give only very brief answers, speak only to the leader, and not comment on any other group member’s responses. By requesting only very brief answers, the leader makes it easier for those group members who are fearful of speaking in a group or who have limited English proficiency to make verbal contributions to the group process. Since group members are only receiving feedback from the leader, they can be consistently assured of receiving understanding, supportive, and empathetic comments throughout the session. Group members are protected from being confronted and receiving criticism from other group members since the leader actively discourages group members from criticizing or commenting on other members’ responses. The PGC leadership, structure, and group process provide patients with the opportunity to verbalize their views, beliefs, and feelings without being criticized or attacked, and to compare their responses with others. The leader seeks to protect members from experiencing embarrassment, decreased self-esteem, and interpersonal conflicts. The leader always protects a patient’s right to decide not to self-disclose at any time without ever having to give a reason or explanation for their decision. The PGC leader encourages patients to benefit from being attentive, participant observers when they are unwilling, unable, and/or unready to selfdisclose. Vicarious learning can occur when patients assume the participant observer role. In PGC, the level of participation is always determined by each group member. The leader encourages members to participate by first silently reflecting on their own responses to questions being posed to them by the leader, and then to silently reflect on others’ responses to these same questions, and compare them with their own. Practicing self-reflection and giving thoughtful but succinct answers to all questions is a core psychological task for group members, one which may be simplified for them by explaining it in the form of an analogy. The leader might say “You go to a gym to develop your physical abilities. You won’t benefit much if all you do is watch and criticize what others do. You benefit most from focusing on yourself and expending your own physical effort.”

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Respect for the Individual While PGC is conceptually based upon the belief that human beings are more alike than different, it acknowledges the need to respect each individual’s uniqueness. Since PGC leaders are completely responsible for the Plan (MiniLecture, Word Association, Psychological Questions), they are regularly challenged to increase their multicultural competency by having to cope with patients who come from different backgrounds and cultures, and who therefore are linguistically dissimilar, and might conceptualize and respond to the psychological questions and exercises differently. We agree with Sue et al. (1998) that a key component of adequate service delivery in the mental health field is the continuing development of multicultural competence. The PGC leader shows respect for each individual by always listening attentively, sensitively, and respectfully to each patient’s response. The leader repeatedly encourages and gives all group members the opportunity to question the leader and make final comments at the end of each session. This is very important and necessary feedback for the leader, because it is the leader’s responsibility to make sure that what patients are being asked to do is being understood and accepted.

Respect for Others The PGC method fosters respect among individuals in each session. Patients are expected to listen attentively to—but not comment upon—others’ responses, and to wait their turn to respond when called. By asking patients to practice self-restraint and not comment upon others’ viewpoints and ideas, particularly ideas that may seem strange, foreign, or very different, PGC promotes interpersonal sensitivity and respect for mental and cultural differences. In PGC, patients are treated as independent individuals but are also told that to benefit from this group method they must be responsible group members. Each individual is repeatedly reminded that they are an essential part of this group treatment approach, and that they must be careful and thoughtful but honest about what they say. Since the leader writes verbatim all members’ responses to the psychological questions on the blackboard, members are compelled to think about their responses and are encouraged to express their honest views succinctly and coherently. Watching a caring, accepting, supportive professional trying to accurately write their verbatim responses on the blackboard for all to see

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while the remainder of the group calmly observes is a novel experience for many group members. What the leader hopes to communicate is that each patient’s response is valued and an important contribution to the group process, and that all group members are entitled to be respected for being present and for contributing to the best of their ability. This process promotes member empowerment: they are encouraged to value their opinions and those of others.

LEARNING TO USE PGC This handbook was written to provide mental health group leaders with a replicable model of PGC. To learn how to use the method, group leaders need only their existing leadership skills and the handbook’s detailed instructions. Easy-to-follow, step-by-step plans are provided for a variety of intrapsychic and interpersonal concerns common to group members. Group leaders can select those plans that are most appropriate for their patients’ needs and clinical situations. Leaders have the option of scheduling a single session, or multiple sessions over many months. Each session must stand alone, enabling all patients to benefit regardless of whether they have attended past sessions or will attend future sessions. This provides group leaders maximum flexibility to treat patients in all of the five stages of emotional readiness, as defined by Prochaska, DiClemente, and Norcross (1992): precontemplation, contemplation, action, maintenance, and termination. Our hope is that PGC will help many group leaders with a new and more professionally satisfying way of working with a wider variety of patients who are underserved, but who desperately need psychological help. We believe that there are many group leaders today who are equally frustrated and disappointed by their inability to be more helpful to a wider range of patients and clients. If you are one of these group leaders, then we invite you to learn this method, because it will give you an additional way of helping very reluctant patients achieve limited but significant therapeutic objectives in a group where they feel more accepted, safe, respected, hopeful, and connected to others.

Chapter

Two Theoretical Framework

In determining what would be the most appropriate title for my new group method, I decided upon Planned Group Counseling for several reasons: one, to emphasize that this new group treatment model was based upon a counseling perspective; two, to use familiar and positive terms that would be easy to communicate to and be understood by most patients; three, to signal to patients that the method was new and different from traditional existing group treatments; and last, to stimulate patients’ curiosity about what was being “planned” and what the group leader would expect and require of them in this particular group treatment approach. Using the word “Plan” in the name was essential, since the “Plan” was needed to provide the safety and protection for all group members, and was what helped define the group process. What follows is a description of PGC’s basic beliefs, why and how the method was conceptualized, the theoretical concepts and techniques that it relies upon, and finally, its basic assumptions.

BASIC BELIEFS Chemically dependent, MICA, and psychiatric patients are people struggling with all the existential issues common to humankind, but unfortunately they have the added burden of coping with the additional physical and psychological difficulties of daily living, which are often chronic and disabling. Some of these difficulties occur due to their environmental/social/biological inheritance; some from the values and habits they have had the misfortune to acquire; and some from the choices they continue to make. 15

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Other people teach us when and how to use legal and illegal drugs. Some seek to teach us to use in moderation and responsibly, others teach us to avoid all drugs, and others teach us to use drugs in order to exploit unsuspecting people for financial gain and/or sexual favors. Family and friends are usually the teachers. All people in our society must learn the consequences of the misuse of legal and illegal chemicals, and learn how to completely avoid or responsibly use legal drugs. Physiologically, the effects of a drug differ from person to person, depending on biological (e.g., genetic) factors. Psychologically, all drug usage is learned behavior, differing from person to person according to learning history and social factors. Chemically dependent patients are usually innocent, ignorant, and naı¨ve at the time of their first personal experience with legal or illegal drugs. People do not become chemically dependent by choice: they make choices that result in chemical dependency. Chemical dependency is not the goal of drug usage; it is the unintentional side effect. It may take much suffering and a long time for a person to acknowledge that they have become chemically dependent and need professional help. Clinical observations suggest that from the patient’s perspective, it is usually an unexpected occurrence when they realize they have become chemically dependent. People know that others are chemically dependent and that they themselves can potentially become chemically dependent. But they usually do not believe it will ever happen to them. For many people, accepting the patient role is psychologically painful and threatening, since they also experience a profound decrease in their selfesteem due to their public acknowledgement of their chemical dependency problems. They question whether they will be able to make all the required changes, tolerate the necessary treatments and what will be expected of them, or have the patience to stay in treatment. Acceptance of the patient role immediately places them in a potentially life-saving and very helpful physical and social environment. For them to accept this patient role represents a major psychological development, because it signals that the person is beginning to rely upon psychological and social means, rather than biological and chemical means, to cope with their problems in living. Upon entering treatment, many patients feel hopeless about their future, and they are usually unaware of the extent of their treatment needs. Often they are unprepared to become a patient, because the period of time that is required may be much longer than they desire or had anticipated. Also, acknowledging the need for psychological help is not the same as accepting all the other professional help they will require. For example, many chemically dependent patients may need all of the following professional

Theoretical Framework

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services: social worker, physicians (psychiatrist, neurologist), nutritionist, lawyer, physical therapist, psychologists (clinical/counseling, behavioral, and neuro), and vocational and educational counselors. Human beings function better when they are in caring, supportive, and constructive relationships. Psychiatric patients with or without chemical dependency problems often have to cope with social alienation and isolation because their social skills are undeveloped or have deteriorated as a result of their psychiatric disorders and/or chemical dependency problems. If they have had the misfortune to become dependent upon illegal chemicals, then their social behavior is usually even more impaired compared with patients who have become dependent upon legal chemicals, because they must constantly cope with the possibility and fear of being arrested and incarcerated. Therefore, many become increasingly avoidant, distrustful, and fearful of authority figures. They attempt to protect themselves by avoiding nonchemically dependent people, especially authority figures (all medical and mental health professionals). They are more comfortable relating to, and tend to rely almost exclusively upon, other chemically dependent people and criminals. These patients tend to become almost exclusively engaged in exploitative, manipulative, and destructive reciprocal relationships. PGC seeks to help patients return to and/or learn how to better relate to caring family, friends, and peers—those people who sincerely want to assist patients in improving their physical and psychological conditions.

THE CONCEPTUALIZATION OF PGC Although all of our patients were veterans, their military and wartime experiences varied greatly and they all came from diverse social, cultural, racial, religious, economic, educational, and occupational backgrounds. Many of them had to struggle with the additional stress of being members of minority groups, namely African-American and Latinos. The clinical challenge was to treat all of these patients representing so much diversity with a safe and harmonious group treatment approach. PGC was born of necessity as a response to this clinical practice challenge and not derived from theoretical speculation. At the time, the combination of my group skills and techniques, and the group methods that were available to me, were adequate to meet the needs of nonreluctant patients who could follow group norms and therapeutic directives—but inadequate to meet the treatment needs of very reluctant psychiatric, MICA, and chemically dependent patients, who could not or would not conform to what was expected of them.

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Planned Group Counseling

In trying to understand this situation, I sought to account for it by first thinking I was responsible, that is, my inexperience and lack of talent for group work was the problem. However, my more experienced and very talented colleagues maintained that the patients’ “lack of motivation” was primarily responsible for their noncompliant behavior. I was not satisfied with this explanation for the following reasons: first, because it blamed the patient, implying that as professionals we did not share any of the responsibility for unsuccessful treatment outcomes, and second, because it seemed to me that there were only two solutions to the “motivation problem,” neither of which were acceptable: that I would either have to wait for the patient to become motivated through some significant life experience, or I would have to assume the responsibility for motivating them, which I was not trained to do. I concluded that neither of these two courses of action seemed to be in the best interest of these patients. I asked myself what other explanations could possibly account for why so many patients either avoided or actively resisted complying with existing group treatment requirements. I took comfort in believing that perhaps I could find other explanations for why patients were uncooperative and noncompliant with treatment directives, since human behavior is such a complex phenomenon and can have multiple causations. I hoped that perhaps other explanations would enable me to use my existing group counseling skills with chemically dependent, MICA, and psychiatric patients who were labeled “unmotivated” and “resistant” to group treatments. I believe it is more helpful to clinically address what many very reluctant patients bring to the treatment session, namely their anxieties, hopelessness, and fears, rather than what very reluctant patients do not bring to the treatment session, namely “motivation”! Fear of other patients, fear of self-reflective experiences, and fear of professional group treatment—any or all of these fears can be significant contributing factors which might cause some patients to avoid and/or actively rebel against the efforts of group leaders to establish therapeutic norms and goals in existing group treatments. The above explanations for patients’ “lack of motivation” are based upon my clinical observations, and are what guided the creation of the PGC method’s leadership style, group goals, norms, tasks, and techniques.

Fear of Other Patients Many very reluctant patients are afraid to be associated with people who suffer from severe mental disorders. For some patients, many of whom may

Theoretical Framework

19

be receiving psychological treatment for the first time, this can be classified as an anticipatory fear. Their notions of mental illness and group treatment are often exclusively based upon those memorable misrepresentations regularly provided by the entertainment industry: comedies, dramas, and horrors seen on television and in the movies. For example, in the classic Alfred Hitchcock horror movie “Psycho,” a woman is violently attacked while showering. Ever since, the word “psycho” and perhaps even the word psychological have acquired negative associations with people who display any form of unusual behavior, including the complete range of mild to severe mental disorders. Unlike medical patients who usually receive additional attention and support from caring family members and friends, recently diagnosed psychiatric patients requiring mental health services are often denied the increased attention and support they need because their families and friends are equally prejudiced, having also been exposed to the entertainment industry’s misrepresentations of psychiatric treatment and the experiences of the mentally ill. Some patients have learned to enhance their damaged self-esteem by ridiculing, criticizing, and humiliating others. Because of this behavior, they are often in conflict with other people—while denying any role in creating conflict—and are unwilling or unable to acknowledge that their behavior is harmful. As any experienced group leader knows, such patients pose a real threat to the emotional security of other patients. A subset of these individuals goes beyond verbal taunts and abuse in their attempt to defend against the imagined harmful intentions of their fellow patients, posing a real threat to both the emotional and physical safety of other patients. People struggling with their own emotional problems will often have difficulty relating to the two types of patient behavior just described, and may be unable to respond in constructive ways. For instance, newly hospitalized patients are under considerable stress due to their emotional problems, as well as the adjustment of living in an unfamiliar environment where their every move is monitored. In addition, they are suddenly surrounded by other individuals who, like themselves, have serious interpersonal and emotional problems. The new patient does not know which patients pose a possible threat, which are harmless, and which could potentially be helpful. They did not come to the hospital with the notion that receiving psychiatric care would mean acquiring additional physical and emotional problems, so they fear emotional contamination (acquiring the anxiety and depressive states of others through interpersonal contact) as well as their own inability to cope with interpersonal conflict (which inevitably arises on the unit and in groups because of miscommunications and differences). These factors combine to form a dense barrier of mistrust that prevents many individuals from realizing the potential benefits

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Planned Group Counseling

of group treatment. The same obstacle is encountered by group leaders who work with chemically dependent or dually diagnosed patients in an outpatient setting.

Fear of Self-Reflection Experiences Psychological “literacy” is a learned behavior; it can be defined as the ability to acknowledge, label, and use words to disclose to others our emotional reactions and any accompanying thoughts. When others devalue, discourage, or punish these mental activities, psychological “illiteracy” can be the result. Because of many reluctant patients’ life experiences, they have learned that one way to escape emotional or physical pain and vulnerability is by devaluing and actively avoiding any interpersonal situation that focuses attention upon internal or subjective experiences, or that encourages the verbal expression of their private thoughts and feelings. Many reluctant patients learn to rely only on actions to establish trust in others; they devalue and distrust words, because many have not had the social advantages of being cared for by people who can provide the necessary models of what it is to be psychologically “literate.” Self-reflection can be experienced as “self talk,” that is, having an internal dialogue. This may be an uncommon and/or threatening psychological experience for some very reluctant patients, especially patients who have had to develop survival skills that rely primarily upon actions, not words. Expanding your emotional experiences, and labeling, acknowledging, and disclosing them to others, can be a very threatening event, especially for patients who have had the great misfortune of having their past self-disclosures used against them, thus causing them physical and psychological damage. Therefore, to encourage these patients to engage in self-reflective experiences requires providing maximum psychological sensitivity, support, and interpersonal security. Very reluctant patients fear self-reflection experiences because they may yield unwanted disturbing thoughts and feelings, they have little trust or faith in their ability to cope with an increased awareness of these alien thoughts and emotions, and they also may be ashamed of them. The avoidance of professional group treatment can be viewed as “an adaptive response” by the patient to perceived and/or anticipated intrapersonal and/or interpersonal threats. In their attempts to be self-reliant and to avoid what they fear, they do not receive one of the primary benefits of group treatment, which is to help reduce the social isolation and alienation that can potentially cause both physical and psychological deterioration.

Theoretical Framework

21

Fear of Group Treatment There is a group of patients who have had past negative treatment experiences; they have terminated their treatments prematurely, and some have been prematurely discharged because of noncompliance with the program’s goals and procedures. Both voluntary and involuntary patients’ premature terminations are to be avoided for three reasons: first, patients who are extremely chemically dependent (legal and illegal drugs) need all the help they can get to avoid further physical and psychological regression, as well as prison sentences; second, premature terminations have a demoralizing effect on many patients and staff; third, because costly administrative and professional services are wasted (e.g., admission and required physical and psychological assessment procedures). The fears described above could help explain why some patients who reject professional group treatment still continue to accept self-help group experiences. It is my belief that a number of patients view self-help group experiences as less threatening. Self-help groups are very accepting and accommodating of group members’ attendance patterns and level of group participation, and may arouse less fear in group members, permitting them to have greater control over when they attend and how much they will participate. I believed that if I had a professional group method that could offer the same level of acceptance as self-help groups, and which would be equally accommodating towards all patients receiving group treatment, this might make receiving professional group treatment more tolerable to a greater number of very reluctant patients, and might encourage them to continue receiving treatment.

THEORIES, CONCEPTS, AND LEADERSHIP TECHNIQUES My therapeutic challenge was to provide a limited but significant social, educational, and therapeutic group treatment that would accept and accommodate a diverse range of both very reluctant and nonreluctant (“motivated”) patients. To respond to this clinical challenge, it was necessary to create another group method. This was made easier because no new theories, concepts, or leadership techniques would be needed, since there was already an abundant selection to choose from. The selection of which theoretical concepts and leadership techniques to use, when and how much to use and modify them,

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Planned Group Counseling

and determining what sequence would be most acceptable and effective, was based on clinical observation as well as trial and error. The guiding theoretical questions then became what could and what would both reluctant and nonreluctant patients be willing to do in the group together on the day they attended, i.e., what would be the more tolerable and acceptable choice of leadership styles, group process, tasks, and techniques. PGC is a new group model based upon existing familiar and relatively accepted and commonly used theories, concepts, and leadership techniques. There are no new theories, concepts, and leadership techniques for group leaders to learn. PGC is not a psychoeducational group, individual therapy in a group, a relapse prevention group, a psychological workshop, an experience in human relations training, a sensitivity group, or traditional group therapy. It is a borrowing and blending of significant parts of each of these group experiences to form a new gestalt. PGC is a new group method because of the unique organization and integration of a wide variety of existing concepts and techniques found in a broad range of theoretical perspectives, including humanistic/existential, gestalt, person-centered, psychoanalytic, social learning, reality therapy, and rational-emotive cognitive-behavioral, and incorporates some practices found in self-help groups. Relying on such a wide variety of theoretical positions and techniques as well as self-help practices is not to achieve a clever or fashionable eclecticism, but to better accommodate those patients most in need. Following are the theoretical perspectives from which PGC is derived.

Humanistic/Existential/Gestalt The PGC method seeks to understand universal human experiences, to help patients identify and change behaviors that are harmful to them and to all others with whom they relate, and to encourage them to try new behaviors and continue helpful behaviors. The method focuses attention on a patient’s subjective experiences in the “here and now,” and asks the patient to directly and briefly verbalize their thoughts and feelings honestly. They are repeatedly challenged to examine how their perceptions, thoughts, emotions, and actions relate to the choices they have made in order to help them better answer some of life’s basic existential questions: what gives their life meaning, how related to others they wish to be, and how authentically they wish to live their lives. The PGC method is an invitation to consider changing a patient’s harmful ways of behaving. The method provides the guide to help them learn to

Theoretical Framework

23

distinguish between what they can and can’t change, what they need to change to live a more constructive life, and where to get the help they need. The method focuses upon increasing self-awareness, which can lead to more and better life choices, an improvement in the way patients cope with life’s demands, greater freedom to choose, the ability to recognize that they are responsible for their actions, and then ultimately to assume responsibility for these actions. The PGC leader encourages self-determination rather than permitting environmental factors and/or other people to determine how patients should live their lives, and invites patients to take the risks associated with expanding and expressing their emotional experiences and behaving in new ways. The content of many sessions is designed to increase awareness regarding the choices patients are making and asks them to reflect upon their choices and consider making different choices to better cope with all of life’s demands. The psychological exercises in PGC provide group members with the opportunity to compare their perceptions, thoughts, feelings, and actions with their peers. In Gestalt group treatment, as in PGC, the leader uses the “going around technique” and asks each group member to make a brief “here and now” statement of what he or she is aware of. The PGC leader relies upon and regularly uses this technique, but will often modify it to better achieve the therapeutic goal of a particular session. This is usually done by making the question more specific. For example, the PGC leader could ask each group member to make a brief “here and now” statement of what thoughts or feelings they are aware of, rather than the more general and less focused question of “what are you aware of.” Emphasis on the authentic and present moment quality of the patient’s experiences provides a common group experience, increasing the patient’s relatedness to others (Perls, 1969), albeit incrementally.

Person-Centered All of the PGC leader’s directives are created and communicated to achieve a nonthreatening, secure, interpersonal atmosphere and constructive group process. Patients are permitted and encouraged to reveal their usually hidden subjective experiences, and are provided with a protected opportunity to experience and express more of their thoughts and emotions. To achieve the necessary trust in the group, the leader limits the group process in order to minimize potential misunderstandings and interpersonal conflicts. The leader seeks to communicate to all patients a caring attitude, solely because they exist and not based upon judgments of their thoughts, emotions,

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and actions. The leader attempts to convey this nonjudgmental attitude at all times to each patient and to the entire group, especially when responding to those patients who are verbally abusive, hostile, or seeking to change the group’s tasks and leadership style. By maintaining a caring, concerned, and cooperative attitude when patients are regularly behaving in ways that may lead to expulsion from group treatment, the leader is presented with an excellent therapeutic challenge and opportunity to potentially achieve two important therapeutic objectives. The first is educational: the leader honestly explains why PGC has the structure, limited group process, and leadership style that it has, how PGC is similar to and different from other group treatment methods, while stating the advantages and limitations of this group method. The second is psychotherapeutic: when the PGC leader genuinely accepts the behavior, he or she thereby offers group members an example of another way to react to behavior that usually elicits an anger and/or avoidance response. The leader honestly tries to understand the patient’s behavior and empathizes with their subjective experience, that is, the thoughts and feelings that are motivating their “unacceptable” behavior. The leader also communicates that professionals are trained to accept behaviors that are customarily unacceptable in other social settings. This professional response, which ideally always seeks to understand behavior rather than judge it, is not to be interpreted as approving of the behavior or implying that the behavior is justified, since this behavior may be very harmful to the patient and/or others. The PGC leader relies and regularly uses Roger’s concepts of Genuineness, Unconditional Positive Regard, Empathy, and Acceptance (Rogers, 1957).

Psychoanalytic The PGC method was designed to address both intrapersonal and interpersonal resistance. In our clinical experience, reluctant patients actively seek to avoid experiencing anxiety, which arises when unwanted perceptions, thoughts, emotions, memories, desires, and experiences may be about to enter consciousness and be acted upon. The anxiety may also be a reaction to coping with ambiguity, making new choices, and/or ending and forming new relationships. In either case, The PGC leader expects and is prepared to cope with the patient’s characteristic ways of coping with all unwanted subjective experiences. The leader will usually be given many opportunities to respond

Theoretical Framework

25

to patients’ ego defense mechanisms, because when they enter treatment they are often anxious and highly defensive. The leader informs the group members that becoming more aware of our own defensive reactions and those of others can help us to better cope with what is making us anxious, and help us to react better when we are confronted with the defensive behavior of others. When group members’ behaviors provide a compelling sample of their defensiveness, the leader always has the option to deviate from the “plan” specifically prepared for that day. For example, some new patients may have a negative transference reaction to seeing the leader standing in front of the room writing on a blackboard. They will then project some very negative thoughts and feelings onto the leader. Some of these patients will express themselves in a verbally aggressive manner to the leader. This gives the leader a perfect opportunity to deviate from the “Plan” and to focus the group’s attention upon this interaction, because this event could provide a more compelling learning experience compared with what the leader had planned for that particular session. The leader has the opportunity to define and describe “transference” and “projection” as well as show how ego-defense mechanisms can help and hinder us. Time permitting, the leader may also choose to introduce some of the other ego-defensive mechanisms: denial, repression, regression, displacement, reaction-formation, and rationalization (Freud, 1946). Group members can be counted upon to provide the leader with many opportunities to respond therapeutically to transference and ego-defensive behavior. The leader’s clinical judgment and therapeutic objectives for the group determine whether or not it is best to pursue this potentially very instructive content area. The leader uses one of Freud’s basic psychoanalytic techniques, “freeassociation,” to experientially demonstrate that important subjective experiences can occur outside of our awareness, and that certain thoughts and feelings which we are unaware of can influence our actions and how we behave towards others (Corey, 1995). Group members are always given the choice to increase self-awareness; however, they are also told that a basic psychological belief is that it is better to know about ourselves than not to know, and that in order to increase self-awareness, we need to take the time to actively self-reflect. PGC uses the free-association technique in a modified manner to achieve a more limited therapeutic objective, namely, for group members to become more aware of the varied, subjective meanings of their words and the words of others, while at the same time creating a unique group experience and furthering the group process. During the Word Association exercise, the leader directly addresses each group member and asks the

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member to briefly verbally respond to the word written on the blackboard and the leader writes down their response verbatim on the same blackboard. This is a basic PGC group task which requests cooperation from all group members.

Social Learning Theory The PGC method relies upon one-trial learning, vicarious or spectator learning, and learning through imitation (Bandura, 1986) and views all these different ways of learning as valid pathways to developing more effective social skills. For many chemically dependent patients, no longer relying upon chemicals and the social world in which they have survived means that they need to create a new social identity. The PGC group experience allows them to watch other patients—who have similar problems and who have learned how to change some of their self-defeating behavior patterns—respond to the group tasks provided by the group leader. These more advanced patients are often more open and honest, and are sincerely seeking to change their harmful ways of behaving. Many of these patients regularly and enthusiastically engage in the PGC group tasks, thereby providing the necessary constructive peer models both inside and outside the PGC group. The PGC leader has the professional task of providing a model of acceptance, nonjudgmental thinking, and accurate empathy. The PGC method seeks to foster interpersonal learning through direct and indirect learning techniques. When using direct learning techniques, the leader seeks to help patients cope with intrapersonal and interpersonal issues by planning sessions with specific topics. For example, if the issue concerns possible relapse, the leader might select topics such as coping with thoughts of controlled usage, and thoughts of resuming socializing with friends and relatives who are actively using. Other topics might include identifying, experiencing, and expressing the emotions that might cause relapse (see Chapter 8 for a selection of suggested PGC plans focused on intra and interpersonal issues). Indirect learning potentially occurs in PGC every time the leader invites and encourages all group members to practice waiting, and speaking honestly, directly, and briefly. This systematically occurs in each section of the planned group structure every time the leader asks (and sometimes challenges) each group member to ask questions and/or make comments after the Mini-Lecture; to respond verbally to the Word Association exercise, Psychological Ques-

Theoretical Framework

27

tions, and Final Comments and/or Questions about what they have experienced in the day’s session. All of this provides an implicit opportunity to indirectly improve each patient’s attention tolerance and listening skills. The generalization of these important social skills can help patients relate better to family, friends, coworkers, and employers in the future. The PGC leader plans sessions that focus on group members’ relationships—peers, friends, lovers, family, teachers, bosses, physicians, etc.—and their subjective experiences—perceptions, emotions, thoughts, expectations, etc. Intrapersonal and interpersonal coping skill deficits can contribute to a patient’s misuse of chemicals or a potential relapse after abstinence has occurred (Monti, Abrams, Kadden, & Cooney, 1989). In psychiatric patients, psychological regression may also occur, especially if they are under additional and/or new stresses, in which case their deficient coping abilities can lead them to behave in ways that alienate them from the potentially supportive people in their lives—just when they are needed most.

Self-Help Experiences Whenever possible, the PGC leader gives the patient responsibility for when they attend each group, how long they stay, and when and how much they self-disclose. Group members are always welcome to attend as many scheduled group sessions as they choose. This open group approach has admission criteria and group norms similar to self-help groups. If they are in locked wards, court-mandated treatment programs, or prison settings, or if not attending a scheduled group treatment session would have negative consequences (for example, patient would lose their job or their significant other would terminate their relationship), then this would be acknowledged by the group leader by informing group members that although they may not want to be part of this group experience today or have reservations about participating, their in-group participation is always voluntary. However, the leader always encourages maximum participation, and reinforces all group members when they arrive on time, stay for the entire session, actively participate (listen to others and answer the leader’s questions), and attend regularly. The leader also actively and regularly challenges group members to make a greater commitment to their treatment program and personal psychotherapeutic goals. PGC’s admission criteria and group norms are used to communicate respect for the patient as an adult, as well as the belief that each person has the potential to make better and more constructive life choices. Yalom (1995) reports that the instillation of hope and its maintenance is a fundamental aspect of self-help groups, and he believes that it is essential

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for all psychotherapy. He observes that past and present psychiatric patients in Recovery Inc. and chemically dependent (alcohol) patients attending Alcoholics Anonymous meetings benefit from the inspirations provided by their peers. The PGC leader actively promotes optimism. The leader will focus the group’s attention on a member’s constructive behavior change whenever the opportunity arises. The PGC leader is committed to demonstrating that the group method can help each group member achieve limited but significant therapeutic goals. During any part of a PGC session, the leader is always free to use any behavioral observations, verbal and nonverbal, as a vehicle to promote hopefulness. For example, if a regular attending group member offers a spontaneous description of how this group experience has helped them, the group leader will thank them for their positive testimonial, and point out that “their constructive comments are needed to encourage the new and very skeptical members of the group to remain in treatment and benefit from all the professional services that are available.” In PGC, group members are told that their cooperation and active participation is necessary to create the most potent social, educational, and therapeutic group experience. The leader invites and encourages all group members to help themselves by helping others. They are informed of the therapeutic value of a reduction of their self-absorption, which comes from listening more attentively and seeking to understand another’s point of view. The more fully they participate in the group’s tasks, the more they benefit and the more they help others. Yalom (1995) describes psychiatric patients as beginning treatment believing and feeling that they have nothing of value to offer others. Many chemically dependent patients as well as many psychiatric patients believe that other patients have no therapeutic value because they are patients and are themselves addicted. Whenever a group member’s behavior is particularly helpful to achieving the group’s tasks, the group leader will not only reinforce the behavior, but will also communicate how important each group member’s response is to creating the most beneficial group process for all.

Reality Therapy The PGC method provides group leaders with a group structure and process that permits them to regularly focus on a patient’s psychological ability to increase control over their thoughts, feelings, and actions, and their capacity to learn more constructive and effective behaviors. The method is also used to help group members avoid making excuses for their behavior. The leader

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challenges members to explain rather than excuse their behavior (perceptions, emotions, thoughts, and actions) and to accept responsibility for it. The leader creates and selects only group tasks that all patients can successfully fulfill. Group members are regularly invited to answer questions and contribute comments, but are asked only questions that have no right or wrong answers. The leader expects them to have an answer but does not expect them to reveal the answer. The choice whether or not to disclose their subjective experience is always respected. When group members do not have an answer because of their inattention, for example, they state they did not hear the question, the leader in this case would point out that “although you can’t expect a person to answer a question they did not hear, this is an unacceptable excuse from a psychological point of view, since it is their responsibility to listen. However, it is very acceptable as an explanation, since we all frequently fail to attend to others for a wide variety of reasons.” The PGC method seeks to replace a failure identity (patients presenting themselves as inadequate, deficient, or not capable) with a more successful one (Glasser, 1965), because a failure identity leads to a self-fulfilling prophecy. Thus, when patients claim not to be able to answer questions or make comments, that is, give an “I can’t” as a response to the leader’s questions, the leader will usually react to it as an “I won’t” response and continue to engage the group member in a psychological dialogue, which seeks to increase their sense of power and emphasize their strengths and successes. In clinical settings in which patients are involuntary, the PGC method relies upon carefully selected paradoxical questions as a psychological exercise. The creation and use of paradoxical questions is another way to help group members become more aware of thoughts and emotions which they may be avoiding, but acting out in ways which are harmful to themselves and/ or others. The leader uses this paradoxical technique because the method incorporates the belief that to achieve certain therapeutic objectives and desired changes, it is sometimes more efficient and potentially more effective to do it indirectly.

Rational-Emotive Cognitive-Behavioral The PGC method is used to help patients become aware of how irrational thoughts and emotions outside of awareness, especially those that are in conflict, can cause chemically dependent patients to relapse (Brill, 1938; Ellis & Bernard, 1986). PGC teaches patients that they are responsible for their perceptions, emotional reactions, thoughts, and actions, and that they

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have the potential ability to change them. Many PGC sessions are devoted to helping group members identify and consider changing harmful thoughts and emotional reactions that they have about themselves and/or others. Defensive behavior frequently stimulates defensive behavior and/or avoidance reactions in others. Increasing self-acceptance can lead to increased self-esteem. This can reduce patients’ defensive behavior and hopefully increases constructive relationships with others. Since PGC is founded upon these beliefs, the PGC leader focuses as much as possible upon those group members’ responses which demonstrate a lack of self-acceptance. This is done in an attempt to help group members become more aware of their self-rejecting comments and to consider changing; that is, become more self-accepting. The PGC method incorporates the belief that the use of humor has both cognitive and emotional therapeutic value, and at times can be a very effective technique for reducing group tensions and defusing potential interpersonal conflicts. However, like all therapeutic interventions which rely upon highly active and directive techniques, humor must be used carefully to achieve one of PGC’s basic objectives: “do no harm.” Humor is one of life’s pleasures that we all can share; it reduces the psychological distance between us and it can provide a welcomed pause from the efforts required by patients to make all the difficult choices and changes necessary for them to reduce their suffering.

HOW BASIC THEORETICAL ASSUMPTIONS ARE INTEGRATED INTO THE PGC METHOD People are more alike than different, and are inherently curious and capable of further psychological development. The ethos of PGC is consistent with a model of development across the life span (Erickson, 1950; Murphy, 1958; Sullivan, 1953) and is also accepting and affirming of individual differences (Kelly, 1963). People relate to others in order to survive, to feel secure, and to achieve physical and psychological intimacy. People have a need to communicate. Honest communication of thoughts and feelings is necessary for psychological well being. These skills are critical to help find, form, and maintain relationships that are caring, secure, supportive, and intimate (Yalom, 1995). The PGC method is designed to help patients practice social skills that will help improve their relationship with others. Knowing when, how, and what to self-disclose is a very complex issue, as is knowing when and how to caringly confront another (Jourard, 1971).

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Sensitive to many patient’s deficits in this area, the PGC leader encourages group members to express their thoughts and feelings only to the leader, in a dialogue fashion, thwarting aggressive or premature confrontation from other group members. Despite the limitations imposed on member-to-member interactions, focusing on expressing thoughts and feelings in the “here and now” gives the patient an opportunity to practice verbal self-expression (vs. acting-out behavior). To better understand another, one needs to know how others experience their world. To be better understood one needs to disclose some of one’s own subjective experiences. Mutually shared experiences can lead to greater human understanding and relatedness. The abilities to self-observe and selfreflect are crucial and basic to all psychotherapeutic approaches where understanding is a primary therapeutic variable. Safety comes from the “Plan.” The leader assumes sole responsibility for its creation and execution, and flexibility comes from the leader’s freedom to change and/or deviate from the Plan whenever it is needed to better address the needs of the group members present that day. Harris (1995) states that the development of empathy is even more crucial for counselors of treatmentresistant patients. When the leader uses directives to achieve a group goal or task, the leader is striving to communicate the highest level of respect, support, acceptance, and empathy to each and every group member. The PGC leader uses the Plan to minimize the occurrence of interpersonal conflicts and to offer each person a thoughtfully and carefully organized agenda which seeks to treat each group member equally, permits all group members to participate at their own pace, respects their different values, beliefs, emotions, life experiences, and levels of intelligence, protects them from criticism and confrontation by other group members, and increases their self-awareness while improving their social and psychological functioning in the group. PGC’s flexibility is a function of its dependence upon a self-contained workshop model, and is similar to the brief therapist’s view of each session as potentially the “first, last, and only” (Talmon, 1990), as well as Bandura’s (1986) one-trial learning, vicarious learning, and learning through imitation. Patients are, of course, encouraged to attend additional sessions to obtain additional benefit. In a figure/ground reversal, PGC shifts the therapeutic focus from the individual’s resistance to acceptance of responsibility for his or her thoughts, feelings, and degree of commitment to psychological treatment (c.f., Glasser, 1965). The PGC leader regularly uses psychological exercises to demonstrate the importance of this psychological process. To be able to quickly create an effective therapeutic alliance with very reluctant patients in group treatment, two conditions need to be met: first,

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patients need to perceive and believe that the leader can be trusted and is relying upon group techniques that are effective and have been chosen especially to meet their needs; and second, the leader must have a group method that is very safe, flexible, and acceptable to most patients. The efficacy of the PGC method hinges upon the quality of the relationship that the group leader is able to establish with each member of the group. The therapeutic relationship has been seen as a central curative agent in the experiential tradition (Rogers, 1951, 1957), and continues to be conceptualized this way by contemporary experiential theorists (Greenberg, Rice, & Elliott, 1993). The PGC method was created to provide the means by which a group leader would be able to quickly form a working alliance with each group member. Safran and Muran (2000) conclude that “after approximately a half century of psychotherapy research, one of the most consistent findings is that the quality of the therapeutic alliance is the most robust predictor of treatment success . . . across a wide range of treatment modalities” (c.f., Garfield, 1992; Young, 1992). Assuming responsibility for using group treatment methods with nonreluctant, reluctant, and very reluctant patients in the same treatment session poses two challenges. The first is for the leader, whose authenticity, sensitivity, commitment, and therapeutic skills will be tested. The second is to the group method, which in our clinical experience reveals itself to be a very reliable vehicle. Using existing individual and group psychotherapeutic skills, and precisely following the guided instructions, professionals will be able to provide a safe social, educational, and therapeutic experience while achieving limited but significant psychotherapeutic goals, and will thus be able to share in the professional satisfaction of being helpful to a group of patients who need psychological help.

Chapter

Three The PGC Leadership Approach

HISTORY Since the PGC leader is responsible for creating the plan and content for each session, as well as defining and controlling the group process throughout the session, the leader needs to rely upon very active, directive, and protective leadership skills, and is frequently required to invite and challenge patients to accept more responsibility for controlling their behavior. This may sound like the last thing one would want to do as a group therapist or counselor; in fact, that was my initial reaction. “Could I do such a thing?” I asked myself. Just how active, directive, and protective would I need to be, and how much inviting and challenging would be necessary? Did I want to assume this much responsibility, and be this active? The answer was no, because this was not the group therapy or counseling I was trained to do. The group therapy and counseling I was trained to do was based upon the group leader encouraging group members to freely interact. One of the reasons why I was attracted to counseling was because counselors were not held responsible for what people thought and felt; but they were responsible for helping people identify their thoughts, emotions, and behavior patterns, and for evaluating the effects these had upon themselves and others. The thought of having to become a very active, directive, protective, and controlling group leader reminded me of my elementary school teaching days, where control was crucial but necessary, and where questions were asked with the intention of obtaining right or wrong answers in order to 33

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achieve didactic goals, rather than—as they are in counseling—to further therapeutic objectives. As a teacher, I was responsible for the content, which the pupils had to consume and incorporate. I remember manipulating the class dynamics by posing stimulating questions, encouraging discussion, and asking for comments. I used these techniques strategically to help pupils remember the content. True, I surmised, teachers and counselors often had to rely upon similar professional skills. Both required getting uninterested people to focus their attention and to listen as a way of helping them to remember important concepts. Both were well versed in posing stimulating questions, encouraging discussion, and asking people to verbally express themselves. But still, did I want to behave more like a traditional teacher, who talks, directs, and controls more? Did I want to assume a leadership role similar to a wellprepared teacher, who plans to present specific content, who relies upon a variety of dependable and effective teaching techniques at his or her command, and who is often required to restrict the pupils’ dialogue? Did I really want to stand in front of a blackboard again, with chalk in hand, looking at patients sitting in modified rows, as opposed to a circle, instructing them to look at the “Plan” written on the blackboard, and then ask each person in the room to speak honestly, directly, and briefly, and only to me, while the other members are expected to listen? Wasn’t this description more appropriate for a typical classroom than a psychological group treatment room? I professionally and personally did not prefer to use such an active, directive and protective leadership style, and to have to limit the group process and be responsible for planning the group session. I preferred to be the traditional counselor, who listens, frequently relies upon nondirective leadership techniques, invites and encourages group members to speak freely to one another, and then analyzes the interactions. But since I wanted very much to provide psychological treatment to the patients that had been assigned to me, and since the results of my reliance upon existing group methods seemed ineffective with this population, I reluctantly began to modify the existing group methods. What I observed, through trial and error, was that the more I planned, the more active, directive, and protective I became as a leader, and the more I controlled and limited the group process, the more cooperative, compliant, and willing to explore thoughts and feelings patients became, and the more receptive and responsive group members were to my changed leadership behavior. As I incrementally reduced the amount of time group members were encouraged to freely interact with each other, and then ultimately omitted this element from the group process, I was surprised to witness that most

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patients did not appear to miss the opportunity to freely interact with one another, and only a small minority of patients complained about being in a group where they lacked the freedom to freely communicate with other group members (please see Chapter 5 for illustrative examples of how a PGC leader responds to patients who complain about not being able to speak freely to other group members). The more directive the leadership and the less group members were expected to interact with each other, the more cooperative and amenable they were to following most therapeutic directives. At the same time, the method enabled me to achieve limited but significant psychotherapeutic goals. Many reluctant and very reluctant patients responded by becoming more compliant and participating in the group tasks. Some expressed what appeared to be sincere appreciation of the leadership approach and limited group process. Since the method I created was part of an interdisciplinary group treatment program, I also speculated that perhaps one influential factor in the method’s positive reception by the overwhelming majority of patients was the many opportunities they had to freely interact in their other group treatments, and that PGC may have been viewed as a different and welcomed change from their other professional group treatments. Whatever the reason or reasons, I was very pleased to have a group method that could accommodate a wider variety of patients. In conclusion, what I learned was that with PGC it was possible to consistently achieve limited but significant social, educational, and psychotherapeutic goals by using very accepting, directive, and protective leadership techniques to create a relatively safe and conflict-free interpersonal environment. The method allows patients to voluntarily participate in psychological exercises designed to increase their self-control, self-acceptance, mental flexibility, and empathy, while at the same time asking and expecting them to assume responsibility for becoming more aware of their thoughts and feelings and for expressing them honestly, directly, and briefly without harming themselves and/or others.

LEADER’S BEHAVIOR A Helpful Metaphor Imagine you are an experienced and skilled captain of your own sailboat, and you have accepted an assignment to provide a safe ferry ride to a varied

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group of passengers, some who are very fearful of sailing and drowning, but who all need to cross a very large bay and must make the return trip. The main purpose of this mission is to make the journey without increasing anyone’s fear of sailing, and to get the passengers to want to take the return trip with you. You have never sailed these waters before, but you have been given a very specific set of plans by another captain who has made these crossings thousands of times. The weather is always unpredictable, but you have as much time as you need to make the voyage safely. You will also need the cooperation and help of as many passengers as possible to sail the ship.

Guiding Therapeutic Objectives In PGC, the leader’s efforts are aimed at achieving the following three basic therapeutic objectives: first, to engage and win as many patients’ cooperation as possible; second, to provide a meaningful constructive group treatment experience for all who attend; and third, to encourage and support each patient’s commitment to other professional treatments and self-help group experiences. PGC group leaders will be able to achieve these objectives by relying upon traditional therapeutic factors, namely, being committed to communicating the highest possible level of professional caring, sensitivity, emotional involvement, acceptance, respect, and empathy. The more acceptance, respect, caring, nonjudgmental attitude, and empathy you can communicate, the better. The leader actively seeks to understand all group members’ behavior rather than judge it, to communicate to patients that this group treatment can be helpful to all who attend, and to challenge patients to change their maladaptive behavior—while at the same time expecting that group members will differ with regard to how conflicted or committed they are to achieving their treatment goals, and on how noncompliant or cooperative they will be with the leader’s therapeutic directives.

Professional Caring and Sensitivity The leader communicates these traditional therapeutic factors through actions and words for each component of the PGC method, beginning with the amount of concern, care, and thought that goes into the creation of the “Plan.” The leader’s feelings concerning the content of the “Plan” are equally important, since how the leader introduces the day’s Plan will influence the

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reception it receives from group members. The preparation of the Plan and its presentation is the leader’s “gift” to the group members. It represents the leader’s caring and intentions. The leader’s sensitivity is demonstrated by the selection of the group topic and by the leader’s response to how group members react to the Plan and the topic. For example, during the Questions and Comments section of the Mini-Lecture, if the leader discovers that the day’s selected topic does not meet the current needs of the patients attending that day, the leader may then respond to group members’ reactions by choosing to deviate from the proposed plan.

Emotional Involvement Ideally, there is an optimal level of emotional involvement by the leader, in order to serve professional rather than personal goals and to conduct an effective group. Since the leader is solely responsible for the day’s Plan and topic, the leader should never have to feel obligated to handle a topic on any particular day that is too emotionally demanding, and which could jeopardize the ability to conduct an effective group. To be able to best care for others, the leader has to care for him- or herself.

Acceptance and Respect The PGC method is based on actively accepting all patients’ behavior except acts of violence. The first opportunity the leader has to demonstrate respect and acceptance of group members’ behavior is when they arrive, enter the room, and take their seats. New patients are as important to the group as those patients who attend regularly over a long period of time. There is no seniority in PGC, and therefore no special status is given to regular attendees. Since the leader wants all new patients to feel needed and accepted immediately, it is not uncommon for the leader to personally escort new group members to an available seat while praising them for coming to the day’s session. The hope is that the leader’s special welcoming attention will help new patients feel good about choosing to attend the day’s session. Patients are welcomed at any time and will often receive praise whenever they arrive. The leader’s welcoming behavior is the same whether the patient comes on time or five minutes before the end of the session. The leader’s acceptance is the same regarding each group member’s level of participation. What the leader seeks to communicate at all times is that patients are always

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responsible for their participation, and that their chosen level of involvement will always be accepted by the leader. The leader always protects “nonparticipating” patients from their peers’ attempts to actively increase these group members’ level of involvement. The PGC leader treats all group members as adults who are struggling with making significant life changes and who are responsible for making different choices each day. Thus, when patients decide to leave sessions before their completion, they are told that this is acceptable behavior, but certainly not preferred behavior. There are three reasons why it is preferred that they stay for the entire session: first, patients need what PGC has to offer them; second, the more they participate the more they will benefit; and third, each group member is needed to maximize this group methods’ effectiveness, because their responses will often be helpful to other group members. However, patients are told that their decision to leave will always be respected, and that the leader looks forward to seeing them in future sessions. The leader may then take the opportunity to thank them for attending and participating that day. Whenever group members leave the group early, the leader hopes that their leaving will be more helpful to their achieving their constructive life goals, than if they had stayed for the entire session. Leaders always need to use their sensitivity and judgment to determine how much attention to devote to lateness and early departing group members. However, the attitude underlying the communication is always one of acceptance and respect. The way a leader handles lateness and early departures influences whether patients decide to come on time in the future and whether or not they ever stay for the entire session. Furthermore, it is a very dramatic event when consistent latecomers and early departing patients decide to come on time and stay for the entire session. This change in behavior has a very positive effect on group cohesiveness. If you can get the passengers to take a return trip, you have accomplished your mission. In PGC, the leader also demonstrates acceptance and respect by listening and responding to each patient’s answer as a psychotherapist or counselor does when trying to establish rapport and form a therapeutic working relationship with a new patient. The leader does not ask individual group members questions that have right or wrong answers, and does not criticize group members’ answers, even though some answers may be very different from what is expected. Group members’ responses to the leader’s questions are treated by the leader as “a gift to the group.” The act of giving the gift is always more important and valued than the actual content. The leader is very thoughtful and makes careful comments regarding group members’ answers

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to questions asked during the Analysis portion of the group session, because from a psychotherapeutic standpoint, the answers may represent and be closely connected to the person’s self-image and self-worth. Patients with low selfesteem are particularly sensitive to criticism. Thus, psychologically, to criticize or reject the answer could be equivalent to directly criticizing and rejecting the patient in the presence of their peers. They are more receptive to supportive comments and praise for their efforts to comply with the group’s tasks. The PGC leader wants to minimize the risk of offending any group member, because the leader at all times wishes to avoid hurting any group member and providing any group member with a reason or an excuse not to participate in the group’s tasks. The leader’s major objective is to always provide a group treatment experience that is acceptable and tolerable to as many patients as possible.

Empathy When a patient’s self-disclosures receive an empathetic response from a caring professional within a therapeutic relationship, many clinicians and contemporary experiential theorists consider it to be a crucial therapeutic agent (Rogers, 1951, 1957; Greenberg, Rice, & Elliot, 1993). Harris’s (1995) clinical experience supports the belief that the development of empathy is even more crucial for counselors of treatment-resistant patients. The PGC leader repeatedly encourages patients throughout the different components of a PGC session to say freely and directly to the leader what they honestly think and feel. The first time the group members receive this directive is after the Mini-Lecture, when they are invited to ask any questions and/or make any comments they wish regarding the content of the MiniLecture. Group members’ responses provide the first opportunity for the leader to give genuine empathetic responses while other attentive group members listen. Our clinical experience supports Harris’s (1995) conclusion that reluctant and especially very reluctant patients need all the empathy they can get. These patients are sometimes referred to as “complaining help rejecters” because their very defensive behavior and their commitment to irrational ideas concerning their chemical dependency often causes them to behave in ways that can easily provoke a countertransference response, such as anger or avoidance from treatment staff. Many reluctant patients have honed their interpersonal skills to such a high level that they can regularly alienate and

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convince others that they are hopeless and that the treatment program’s caring, dedicated, and effective staff are uncaring and incompetent. The PGC method permits group leaders to consistently and regularly challenge this type of maladaptive behavior, particularly with very reluctant patients, while regularly providing acceptance, respect, and empathy throughout the group session.

LEADERSHIP AND PSYCHOTHERAPEUTIC SKILLS Training and Experience Both experienced and inexperienced professional group leaders who have been trained at the master’s level or its equivalent can lead an effective PGC group session without being required to learn new group leadership and psychotherapeutic skills. Their existing individual and group psychotherapeutic skills and group leadership experience, plus a careful reading of this book, will be sufficient to lead an effective PGC group session. This may be a very different leadership experience for some group leaders, especially those who have been primarily trained in and are experienced only with group methods that generate the group process by encouraging members to freely interact with one another. It has been our experience that new PGC leaders are often skeptical of the PGC method until they have had the opportunity to observe and experience the effect that the method has upon nonreluctant, reluctant, and some very reluctant patients. Many of the psychology interns who were trained in PGC for group supervision later admitted how initially skeptical they were about the method and how surprised and delighted they were to see how positively patients responded to this group leadership, structure, and process. For those group leaders who have received training and have led groups that follow and rely upon didactic and behavioral techniques to achieve therapeutic objectives, the PGC method may appear less different because they are more experienced with greater leadership activity and giving directives. However, unlike those psychoeducational and relapse prevention groups which operate from a defined curriculum, the PGC method is not content or topic driven, because how the member relates to the leader and to peers is the fundamental concern of the PGC leader. Examination of the day’s topic by group members is always secondary to PGC’s group process whereby group members are repeatedly invited to verbally express their thoughts and feelings to the leader, as they occur, freely, honestly, directly, and briefly in the presence of their peers, thus replacing harmful acting out behaviors.

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Active and Directive Leadership Skills Although the PGC method does not require group leaders to learn new leadership skills, it does oblige them to be prepared to have their leadership role repeatedly challenged, to be very active and directive, to be protective of vulnerable new group members, to be tolerant of distracting group members’ behavior, and to be very patient. Just as you may, in individual treatment, have to take a very active, challenging, and directive approach with a new patient who needs such a therapeutic intervention to form a therapeutic alliance, to lead a PGC group you will need to use these skills regularly. How often will you need to be very active, directive, challenging, and protective? That will depend upon your clinical/counseling setting and your program’s therapeutic goals. For example, if you are leading a regularly scheduled weekly group where you have already formed a working therapeutic alliance with some of the regularly attending group members, some of these group members will become your therapeutic allies, and they will at times greatly enhance the potency of the PGC method, as well as make it easier for you to achieve your therapeutic goals for that session. Your allies’ compliance with and acceptance of PGC’s group norms and tasks will provide a helpful model for the new and less defensive group members. However, if you are going to lead a group of new patients and will be seeing them only once, for example, on an inpatient detoxification ward where you will treat a new group of patients each week, in this clinical situation you will need to use very active, directive, and protective interventions repeatedly, since you do not know how many allies you will have, if any. The larger the crew the less the captain has to do. When you are trying to engage new, angry, and sometimes very distrustful patients who are actively and directly testing your leadership role, often your “allies” will provide additional therapeutic support just when you may need it most, by using verbal and nonverbal behavior to assist you. In this situation, they will repeatedly choose to respond more quickly to your directives than usual. They will also take on a more serious attitude which is communicated by facial expressions and more focused attention, and spontaneously make positive comments about their past PGC experiences. Their constructive behavior will often serve to modify and reduce the amount of acting out behavior of the new very reluctant patients. If the new and challenging group members are perceived as “troublemakers” by the regularly attending group members, your “allies” may disobey your directive to speak only to you, and may directly confront and verbalize their anger and critical and punitive thoughts to the new group members.

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This is an example of well-intentioned group members changing the group process, and thereby simultaneously taking the group in a different direction, one in which many patients are familiar, because it is more typical of the more traditional group treatments which rely upon members freely interacting to create the group process. This is not the direction in which a PGC leader wants to go, because it can quickly and easily result in conflicts between group members. This situation usually requires the leader to take swift action to redirect the group process. The PGC leader expects patients to disobey directives and is always prepared to take immediate action by deviating from the Plan and redirecting the group’s focus of attention in order to avert the potential conflict this situation could cause. A safe voyage depends upon always staying on a course that avoids the rocks. Our experience has shown that although PGC requires the leader to be more active, directive, and protective, the leader also gets more patients to comply with therapeutic norms, tasks, and goals than if the leader were less active, directive, and protective.

Psychotherapeutic Skills Leading a group of patients which collectively includes nonreluctant, reluctant, and at times, some very reluctant patients, requires leaders to be capable of calling upon any number of their therapeutic skills and ideally to be able to quickly change them to meet the specific needs and demands of each group member. Experienced and inexperienced group leaders will need to practice relying upon and frequently use the above-mentioned group leadership skills and the following psychotherapeutic skills which they already possess: giving directives, listening, facilitating, supporting, flexibility, selfdisclosure, and confronting noncompliant patients.

Giving Therapeutic Directives All of PGC’s therapeutic directives are given to establish and maintain PGC’s group norms, as well as to make the execution of the day’s plan possible. These directives are sincerely presented by the leader to all patients as requests and invitations to participate in this unique group treatment. One of the goals of PGC is to encourage all group members to become more aware of themselves and others and to assume more responsibility for their behavior, and so the leader asks them to follow the directives as a means to achieve this. However, the leader always wants their compliance with all therapeutic

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directives to be voluntary. Thus, the leader gives all directives in the form of “a true invitation.” In many social, family, and work settings the word invitation is used, but the real communication is that the invitation cannot be rejected without some negative consequences. When the inviting person does not offer a “true” invitation, the indirect communication is that the invitation is really a “demand.” The PGC leader delivers only “true” therapeutic invitations, that is, the patient is always free to accept or reject the invitation, without any negative consequences, and is not expected to have or give a reason for the rejection. The PGC leader will not only respect and accept the patient’s choices, but often will reinforce and praise a group member for honestly rejecting an invitation to follow the directive rather than behaving in a false manner. When the PGC leader gives a directive, e.g., “please wait your turn before you respond to the question,” what is being communicated is a sincere need for each group member’s cooperation and compliance. The PGC method is dependent not only upon the leader and the plan, but upon each group member’s contribution to the group experience. Through the leader’s directives, what is constantly being communicated is that each patient is needed to increase the potency of this group method. At the same time, the leader does not want to use any inherent leadership power to manipulate the patient into cooperating and complying with the leader’s directives, no matter what the therapeutic potential may be. In PGC, the leader expects that patients will frequently not comply with the leader’s directives, for example, the directive “speak only to the leader.” How often a PGC leader will need to repeat this directive will vary from group to group and session to session—not unlike the experience of a group leader who is facilitating a newly formed “freely interacting” group, and who has to repeat the directive “speak to the group.” In this situation, the leader is prepared to make the most of this noncompliant behavior therapeutically. This noncompliance often provides the “here and now” behavior which the leader uses to illuminate and identify significant intra- and interpersonal issues, for example, thoughts about oneself, accepting help from others, and intimacy problems.

Listening The quality of the listening behavior of the leader is crucial for group members to establish trust in the group leader and the group method. The leader relates to each patient as an individual. How well the leader listens and communicates what is being heard will influence how self-disclosing the group member

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will be, and whether that group member will continue the therapeutic dialogue with the leader. To listen therapeutically demands that the leader focus full attention on the speaking group member. Ideally, the leader’s attention will be directed to all of the patient’s nonverbal and verbal behavior. The leader needs to use all the behavioral information group members provide to be able to better understand what the patient wishes to communicate. Therefore, beginning with noticing where new patients choose to sit, their sitting posture, their attention to others, how they are dressed and groomed, and other nonverbal cues, as well as their verbal and nonverbal interactions with the other group members in the room, helps the leader to listen better and more accurately communicate understanding and empathy. Listening to each group member’s response to the material and questions presented by the group leader is the shared experience. This experience provides the basis for the therapeutic relationship the leader seeks to establish with each new patient. Trust in the leader is established by how the leader relates to each group member and the group as a whole. When the leader demonstrates a genuine, caring, and noncontrolling interest in each patient’s reactions to the PGC group tasks, and when group members perceive that the leader sincerely believes that what is planned for the day’s session will be potentially helpful to all who have chosen to attend, then two therapeutic objectives will have been achieved. One, the patient will have had a constructive interpersonal experience of being listened to by the leader, and other attentive group members. Having a positive experience relating to the group leader in the presence of their peers increases a patient’s relatedness to others. As Yalom (1995) reminds us, being more related to others is necessary to promote psychological well being. Loneliness and social isolation are associated with psychiatric and chemical dependency problems, so for many of these patients, increased relatedness can aid in preventing relapse and psychological regression. The second therapeutic objective that has been achieved is that when a patient perceives that they are being attentively and caringly listened to, this communicates that the person is worth being listened to and is capable of being understood.

Facilitating The leader’s caring and careful listening is intended to encourage group members to focus upon their thoughts and feelings, and to make it easier for them to take the risk of verbalizing these thoughts and feelings, as well as their expectations and conflicts, while their peers listen. The leader seeks to involve each group member in a therapeutic dialogue in which clear, direct,

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and brief communication is practiced and reinforced throughout each component of the group session. The leader helps group members to become more aware of when and how they are avoiding self-disclosure and when they are choosing not to change their harmful behavior patterns. The leader encourages members to generalize what they learn to their significant others, and supports all the efforts they make to change maladaptive behavior.

Supporting Knowing when and how to make supportive comments which appropriately reinforce and encourage patients to continue constructive behavior that leads to significant personal change requires the leader’s judgment. If the leader perceives a patient’s responses as insincere or deceptive, the leader would take a more neutral stance rather than a supportive one. Many reluctant patients are very skillful at using words that they believe the leader wants to hear and playing the role of the cooperative and compliant patient. The leader always supports observable behavior, for example, attendance. Even if a patient’s attendance is mandated, and the patient demonstrates no intention of benefiting from a PGC session, the fact that the patient has chosen to obey the law is always supported. The leader compliments and praises patients for attending the session, and will give additional recognition to those patients who remain for the entire session and who have attentively listened to their peers’ responses to the group tasks. The leader will accept, support, and encourage all direct, brief, verbal communications of patients’ honest thoughts and feelings to the leader. This does not mean that the leader agrees with the thoughts and feelings that the patient may be expressing nor that the leader does not communicate this lack of agreement at times. What patients can always expect is support for their honest, direct, and brief communication of their subjective experience. Many patients’ self-esteem can be increased when the leader recognizes, thanks, and praises them for their cooperation, and for choosing to perform the PGC tasks. The leader also informs them that the more each person participates, the more everybody benefits. If you can get all of the crew to do their part, you don’t need much wind to sail far. The leader also points out and supports group members who have demonstrated an improvement in their listening skills, for example, a patient who has had great difficulty in listening to other patients give their responses, and who now appears to do this with less difficulty. The more uncooperative and noncompliant the reluctant group members behave, the more dramatic is their change when they decide to comply with the group process and

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engage in the group’s tasks, and the more positive effect this will have on the group cohesion.

Flexibility One of the most important leadership skills necessary to lead a PGC group is flexibility. Although the PGC plan is created to help the leader achieve specific achievable psychotherapeutic goals in a safe interpersonal learning environment, the proposed plan can always be changed to meet the needs of the given group situation, particularly since the leader does not know in advance exactly who and how many patients will attend each scheduled session, and what their emotional and mental conditions may be. The leader determines the therapeutic goals and decides which are achievable with a specific group of patients on a particular day. This allows the group leader total leadership and therapeutic flexibility. The leader’s assessment and clinical judgment of what is therapeutically possible should always determine the group’s direction and focus. Group leaders also demonstrate flexibility when determining how active, directive, protective, and challenging or confronting they need to be but always seek to be as minimally active and directive as possible. Because this method accommodates and accepts patients’ lateness, irregular attendance, and changing membership, having this flexibility enables the leader to better cope with this inherent, relatively higher level of ambiguity. How active, directive, protective and challenging/confronting does a leader need to be? Probably no more then those clinical and counseling situations in existing group treatments which require a higher level of therapist activity to protect vulnerable patients.

Self-Disclosure There will be situations in which the leader’s honest expression of thoughts and feelings concerning the group process will be necessary for three reasons: first, as an intervention to return the whole group’s focus to the planned group’s tasks; second, to avoid the leader acting out thoughts and feelings that would not serve any therapeutic goal and could potentially be harmful to the group members; and third, to demonstrate other ways of behaving which are more helpful rather than harmful in establishing and maintaining relationships with others. For example, if the leader is feeling overwhelmed because a number of group members decide to speak among themselves loudly and have their own

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subgroup treatment experience which excludes the leader and the remainder of the group members, the leader may choose to self-disclose those thoughts and feelings which would help redirect the group to the planned group task. All of the leader’s “mistakes” and imperfect behaviors also provide excellent opportunities for the leader to self-disclose, and to provide patients with a model of behavior which may be more helpful in their establishing and maintaining relationships with others. For example, while leading a PGC group that contains a large number of reluctant to very reluctant group members, it is not uncommon for a group leader to become momentarily distracted due to noncooperating and noncompliant patients’ behavior. In this situation, the leader may forget to tell a new group member that “passing” is an option when the leader poses a question, and the leader will proceed to ask this patient to participate in the group’s task by asking “please reveal your first name to the group.” Let’s say this patient is very distrustful and responds by taking offense at the question, and angrily refuses. The leader could admit that it would have been better to inform the patient before asking the question that no group member has to answer any question and can always choose to pass, and that the leader is sorry for not communicating this information before asking the question, and then explain that the leader either forgot or thought that this comment had been made earlier in the session. This is the ideal opportunity for PGC leaders to admit their “mistakes” and imperfections as group leaders, and to express that they had no intention of harming the patient. Some situations require leaders to explain to the group that with all the training, experience, and good intentions they have, they are human and make mistakes, and that unfortunately they are capable of unintentionally “harming” another through forgetting and being distracted. The leader might continue to say “we all make mistakes, and learning to apologize is a helpful social skill that we all need to rely upon from time to time.” The leader could also praise the offended new group member for verbalizing his or her thoughts and feelings, rather than acting them out by leaving the group or not returning to the next scheduled group session. The leader might end the dialogue by asking the patient for forgiveness.

Confronting Noncompliant Patients In PGC, before a leader challenges patients to change some of their maladaptive group behavior, for example, when they reject group treatment by being uncooperative and noncompliant with the leader’s directives, the leader must be certain that he or she is choosing to confront these group members because they have rejected all of the leader’s invitations to engage in the PGC process,

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and that the leader has exhausted all other means of winning the members’ cooperation and compliance. When a leader is forced to confront a group member who is rejecting group treatment, this usually gets the entire group’s attention. Therefore, it is very important that the leader be capable of delivering the message in a very caring manner, because otherwise the communication can be easily interpreted by the confronted group member and many other group members as a critical, uncaring, and retaliatory attack. If at all possible, the leader should only make this intervention at the optimal time, although choosing the optimal time to confront group members who are actively being uncooperative and noncompliant is often not possible. The purpose of the PGC “Plan” is to help group leaders achieve their therapeutic objectives and provide direction and safety for the psychological exploration for that day. These Plans will permit you to stay safe in the channels and avoid the rocks. Although the “Plan” is to be followed and completed whenever possible, it is very acceptable if a challenging intervention prevents its completion. In fact, the PGC method does not require or necessarily expect that a leader complete the Plan for the day. To make the voyage more acceptable and enjoyable the captain can take as much time as necessary. Whether or not the leader chooses to depart from the PGC Plan will depend upon the leader’s judgment and how many group members are capable of and willing to follow PGC’s group norms and complete the group’s tasks on that particular day. It is always more desirable to engage group members who are rejecting the group method, even if this confrontation prevents the leader from following the Plan to its completion, because the priority of PGC is to win the cooperation and compliance of as many group members as possible. PGC attempts to achieve this, while providing the remainder of the group an opportunity to learn something important about themselves and others (please see Chapter 5 for illustrative examples of how and when a PGC leader confronts group members).

COLEADING A PGC GROUP There are two reasons why the coleadership model is ideal for leading a PGC group and for supervising and training leaders. First, group members receive more attention. Second, group leaders benefit from having other professionals share the experience with them, specifically the observations, questions, suggestions, and critical and supportive comments from the coleaders.

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Especially in the case of training interns, the method can easily accommodate having different coleaders lead different components of the Plan, although the supervising group leaders should use their judgment in determining when and how much responsibility the trainees should take in leading any specific group. Since the PGC method is composed of five separate distinct components (1. Welcoming/Orientation, 2. Mini-Lecture and Questions/Comments, 3. Word Association and Analysis, 4. Psychological Question and Analysis, and 5. Final Questions and Comments), the supervising group leader can assign the leadership of different group tasks to be covered by one coleader while the other coleaders observe but then participate in the Analysis portion of the selected component. For example, one intern could present the word being used for the Word Association task and record the group members’ responses verbatim on a blackboard or the equivalent, and all of the coleaders could give an individual analysis of the results, as well as discuss the results among themselves as the remainder of the group observes and listens. This model for coleadership has often been well received by many of the patients. In our experience, once patients develop trust in the supervising group leader they often are more willing to accept the directives of the coleaders. However, since many group members are reluctant or sometimes very reluctant, they often do not hesitate to test the coleaders’ leadership skills rather than take advantage of the opportunity to benefit from the attention and care that additional professionals can provide. This gives coleaders an excellent training experience to develop their leadership skills in dealing with very reluctant patient behavior.

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Four PGC Group Process

SINGLE-SESSION WORKSHOP MODEL The PGC method relies upon a single-session workshop model. Its group process places a high priority on what is happening in the “here and now.” Free interactions between group members are not essential to achieve PGC goals, and therefore the group process is most similar to group treatment approaches where unrestricted verbal communications between group members are not crucial and do not define the group process, as in psychodrama, gestalt, large-group awareness training, transactional analysis, behavioral therapy, and psychoeducational/theme-oriented approaches (Corey, 1995; Lieberman, 1994; Yalom, 1995). PGC relies on the leader’s ability to engage each member and have them perceive the leader as their protector and helper. The leader invites each member to help create a group process by verbally responding to the leader’s questions and comments, by briefly verbalizing their thoughts and feelings, and by assuming the role of participant-observer who gives feedback under the guidance and direction of the leader. The PGC method is based upon a workshop model because this model gives the leader maximum flexibility to respond to a wide range of clinical challenges and issues. The method can easily accommodate a variety of unexpected clinical events. PGC leaders are always free to select topics that meet the specific needs of their patients in their settings. For example, if one morning a patient is discharged for violent behavior and a PGC group happens to be scheduled for that afternoon, the leader might select a topic that could directly address any of the numerous aspects of this event, for example, the leader could choose the topic “How can we express anger without hurting 50

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ourselves and/or others?” If other PGC sessions are planned for that week, and if the leader and staff believe there would be therapeutic value in the further exploration of this event, they could arrange for additional PGC sessions. Thus, leaders and staff are able to take advantage of the method’s flexibility to better care for the needs of their patients, since what happens in a multidisciplinary treatment program often affects everyone. The PGC group method exists and is always used to serve the needs of the individual. The group leader relates to each patient as an individual in a group context, but both the leader and group members are aware that what they say and do will influence and may affect the behavior of the other observing group members in the room.

GROUP COHESION As participant-observer in a common psychological group experience, group members are asked to respond to specific therapeutic directives, follow instructions, observe their own responses, and compare them with those of their peers. In PGC, the leader assumes responsibility for what happens between members and offers each group member protection and safety while giving patients a vicarious learning opportunity and potentially activating their capacity for imitative behavior (Bandura, 1986). The therapeutic dialogue between the higher functioning group members and the leader offers a model of more adaptive social behavior. Group cohesion develops as more members increase their participation in the group’s tasks. The leader’s confrontation of noncompliant behavior as a whole creates a group process similar to gestalt, psychodynamic, interpersonal, and person-centered group approaches, because although the PGC leader seeks to minimize confrontations between member/s and the leader, confrontations are not discouraged. Throughout the session the leader repeatedly and regularly invites members to freely verbalize thoughts and feelings to the leader. This provides more protection for group members because the leader’s training and experience are guiding the interpretations and handling of the potential confrontations, challenges, and rejections of the leader’s instructions.

CONFIDENTIALITY EXPECTATIONS Confidentiality is not a requirement or even expected in PGC, because this group method does not make the assumption that group members are commit-

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ted and have the ability to maintain confidentiality. This makes PGC different from those group methods that rely upon group members maintaining confidentiality. In PGC, patients are never alone with the leader and their conversations are never private because ideally all group members are listening to the dialogue between the leader and each group member. When appropriate, the leader repeatedly reminds group members that whatever they choose to self-disclose is not confidential, and confidentiality is not expected or required of PGC group members. The leader also tells group members that although this is one of the limitations of this group method, maintaining confidentiality is not necessary to benefit from a PGC session. Patients are informed that if they desire and require confidentiality, an important ethical and legal advantage of professional individual treatment—with some exceptions—is confidentiality.

LEADER-CENTERED GROUP PROCESS The PGC method conceptualizes its group process as composed of two distinct processes. The first process is leader-centered, defined as all leaderto-member/s and member/s-to-leader communications. The leader-centered group process is always preferred in PGC because it reduces the risk of interpersonal conflicts and permits the proposed Plan to go forward in a safe interpersonal environment. PGC’s leader-centered group process differs most from traditional and modified group treatments where the leader encourages, relies upon, and is consistently focusing the group’s attention on their member-to-member interactions or the lack of such exchanges (i.e., member-centered). The PGC group process is deliberately restricted in order to limit the potential risk of interpersonal conflicts arising from the group treatment process. The method intentionally does not expose patients to interpersonal situations in which they could directly learn to solve interpersonal conflicts and have corrective emotional experiences. PGC’s restricted group process relies upon the leaderto-member/s and member/s-to-leader exchanges occurring in a brief, orderly, genuine manner to avoid the creation of harmful and destructive interpersonal conflicts that may occur in group treatments that depend upon members freely interacting, even when “acting in” behaviors—for example, verbal abuse—are prohibited (Nitsun, 1996; Ormont & Strean, 1978). In PGC, the leader always seeks to make the leader-centered group process the dominant group process.

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MEMBER-CENTERED GROUP PROCESS The second group process in PGC is member-centered, which can be defined as all interactions between group members. How much attention the leader will need to devote to group members freely interacting will vary in each group session. The variation depends upon the following considerations: 1) the amount of personal control patients have on the day they attend any scheduled session; 2) the composition of the group members, for example, if a subgroup of members are friends and are in the middle of a discussion when they enter the group and continue the discussion even though the leader has begun the Mini-Lecture; 3) whether it is the patients’ first PGC session; 4) how many and to what degree group members are reluctant to accept professional group treatment; 5) how difficult it is for some group members to tolerate the topic that the leader has selected for a particular session. Member-centered behavior in the PGC session is unavoidable, unpredictable, and not preventable. Paradoxically, the leader does not devalue membercentered group process: not only is it acceptable, but it is valuable and instrumental in creating a more “here and now” interpersonal learning experience by offering the leader an opportunity to define PGC’s goals and explain the reasoning behind the method. Sometimes, it can even help the proposed Plan to move forward, for example, when a very respected, sincere, and more experienced group member spontaneously tells new very reluctant group members—who are acting out their feelings towards receiving group treatment by not cooperating or complying with the leader’s instructions—how much they have benefited from past PGC’s sessions. This unsolicited testimonial can either move the proposed Plan forward or cause a conflict. The former occurs when the acting out group members respond by becoming more cooperative. The leader hopes this will happen, because the avoidance of conflict between group members is a major therapeutic objective. What is most important is that the testimonial not lead to a conflict, permitting the proposed Plan to move forward. The PGC method is not designed for and does not accommodate patients directly learning to solve interpersonal conflicts. Although the PGC leader discourages interactions between group members, he or she accepts and anticipates them and tries to understand what is motivating this behavior while seeking to explore and investigate the noncompliant behavior. If returning to the leader-centered group process and resuming the plan requires too much effort on the leader’s part, or the leader judges it not worth returning to because there seems to be an opportunity to achieve a more immediate therapeutic objective, then the leader could choose to deviate from the proposed Plan.

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A potentially beneficial way to cope with these situations is for PGC leaders to relax and have faith in their therapeutic abilities. In fact, some of the most effective learning and therapeutic experiences can arise from unique situations which occur spontaneously. For example, as a way of starting the investigation of what’s motivating noncompliant behavior, the leader might begin with an explanation to the group as to why members are being asked to restrict their communications to the leader and then ask each group member to verbalize their honest thoughts and feelings regarding the leader’s explanation briefly, directly, and honestly to the leader, while the other group members listen. The member-centered group process provides the behavior that is comparable to Yalom’s (1995) “grist for the mill.” Compliance and noncompliance with the leader’s directives provides the “here and now” behavior to be analyzed and changed. The PGC leader, like traditional group leaders, can still analyze and interpret how each member and the group as a whole are responding to all of the leaders’ directives, focusing attention as needed on the group process issue of compliance, cooperation, and resistance to the group tasks. When group members ignore the leader’s attempts to restrict the group process to a leader-centered model and change the group process to membercentered, the quantity and quality of the interactions between group members will determine whether this shift will significantly hinder the leader from going forward with the Plan. The group leader views this as a potential therapeutic opportunity to explore the thinking and feelings of those noncooperative group member/s, while their peers observe these encounters. The leader usually interprets this behavior as acting out. In this situation, the leader would shift the therapeutic objective to helping those group members who are acting out to assume responsibility for their noncompliant behavior, and to encourage them to practice verbalizing their thoughts and feelings regarding accepting the leader’s instructions. Good leadership skills, in addition to basic therapeutic techniques, can help the leader try to understand the behavior in an effort to win the noncompliant members’ cooperation in complying with the group tasks. When group members decide to speak among themselves, this behavior can be viewed on a continuum ranging from minimal interference to maximum interference with the leader’s attempt to follow the Plan. For example, periodic quiet verbal communications, although not preferred, may be tolerated if these exchanges do not seriously interfere with the progress of following the Plan. However, if a loud subgroup of patients who are friends continually speak among themselves, then this would most often be addressed because

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this could become the stimulus for conflict between those group members who wish to follow the leader’s directives and want the Plan to go forward, and those who do not. Here is where the leader could divert from the Plan’s topic and introduce a new and possibly more acceptable topic to explore, for example, “How to cope with conflicts that occur because of differences.” The leader’s rationale for the change of topic would be to avoid potential interpersonal conflicts since one of PGC’s basic objectives is to provide a safe, conflict-free interpersonal learning experience for all who attend. One strategy the leader could use would be to take responsibility for introducing a topic that may be “creating the conflict” since both groups are entitled to thoughts and feelings regarding the topic of the day. What the leader wants to communicate is that group members are always entitled to their thoughts and feelings and will be given repeated opportunities to honestly verbalize them to the group leader who is trained to accept them; but, what they are not entitled to expect is that others will always accept them and they should be prepared to experience rejection of some of their thoughts and feelings by others. All group members need to practice two things: first, learning how and when to verbalize their thoughts and feelings, to avoid harming themselves and/or others, and second, using their judgment regarding to whom these thoughts and feelings should be revealed. For the proposed Plan to go forward a leader-centered group process is needed. Since a member-centered group process is unavoidable and unpredictable, there may be times when this group process will threaten to dominate the group session. This will depend upon the clinical situation, the patient population (a relatively large number of reluctant to very reluctant patients), and the emotional and mental state of group members attending that specific group session. For example, when leading a PGC group for the first time with inpatients in a detoxification program, some of whom may be very irritable, angry at the staff, and very reluctant to accept psychological treatment, the leader would be prepared to make the educational and therapeutic best of this member-centered group process behavior. When treating certain patients who have never been exposed to a PGC group treatment session and who are convinced that 1) the leader-centered group process will be harmful to them; 2) members freely interacting is the preferred group process for them and all other attending patients; and 3) for the leader to be helpful to them, he or she should accept them as “coleaders,” the leader will need to confront and challenge these patients in order to help them accept the treatment they need (please see Chapter 5 for illustrations on when the leader should challenge or confront noncompliant behaviors).

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PGC’S SIMILARITY TO THE SELF-HELP GROUP PROCESS Clinical reality is often greatly influenced and defined by administrative and financial considerations rather than exclusively by professional ideals. There may be professional disagreements as well, since not all professionals may support the theoretical position that patients should be given the freedom and responsibility for determining when they attend and the length of their group treatment sessions. They might not endorse this view because they would not see this as being in the best interest of their patients. However, it is an interesting fact that attendance and participation behavior that is acceptable in self-help groups is not acceptable in most treatment programs and professional groups. The PGC group process is similar to self-help groups in that all PGC sessions are open to all group members whenever they arrive. As soon as patients enter the treatment room they are treated as active participants. The group process makes minimal interpersonal demands upon group members. Group members always determine when they self-disclose and the leader repeatedly reminds group members of their responsibility for choosing to make a comment or answer questions. Group members may also leave the session whenever they choose. The PGC leader always seeks to give each group member the maximum control over their attendance patterns and their level of participation throughout each group session. Lateness, absences, changing membership, and premature departures do not disturb the PGC group process, and do not affect group cohesion. Rather, group cohesion in PGC is dependent upon how many group members are willing to comply with the group tasks in each session. The PGC leader’s attention and concern is highly focused on the patients who have chosen to attend that day’s scheduled session. Group members are praised and thanked for attending. The leader thanks them because the more frequently patients attend, and the more they participate, the more potent the PGC group method will be for them. PGC is a more accepting and inclusive group process because it can accommodate patients with a wide range of intellectual abilities, and educational and occupational achievements, and who come from different socioeconomic classes and multicultural backgrounds. In addition, the group process demands are simple to understand and easy to follow. The PGC leader repeatedly makes the same requests to each group member and seeks to give all group members equal attention whenever possible. Patients can vary greatly in their commitment to their treatment goals and the group process can accommodate patients in all five stages of emotional readiness as defined

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by Prochaska, DiClemente, and Norcross (1992): precontemplation, contemplation, action, maintenance, and termination.

THE “GOING AROUND TECHNIQUE” (GAT) Description The “going around technique” is when a teacher, leader, or group therapist asks students or group members to comment in succession; it is also known as “round robin.” GAT is regularly used in most educational settings as a common didactic technique to engage each student as a means to increase their class participation and to stimulate and increase classroom discussion. Spitz and Spitz (1999) credited Alexander Wolf with originating the use of GAT to further his individual psychoanalytic goals in a group. Wolf and Schwartz (1962) observed its usefulness to activate interactions between group members. Today GAT is often used to increase interactions between group members in clinical and counseling settings. Leaders and therapists whose counseling and group therapy treatments depend upon these interactions to create the group process and achieve their therapeutic goals often use GAT selectively and irregularly. In PGC, however, the leader is dependent upon GAT and uses the technique repeatedly to create the group process and achieve the therapeutic goals for the day’s session. The repetitive use of this technique helps promote a calm, safe, and more predictable interpersonal learning environment.

Introduction to New Group Members In PGC, the leader assumes that most patients have had some past experience with this method. Even if a patient is not familiar with GAT, this does not deter the patient’s equal participation in the group’s tasks, because it can be learned quickly, is easy to understand, and is a very simple procedure to follow. The leader needs to devote very little time to describe GAT to most new group members; in fact, the procedure is so well known that often new group members who arrive late do not even need to have this technique explained to them; many just automatically wait their turn to respond. Since GAT is so familiar to most patients, new nonreluctant patients are better able

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to quickly make a contribution to the group process and immediately feel a sense of belonging with the group.

Equality The PGC leader accepts and treats all group members’ responses respectfully, and communicates a sincere desire to understand each member’s subjective experience as well as assist in their psychological development. GAT permits the leader to repeatedly relate to all group members in a direct, brief, nonthreatening, supportive, and similar way. Group members are entitled to an equal opportunity to verbalize their honest thoughts and feelings when it is their turn to respond, including all group members who are late or who may just be entering the PGC group treatment room, as well as those who persistently pass and whose nonverbal behavior may suggest that they couldn’t care less about being involved in the day’s session. What the leader wishes to communicate through words and actions is that each patient’s responses are needed by the group, and that each patient also needs what the group has to offer. Sometimes occasions arise in which a reluctant group member or other members’ behavior requires additional attention and other therapeutic interventions, making it impossible for the Plan to move forward and for the leader to equally engage each group member. In this case, the leader never suggests that the group member/s’ behavior is accountable for this situation, but rather accepts full responsibility for intentionally not applying GAT equally. The leader explains to the group that PGC uses GAT as a psychotherapeutic technique, and that its application might vary according to the leader’s clinical judgement, because sometimes people—because of their unique needs and communication styles—need a little more time than others, requiring group members to be more tolerant and accepting of the amount of time that others may require.

Implementation Inherent in implementing the “going around technique,” a choice needs to be made with regard to how to begin and conduct the questioning. Typically, the leader faces the group and starts with the nearest person to the leader’s left and then continues in a clockwise pattern. Those patients who have difficulty controlling and limiting their verbalizations may be very eager to

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ask questions and make comments immediately after, if not before, the leader has completed the lecture, and are very eager to be the first to speak. Often these patients may also be dominating group members in their other group treatments. Since the leader is a stranger to them, the leader has little information to evaluate this assertive behavior other than nonverbal cues from the person speaking and other group members, or whether other group members are actively or passively supporting the patient’s request to speak first. In this situation, the leader judges whether or not to ask the person speaking to remain patient and to follow the leader’s directive (i.e., wait their turn) or to permit them to speak first. If the leader decides to let that person speak first, other group members may perceive that the leader was manipulated by this patient, since from their perspective it will appear that the patient determined who got the opportunity to respond first, rather than the leader making that determination. Sometimes the nonverbal behavior of the other group members will support the interpretation that this patient is very needy and also takes pleasure in increasing his or her self-esteem by manipulating others, especially those in positions of authority. In this situation, the leader needs to take other contributing factors into consideration to determine which course of action to take. Even if the leader interprets this patient’s request as a power struggle, the patient is still complying with the leader’s first invitation to participate in the PGC group process, and there may not be any harm in letting very needy patients get some of their needs met by allowing them to “colead.” Permitting a needy patient to go first would also demonstrate that the leader is flexible and willing to let group members influence nonessential aspects of PGC’s group process. In general, as long as patients’ requests do not significantly interfere with the PGC group process, it can be advantageous for the leader to grant requests. Ultimately, it is the leader’s therapeutic judgement that determines whether an assertive patient should be permitted to begin the Question and Comment task, or whether the patient’s request should be denied, returning to the more neutral procedure, which is to start with the nearest person on the left and proceed in a clockwise manner.

YALOM’S THERAPEUTIC FACTORS The purpose of the PGC group process is to expose as many group members as possible to as many of Yalom’s (1995) group therapeutic factors—with

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the exception of the corrective recapitulation of the primary family group— which he describes as the instillation of hope, imparting information, universality, imitative behavior, altruism, and the development of socializing techniques.

Hope All professional treatments, including PGC, as well as self-help experiences, share the same basic therapeutic objective, which is to sustain a patient’s hope, because hope is the foundation upon which all change is grounded. The PGC group process is carefully designed and conducted to foster hope, and the leadership is dedicated to providing a harmless-to-helpful group treatment experience for all group members each time they attend a session. In PGC, at a minimum, the level of hope that each patient brings to the treatment session needs to be maintained, but ideally, the level of hope should be increased. Hope can be increased in two ways: The first is for new patients to observe and compare themselves with group members who are at different levels of achieving independence from chemicals and who vary in their mental functioning. The second is for patients to experience the leader’s optimism. The leader informs new patients that they will improve if they accept all the professional treatments and self-help group experiences they need and that are available to them, and that what they need to do is attend and participate in these treatments and experiences as much as possible. The leader tells them that this is based upon his or her past experience working with patients who have had similar problems. We concur with Yalom (1995) that improved interpersonal relationships is the means to fostering better mental and physical health for all people. Based upon our clinical experience, we maintain that for many chemically dependent and psychiatric patients caring, supportive, and helpful relationships with others are absolutely necessary to prevent the further deterioration of their psychological and biological functioning. Often, patients who request, or who are sent for, professional help have already exhausted most of their personal and social resources to cope with their chemical dependency and psychiatric problems. They are usually desperate. Family and friends may also be exhausted from trying to be helpful and failing. Since chemically dependent patients need to change chemical consuming behavior, they need to transfer their dependency on chemicals to relying upon caring and helpful family members, friends, and professionals. Improved interpersonal relationships will help psychiatric patients reduce their social alienation and improve their reality testing.

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Imparting Information The PGC group process begins with a didactic approach by the leader who provides a Mini-Lecture on that day’s topic. All group members are invited and expected to listen until the end of the leader’s lecture. This didactic approach, often used as a primary teaching method in educational settings, is a very common and familiar experience to all incoming group members, despite whatever differences they may have in the quantity and quality of their formal and informal educational experiences. The leader initially engages new group members as a “teacher” for a number of important reasons. First, because being treated as a “student” is more dignified than being treated as a “patient,” and it implies that group members are capable of learning. Second, because patients’ attention and cooperation are required for them to benefit from the leader/teacher’s efforts. Third, because being in the familiar student role helps to reduce new patients’ initial social uncertainty. Uncertainty can increase a patient’s general level of anxiety as well as acting out behavior. Most patients requesting and requiring treatment do not want or need any additional sources of anxiety. The student role is only preferable to the patient role if being a student is less stressful. Unfortunately, many patients have had past educational failure experiences and may have acquired harmful notions regarding their ability to learn. This is why the leader, when welcoming patients to their first PGC group treatment, informs them that although PGC uses familiar teaching methods, they never have to answer any question or make any comment. The leader tells them that because PGC is a psychological treatment approach, they will not be asked questions that have right and wrong answers. The leader continues to explain that when patients do not wish to answer a question or contribute a comment, they can respond by saying they wish to “pass.” Group members are always permitted to pass as much as they wish without negative consequences, because the PGC leader always wants group members’ responses to be voluntary and honest (please see Chapter 4 for illustrative examples of how a PGC leader seeks to engage patients who persistently pass).

Universality Chemically dependent, psychiatric, and MICA patients share similar diagnoses, suffer from like symptoms, and frequently need to cope with social isolation. Although PGC is theoretically based upon the belief that all human

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beings are more alike than different, each patient comes to PGC as a unique being with a different set of life circumstances and personal relationships, past and present. Their perceptions, emotions, thinking, and actions at times are distinctive. Patients benefit from observing how they are similar to others, because it fosters their relatedness to others. Patients also benefit from observing how they are different from others, because this promotes appreciation of their uniqueness. In order for patients to see how they are similar and different, there needs to be a shared common experience to which all group members have an opportunity to react. PGC’s group process provides group members with repeated invitations to focus their attention upon what is happening in the room in the immediate present, to increase their self-awareness by reflecting upon their thoughts and feelings, and to verbally communicate their honest, spontaneous, subjective responses to the leader as their peers listen. This is PGC’s shared common experience. Although it is always preferred, and would be ideal, for all patients to verbalize their subjective responses when the leader asks, it is not necessary for group members to disclose their thoughts and feelings to others. For constructive change to begin, what is necessary is that patients become more aware of their helpful and harmful thoughts, feelings, and actions. Increased awareness creates new and greater choices to help them cope and, ideally, to change their maladaptive and self-defeating behavior patterns. Each patient is told that they may pass rather than self-disclose and that this can still be very beneficial to them because complying with the leader’s instructions and focusing their attention upon their physical and psychological reactions to the questions they are asked will increase their self-awareness. Increased self-awareness can increase the potential for significant personal change.

Altruism Psychiatric and chemically dependent patients often enter treatment hating themselves for all their failures, real or perceived. Many patients believe that needing and accepting psychological help demonstrates to the world that they are worthless and helpless. They enter treatment defeated and demoralized. Their self-esteem is low and they do not need any additional life experiences which would further lower their self-esteem. Therefore, the PGC leader always seeks to communicate that the patient’s decision to accept professional help demonstrates that they have made a life-enhancing decision, and that to make this choice is a sign of their strength and adaptive ability.

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Following the completion of the Mini-Lecture, the leader then asks each group member whether there are “any questions or comments concerning anything I have just said.” This is when patients are given their first opportunity in a PGC session to actively help themselves and others. The leader thanks them for their responses because the leader wants to acknowledge and reward them for making their contribution to the group process. The leader communicates that all group members are valued and needed. When patients help others, they expand their positive sense of self because to help others requires a shift of attention away from themselves, thus decreasing their negative self-absorption. The PGC leader repeatedly engages all patients in making verbal contributions to the group to generate the group process. Although the leader always accepts each group member’s choice not to self-disclose, the leader continually encourages group members to self-disclose because their responses are needed for other group members to be able to make comparisons. The process of comparing our responses to the same stimulus to which others have been exposed allows us to learn how we are similar to or different from others. The leader and the other group members need members to self-disclose to get the most from the psychological exercises. Therefore, each group member’s compliance with the group tasks is needed and highly valued by the group leader. The leader’s Plan and efforts are insufficient to lead the group session effectively, because the quantity and quality of members’ contributions to the group process are a critical factor in the effectiveness of a group session.

Imitative Behavior The PGC exercises give each group member repeated exposure to how others perceive and respond to the group’s tasks. Group members can compare how they respond to higher-functioning peers, and they can learn to imitate their behavior. Chemically dependent patients who are struggling with identity issues which result from their terminating chemical consuming behavior need new models with which to identify. Patients who have made dramatic lifestyle changes can serve as the needed models. The PGC group process exposes group members to both self-defeating and constructive behaviors exhibited either by group members who are uncooperative and uncommitted to changing their maladaptive behaviors, or by members who more readily accept treatment, make significant behavioral changes, and are committed to a more constructive lifestyle. In addition to encouraging all group members to observe how other members respond to the group’s tasks, the leader also serves as a model for

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alternative ways of responding. All of the above increase the potential for patients to learn vicariously. The leader may also encourage group members to try different ways of responding to the group’s tasks, and to see if these new ways of behaving increase their self-esteem and their relationship with others.

Development of Socializing Techniques In every PGC session, the leader seeks to improve all group members’ social skills. The development of socializing techniques is directly addressed whenever the leader selects a topic and creates a Plan to improve interpersonal relationships (please see Chapter 8 for examples of Plans designed to improve social skills). To relate to others without offending or harming them requires the ability to control one’s responses to others’ behavior. One crucial ability that needs developing is the ability to wait; another is the ability to selfdisclose thoughts and feelings. Each PGC session indirectly fosters the development of these social skills by giving patients the opportunity to practice waiting, listening, and verbalizing their thoughts and feelings. Patients are repeatedly being asked to listen to each other’s verbal responses while waiting for their turn to respond. They are then expected to make verbal, direct, brief, and honest self-disclosures to the group. New uncooperative and noncompliant group members who are not ready to accept treatment will often inconsistently follow the leader’s directives to wait, listen, and verbalize their thoughts and feelings. However, this noncompliance with the leader’s instructions falls on a continuum. Initially, the leader does not know whether patients are unable or unwilling to do the task. Our experience confirms that, in most cases, patients are unwilling, but would prefer that the leader believe they are unable to perform the task.

Chapter

Five Preparing for a PGC Session

Member Selection Diversity. The PGC method was developed to embrace a very diverse multicultural population. It was originally created to meet the needs of day hospital psychiatric patients in New York City, and then was further developed to accommodate the needs of chemically dependent, as well as mentally ill and chemically addicted (MICA) patients in the methadone maintenance outpatient program, and the inpatient and outpatient Substance Abuse Rehabilitation Program (SARP) in the Manhattan Veterans Affairs Medical Center. These patients were primarily male, and approximately equally divided between African-American, Caucasian, and Hispanic, but differed in age (18–70 years old), ethnicity, religion, social and economic class, formal education, work experience, intelligence, emotional maturity, emotional difficulties, contact with reality, and physical problems. Their previous psychiatric treatment experiences were also diverse—some had no history of psychiatric hospitalizations or outpatient psychotherapy, while others were well experienced with both. Patients’ living situations also differed, from single-room occupancies to living with families, friends, or significant others, or in homeless shelters. Patients’ past exposure to and involvement with psychiatric and chemical dependency treatment programs varied from first treatment program experience to many treatment program experiences over many years. Motivational Requirements. A patient’s motivation for attending a scheduled PGC session is not a primary consideration or even a significant reason 65

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for exclusion from a PGC session. There are no motivational screening requirements for attending and benefiting from a PGC session. In any PGC session incidental, vicarious, or spectator learning is always possible; this is a basic assumption of the PGC method (Bandura, 1986). The PGC leader does not focus on why patients choose to attend or not attend a session, if they have a choice. The leader’s concentration is on their “here and now” behavior in the session. Patients representing a wide range of acceptance and commitment to receiving psychological treatment are welcomed in PGC because this method is purposely designed to treat patients who are very conflicted and opposed to receiving psychological group treatment. Exclusion Criteria. As a general guideline, all chemically dependent and MICA patients can be screened by intake staff and assigned to attend any scheduled PGC session. The PGC leader would not be required to provide any additional screening with the exception of some acute patients requiring either immediate psychiatric care and/or detoxification. These patients would be referred to the appropriate treatment staff within the program. The PGC group method is very inclusive because the expectations for acceptable behavior for group members are minimal. Acts of physical violence are not acceptable or tolerated in any PGC session. Apart from acts of violence, the PGC leader uses minimal exclusion criteria. Patients who do not or cannot control themselves are excluded. The PGC leader seeks to protect patients from acting violently towards one another by always being very aware of this possibility and being very quick to intervene. The PGC leader always supports and helps patients increase control over their violent thoughts and feelings; they are given permission and encouragement to leave the group if they feel they may act in a violent manner and are asked to return when they believe and feel they can control themselves.

Group Size The PGC method relies upon a workshop model to cope with varying attendance patterns. Ideally, the group size ranges from 15–20 group members, but it can vary without interfering with the group process. This feature of the PGC method makes it an ideal group treatment for those clinical and counseling situations where patients’ and clients’ attendance patterns are typically irregular and unpredictable. In the 28-day inpatient detoxification, and two-year outpatient Substance Abuse Rehabilitation Program (SARP), the authors’ clinical experience indicates that a group of 15–20 members is ideal for the PGC group method.

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In the outpatient program, the authors were able to successfully recruit 15–20 group members to attend regularly scheduled PGC sessions by having the staff assign 30–50 patients to the group. Typically, a minimum of about one-half of those assigned to a group attended each scheduled session.

Physical Environment and Materials Needed Ideally, a large, light, airy, and quiet room, with separate entrance and exit doors in the front and back of the room, is desired. For 15–20 group members, the room should accommodate 20 moveable chairs, which the leader arranges on 3 sides of a “square,” an equal (roughly) number of chairs per side, with a large blackboard and chalk (or something comparable), and 1 chair in front of the blackboard for the leader, to complete the square (see Figure 5.1). The corners of the square should be left open for easy access and exit by members. On the blackboard, the leader writes the following: 1) the leader’s name and title; 2) one broad, and one specific interpersonal or intrapersonal goal, determined by the objectives and the topic being explored for that day; and 3) an outline of the session’s “Plan.” Placing a chair in front of the blackboard allows the leader to lead the entire group session from a sitting position. However, it is most useful when the chair is used selectively. Standing, and freely moving in different directions, such as moving to the center of the group or to the left or right side of the blackboard, permits the leader to better observe the entire group’s reactions to the leader’s monologues and dialogues with individual group members. The leader’s freedom to move towards and away from different group members gives the leader another nonverbal communication component.

Leader’s Preparation The PGC leader will need approximately one-half hour to prepare for a PGC session. During this time the leader will need to do the following: 1) select the topic for the day, the Mini-Lecture material, the word for the Word Association, and the Psychological Question; 2) prepare the room to receive 15–20 patients, that is, arrange the chairs as described above, which always permit patients to enter and leave the group with minimal interference with the group’s process; 3) write the Plan and goals on the blackboard or equivalent; and 4) prepare physically and psychologically.

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FIGURE 5.1 Seating arrangement for a PGC session.

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Physical preparation is necessary to put the leader in a relaxed and receptive state. Taking a few minutes to do some relaxation exercises would be helpful. To lead a PGC group session effectively the leader needs to be relaxed, ready, and receptive to coping with the unexpected, as well as maintaining a high level of awareness for one hour. Selection of topics and plans is the responsibility of the leader, and patients are not informed of the day’s topic prior to the group session. The PGC leader does this to stimulate patients’ curiosity, to avoid patients prejudging whether or not to attend the day’s scheduled session based on what they think or feel about the proposed topic, and to give the leader maximum flexibility to determine the most helpful topic to explore. The leader decides whether to select an intrapersonal or interpersonal therapeutic goal, depending upon an assessment of what would best meet the needs of the patients on the day on which the session is scheduled. There are two more very important reasons why the leader needs to be free to determine the topic. First, the leadership role requires the leader to be very active and genuinely involved in all aspects of the planned group experience. To achieve this, the leader needs to be emotionally committed to executing the Plan, as well as sincerely curious about and interested in each group member’s responses. To do this the leader selects topics that they find professionally interesting and which they are motivated to explore with their patients. Second, the leader’s optimism and enthusiasm are needed to influence how the topic is received and the level of patients’ cooperation and compliance in performing the group’s tasks.

Preparation and Orientation Patients. Intake staff briefly orient members to regularly scheduled PGC groups. Members need no prior preparation before entering a PGC group. The leader orients all present members when they enter the group, and then briefly new members as they arrive. The leader welcomes them warmly, invites them to sit wherever they wish, but requests that they please remain in their seats. The leader then tells members that this group method may be different from any group method they have experienced because it was especially created to accommodate lateness, varying attendance patterns, and differing levels of commitment to change. The leader points to the PGC goals which are written on the blackboard, briefly explains them, then tells members that there is no confidentiality requirement. Therefore, before disclosing any thoughts and feelings, they should consider that fact. Members are also told

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that whenever the leader asks them a question or invites them to participate in any exercise, they are always free to respond by “passing.” They are asked to refrain from asking any questions or making any comments to any group members, and are told that they will be given repeated opportunities to freely express any thoughts or feelings, and direct any questions and comments about the group experience, but only to the leader. The leader explains that their cooperation and compliance with these directions is necessary to maximize the PGC learning experience, while minimizing potential confrontations and conflicts. Visiting Professionals, Interested Staff, and Students. Since PGC is based on an open-ended group workshop model, it can easily accommodate visiting professionals, treatment staff, administrators, and students/interns as additional group members, bringing to the group a variety of professional disciplines and level of professional skills and experiences, and further increasing the diversity of group members. On separate occasions, these participants could include psychiatrists, psychiatric residents, nurses, nursing assistants, nursing students, social workers, social work interns, occupational therapists, visiting psychologists, psychology interns, and the clinic’s secretary. The PGC leader is free to determine when and how many visitors can attend any PGC session. After orienting prospective professionals to PGC’s goals and method, the leader informs them that they are welcome as “participant observers,” that is, they will be introduced to the group as a visiting staff member, professional, or student who will be attending the session in order to observe how the leader conducts a PGC group and how patients respond to this method. Before entering any PGC session all visitors have to agree to cooperate and comply with the leader’s instructions; thus, they will be invited to contribute to the group process by doing the group’s tasks, and they will have the same rights as all group members, namely, they may pass at any time they wish, and they may also leave whenever they choose. In essence, the leader relates to them like any new group member. There are two very important reasons why the PGC leader seeks to obtain all visiting group members’ assurances that they will not deviate from their “participant observer” role. First, the leader’s ability to lead a PGC group is always dependent upon establishing and maintaining a trusting relationship with each group member; therefore, adding visitors as additional group members requires further trust on the part of patients. If visitors step outside of the participant-observer role to make what they feel is a helpful therapeutic comment to a group member or the group as a whole, they are demonstrating to the patients that the PGC leader misled them. This occurrence could lead to a potential loss of trust. To

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prevent this possible loss of trust, the leader would then need to deal with the visiting group member’s noncompliant behavior. For example, the PGC leader could confront the visitor, thanking them for making a helpful comment, and ask them to please return to the “participant observer” role since the PGC group method is different from other group methods and is not designed to accommodate and benefit from interactions between group members, and that this is one of its limitations. The second reason for which PGC leaders seek to obtain all visiting group members’ assurances that they will not deviate from their “participant observer” role is that it has been our and other staff members’ observation that various patients will self-disclose thoughts and feelings in a PGC group session but will not usually self-disclose in other group treatments in the program. When this occurs, it can be very tempting for a visiting staff member who is also treating some of the PGC group members in the program and already has a therapeutic relationship with them to want to make therapeutic comments and other interventions because they see an opportunity to be more helpful to these patients. Visitors sometimes express the feeling that much more could be done with the material the PGC process generates. Visitors are cautioned during their orientation to resist this possible therapeutic temptation to be helpful and to remain in the participant observer role because PGC accepts limited therapeutic goals to maximize interpersonal safety. It has been our experience that most patients welcome and report benefiting from the contributions of visiting group members. Since the PGC group was designated as a training group for psychology interns, and was different enough to have, from time to time, visiting professionals from diverse professional disciplines wanting to experience it, this added value and prestige to being a patient in a PGC session. We also believe that equal treatment of visiting professionals and patients communicates that in a PGC group each person is perceived to be of equal value to the group process. Thus, for patients who feel demoralized and devalued as people because of their profound psychiatric and chemical dependency problems, to sit next to a professional person and be treated by the leader in a similar manner communicates the acceptance and respect that the PGC leader has for patients participating in professional group treatment.

Organization of Sessions The PGC method is a planned, half-hour to one-hour, single-session workshop model. The PGC model conceives of each session as potentially the first,

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last, or only therapeutic encounter (Talmon, 1990; Walter & Peller, 1992). By contrast, one of the ways in which PGC differs from planned singlesession therapy is that members are actively encouraged to return to future PGC sessions (Bloom, 1992). Each session is conceived of and conducted as a self-contained social, educational, and therapeutic learning experience. Punctuality, participation in full sessions, and regular attendance are encouraged, but members have the freedom and responsibility to determine when they come and go. These group norms are similar to those of self-help and religious group experiences. The PGC method assumes that past or future attendance is not necessary for a member to benefit from a PGC session. Patients are told that there is no preferential treatment or seniority in PGC, and that everyone will be treated similarly and given an equal opportunity to benefit from what a PGC session has to offer, regardless of whether they attend regularly, come on time, or regularly participate in all of PGC’s tasks. Patients are reminded, however, that the more punctual they are, the more sessions they attend, and the more they participate, the more they will benefit. In some programs, it is mandatory for patients to attend all scheduled group treatments and to remain in their treatment groups until the leader ends the group session. In this situation, the patient cannot avoid being exposed to group treatment without penalty of discharge. The model provides optimal flexibility and frequency possibilities from planning a one-time session to planning many sessions in a variety of clinical settings such as inpatient admissions wards, outpatient psychiatric services, and chemical dependency treatment programs. Many patients, after participating in the one-week inpatient detoxification program, accept discharge to the 28-day inpatient program where they attend PGC sessions twice a week. After being discharged from the 28-day inpatient program, many of the same patients accept placement in the outpatient program where they attend a minimum of one PGC session per week, for up to two years.

Leader Arrives Early If at all possible, it is always advantageous for the leader to arrive early for a PGC session, especially if the leader is unfamiliar with the physical environment, in case extra time is needed to prepare the room and write the Plan and goals on the blackboard. If a leader schedules a group at a specific time and patients are told to attend the scheduled session at that time (usually patients are not consulted as to when they will be expected to attend their group treatments), then for the leader to arrive late and be unprepared to

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begin the group at the scheduled time may be interpreted by some patients as a demonstration of the leader’s lack of commitment, concern, and competency to lead their group—or even worse, proof of a complete lack of respect for them as individuals. Many very reluctant patients are hyperaware of interactions in which they experience incongruous words and actions. Honesty and consistent leader behavior are necessary to begin developing trust. The leader’s lateness may only increase doubt in the minds of patients who are already prejudiced against and reluctant to attend professionally led groups. How clearly, honestly, and responsibly the leader communicates the explanation for being late can greatly influence how patients interpret the event, but lateness is definitely discouraged because it places the leader in a defensive position.

Chapter

Six Detailed Description and a Replicable Example of PGC

PGC GOALS PGC was created to increase a patient’s self-awareness and acceptance of psychological group treatment. Ideally, the leader seeks to make very reluctant patients less reluctant; to make reluctant patients nonreluctant; and to help nonreluctant patients expand their awareness so that they can identify and change maladaptive thoughts, feelings, and actions. In PGC, formation and maintenance of the therapeutic alliance provides the leader with the principal means to help patients increase self-awareness and change harmful behavior patterns. The PGC leader relies upon Adler’s concept of a therapeutic relationship that is based upon an alignment of the patient’s and the therapist’s goals. According to Adler (Corey, 1995) both the goals and procedures of group treatments must be acceptable to the patient for treatment to be completely successful. Agreed upon achievable treatment goals are necessary to win the patient’s complete cooperation and participation in the treatment process. “Resistance” is defined as a discrepancy between the therapist’s goals and the patient’s goals. Chemically dependent patients enter treatment for many reasons. Some enter because of external factors, for example, threatened job termination, school/college expulsion, or threat of losing significant others. The goal for a patient entering treatment for external reasons would be for the leader to help the patient to develop internal reasons for receiving treatment. The patient’s reluctant behavior is always treated with respect in PGC, because 74

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the leader accepts the notion that sometimes what professionals perceive as necessary treatment experiences and what patients perceive as necessary and beneficial may be quite different (Wile, 1977). The leader accepts responsibility for helping patients appreciate and find some internal reasons for fully participating in a PGC session. The most important goal of each PGC group treatment session is to provide a harmless to helpful group treatment experience for all group members. This commitment and therapeutic goal supersedes all of PGC’s therapeutic objectives. The goal is to make receiving psychological group treatment tolerable and acceptable to the widest range of individuals; most important, the patients must be able to tolerate and meet the demands and requirements of the treatment process. Therefore, if necessary, the leader will abandon all other therapeutic goals to keep this commitment. PGC was created to accommodate and win the voluntary cooperation, as well as the active and successful participation, of a wide variety of reluctant and nonreluctant patients. As far as possible, all patients are treated equally in a highly structured and meaningful social, educational, and psychotherapeutic group treatment experience and are challenged to participate to the best of their ability.

Basic Goals: A, B, C Acceptance: Increased self-acceptance. This requires that patients accept that they are chemically dependent, that all of their present personal efforts to free themselves have been unsuccessful, and that it is now in their best interest to accept all the professional treatments, and self-help and religious experiences they may need. Behavior: Changing harmful behaviors. Patients are invited to identify their most maladaptive and harmful behavior patterns (e.g., avoiding treatment) that need to be changed and to make as many of these changes as possible. Commitment: Avoiding chemical dependency and confronting the “major” question. Patients are encouraged to make a commitment to continuing treatment and to make needed changes to avoid chemical dependency. In doing so, they increase responsibility for self-development, and increase empathy towards others. Every person who has become aware and accepted that they have become dependent upon alcohol or other drugs—legal or illegal—also has a profound question to answer: Can I learn to use alcohol and other drugs moderately without again becoming chemically dependent, or must I learn to totally

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abstain from using any and all drugs? How each patient answers this question will greatly influence what treatments they will accept.

Humanistic Goals Group members are not viewed, or encouraged to think of themselves, as “drug abusers,” “addicts,” or other stigmatizing labels that ultimately narrow their motivation to change behaviors. All group members are treated as individual human beings with problems and problem behaviors. The PGC method is firmly dedicated to humanistic therapeutic goals. The content of each session is focused upon universal, existential human concerns and their derivatives. Ideally, each session gives each group member an equal opportunity to participate in all group tasks, to experience how they are similar and different from others (both individuals who misuse chemicals, and those who do not), to appreciate their uniqueness, and to leave the session feeling more hopeful, self-accepting, socially related and willing to return to accept all the treatments they may require. To achieve PGC’s goals, patients are repeatedly invited to engage in PGC’s core group tasks, which are practicing self-reflection, listening to others, and honestly self-disclosing in the form of direct, brief verbalization of thoughts and feelings occurring in the “here and now,” while their fellow group members listen. Broad interpersonal goals are to: 1) invite and engage each patient in a psychological dialogue that seeks to obtain the patient’s cooperation and compliance with the leader’s psychotherapeutic directives; 2) provide a supportive, protective group experience that minimizes conflicts and maximizes interpersonal learning between group members; 3) accept and accommodate patients who are very conflicted about changing or receiving psychological help, who are unable and/or unwilling to manage their time, and who attend group treatments irregularly; 4) provide an opportunity for each patient to communicate and be affiliated with others, and to be a significant and needed participant in the group’s tasks; 5) encourage patients to always be responsible for determining when and how much to participate and self-disclose. Specific interpersonal goals are to: 1) offer patients opportunities to learn and practice self-control, and self-disclose their thoughts and feelings without harming themselves and/or others; 2) give patients an opportunity to experience the positive effects of honestly and verbally expressing thoughts and feelings to an empathetic listener; 3) practice listening, and encourage patients to be more empathetic towards others; 4) reinforce patients’ efforts to seek

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and accept help from supportive friends and family members, self-help and religious groups, and all needed professional services. Broad intrapersonal goals are to: 1) encourage patients to practice selfreflection; 2) increase patients’ self-awareness and self-acceptance; and 3) encourage them to direct their attention to and accept responsibility for how they perceive, feel, think, and act in the “here and now,” and compare these experiences with their peers. Specific intrapersonal goals are to: 1) help patients recognize and label helpful and harmful thoughts (especially irrational ones), feelings, and actions; 2) reinforce those which are adaptive, and discourage those which are selfdefeating; 3) help increase their awareness of, and their ability to better tolerate, unwanted emotional experiences, e.g., feelings they tend to deny and avoid (anxiety and sadness); and 4) increase patients’ awareness of how thoughts and emotions, especially thoughts outside of awareness, can contribute to helpful and harmful behavior patterns. The above goals are an attempt to facilitate self-change, leaving it to patients to make their own choices about changing self-defeating behavior that is a consequence of the misuse of legal or illegal chemicals.

CLINICAL SETTINGS: ONE-WEEK INPATIENT DETOXIFICATION, SHORT-TERM INPATIENT, AND LONG-TERM OUTPATIENT REHABILITATION PROGRAMS In this chapter is a detailed description of how PGC is applied as a singlesession intervention in a one-week inpatient alcohol/drug detoxification program conducted in a medical setting with a multidisciplinary staff. This detailed example provides a representative sample of the group method and leadership. What follows is how PGC is used as a multiple-session intervention in both short-term inpatient and long-term outpatient rehabilitation programs. After attending the detoxification program most patients are encouraged to attend outpatient treatment, where many of the same professionals are on the treatment staff. In this case, the PGC session which the patient attended in the detoxification group would serve as an orientation to PGC, since upon entering the short-term inpatient or long-term outpatient programs, they would enter an open PGC group that would meet several times a week. In a subsequent chapter, we will focus on how the PGC method is used to meet the needs of psychiatric patients in inpatient admissions and day

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treatment center outpatient programs, as well as in educational counseling settings.

DETAILED DESCRIPTION: ONE-WEEK INPATIENT CHEMICAL DEPENDENCY DETOXIFICATION PROGRAM The leader is committed to using the PGC group method to support and complement the interdisciplinary program’s general goals, which are to help patients accept that they are chemically dependent, and reinforce and support patients’ commitment to receiving all the medical and psychological treatment recommended by the clinical staff—including self-help and religious experiences—that may be necessary to free them from the very harmful social, physical, and psychological effects of chemical dependency. In a five- to seven-day detoxification alcohol/drug program, patients may be exposed to the PGC group only once, in which case PGC serves as a single-session intervention. The group is composed of approximately twenty chemically dependent and MICA patients. In a group such as this, a group leader can expect that there will be an unpredictable and uneven distribution of nonreluctant, reluctant, and very reluctant patients, both voluntary and involuntary (court ordered).

Leader’s Welcome, 2–3 Minutes Ideally, the leader has the time to become familiar with the treatment room and to write the Plan for the session on the blackboard or something comparable before the patients enter the treatment room. This gives the leader time to accommodate to the physical situation and to get psychologically ready to lead the group. However, if the leader enters a treatment room in which patients are already present, then the leader has to write the Plan on the blackboard while coping with curious patients who are asking questions, commenting, and “joking.” Thus, in this situation, the leader is trying to accomplish the task of writing the Plan on the blackboard while “informally” engaging with the more extroverted patients, some of whom may be friendly and welcoming while others may be confronting and challenging. How patients engage the leader provides the leader with some important preliminary information regarding which patients are likely to require more attention and time, which patients have great difficulty restraining their verbal activity,

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and which patients may be actively hostile toward the leader’s presence and leadership role. To begin, the leader writes her/his title, name and professional affiliation on the blackboard: Ms. Jones, Clinical Social Worker Welcome to Planned Group Counseling, a group method that will help you to: • become more aware of your perceptions, emotions, thoughts, actions • identify those that are helpful and harmful • change those that are harmful to you and others Today’s Topic: Accepting Help from Others Part I.

Mini-Lecture (me)

Part II.

Psychological Exercises: 1. Word Association (me)

Part III.

2. Psychological Question (me) Final Questions/Comments

Questions and Comments (YOU) Response (YOU), Analysis (me) Response (YOU), Analysis (me) (YOU)

Once the leader is in the room, has arranged the seating, and has written the Plan and goals for the session on the blackboard, the leader is ready to make an introduction to all who are present. Leader:

I am Ms. [Mr., Dr.] Jones, and I am a clinical social worker [psychiatric nurse, psychologist, etc].

In PGC the leader is encouraged to use formal titles and professional affiliations for three important purposes: one, using formal titles begins to define the leader as an expert who plans to use professional leadership skills to conduct a very structured group treatment method. Second, listing professional affiliations helps to empower patients by giving them new information. Many patients are confused about the titles of mental health professionals and their different clinical functions, and many patients frequently do not know the difference between administrative and clinical social workers, medical and psychiatric nurses, or psychologists and psychiatrists. This pre-

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sents the leader with an ideal opportunity to begin relating in a didactic manner and to start the relationship by giving potentially useful information (i.e., defining these terms). Third, the professional titles and affiliations communicate and emphasize the differences between the patient and the professional. This is a social reality. Professionals are responsible for defining, designing, and conducting the group treatments which patients are asked to accept and hopefully benefit from, but which may be very uncomfortable for some. The person who accepts the patient role is required to accept an asymmetrical dependent relationship. The asymmetry occurs because professionals have the authority and responsibility to determine the group treatment experience without necessarily consulting the patient. Reluctant patients are often fearful, and lack the trust that is necessary to accept a dependent relationship with another. After making the initial introduction, the leader turns to the blackboard, points to what has been written, and then says: Leader:

Please read what I have written on the blackboard. I hope that what is written and what we will do today as a group will be helpful to all of you.

Members Respond Two typical responses can be expected: first, “I can’t see what you have written from where I am sitting” and second, “I can’t see, I don’t have my glasses.” Careful attention to the tone of voice suggests whether the patient is disappointed or grateful for not being able to comply with the leader’s first directive. If these patients can’t see, then you can’t expect them to participate in the first group task, namely, read what is written on the blackboard. Furthermore, the leader has immediately demonstrated an “insensitivity and ineffectiveness” by asking patients to do something they are unable to do. If what the leader writes on the blackboard is supposed to be helpful and the patient can’t read it, then the leader is being unhelpful. These two responses can absolve some patients of their responsibility to participate in the group treatment and also serves to alert other group members that what this professional says, i.e., “I want to be helpful” is now in contrast to the leader’s actions, namely, asking some patients to do what they can’t. This may suggest to the patients that the leader does not deserve to be trusted and may be incompetent. When leading a PGC group with many reluctant and some very reluctant patients, the PGC leader should expect some of these patients to

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freely interpret the leader’s imperfections and less skillful interventions as proof of the leader’s “incompetence,” because a common excuse used by some very reluctant patients for not changing their self-defeating and harmful behaviors is blaming others for their lack of change. Whenever the PGC leader asks patients to follow the instructions, the leader is assuming patients are capable of doing what is asked of them. For example, in the above scenario, the leader makes two basic assumptions: first, that patients can see the written material, and second, that they can read English. The first assumption was not true. In this case, the leader could respond as follows: Leader:

If you can’t read what is on the blackboard or you don’t feel like reading what I have written, that’s OK, because whenever I write anything on the blackboard I will also read it aloud, for everyone to hear. If you have difficulty hearing me, please feel free to change your seat and sit closer to me. However, for those of you who can read what I have written, if you choose to read what is written on the blackboard, reading will help you to learn and perhaps help you to better retain what you have learned, because you will be actively engaging with the new material when you read it as well as listening to me reading it. This will also help you to learn because the new information is coming from two different sensory channels: seeing and hearing. It’s your choice to read or listen or both. I would encourage you to do both so you can get the most from today’s session, but of course it’s up to you how much you learn today.

While the leader is saying the above, patients will often be entering the room. The leader may often interrupt the above explanation to welcome these most recent arrivals, some of whom may apologize for their lateness. Whenever a patient apologizes or gives an excuse or explanation for their late arrival, it is the leader’s opportunity to communicate that in a PGC group patients are always welcomed, including “latecomers,” who are commended for coming no matter when they may arrive. The leader praises all patients for “just being in the program” and attending the session. The leader may also say that what is most important, at this time, is that the patient remains committed to receiving treatment and that he or she hopes that the sincere invitation to participate in a PGC session will be helpful to them. What the leader seeks to communicate to entering patients whenever they arrive is that

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the leader is glad to see them in the treatment room and looks forward to their participation in the PGC group process, because they are needed and they can benefit from what the group does that day.

BEGINNING THE MINI-LECTURE Purpose of the Mini-Lecture After welcoming patients to the group, the leader’s next objective is to help them focus on the group’s first task, which is listening to the Mini-Lecture given by the leader as an offering of knowledge (“a gift”). In the Mini-Lecture, the PGC leader uses both didactic techniques—giving a brief lecture—and the “going around technique” to serve the elementary objectives of improving patients’ listening skills and reinforcing honest, direct, and brief verbalization of thoughts and feelings occurring in the “here and now.” The Mini-Lecture is conceptualized to complement the various components of the Plan, to give latecomers an opportunity to assimilate and enter the group with minimal disturbance to others, and permits the leader to provide some helpful information to all patients—particularly those who are ready, able, and eager to accept and benefit from professional help. The leader gives information equally to all patients with the hope that it will be useful, and is responsible for communicating the information clearly and accurately, and establishing that the information is received in the manner which the leader intends. This portion of the PGC Plan is conceptualized to provide a “warm-up” experience, that is, to encourage patients to begin to practice the process of listening, receiving, self-reflecting, and giving by briefly verbalizing thoughts and feelings to the group. The leader relies upon didactic techniques to reduce the anxiety that new patients may be experiencing upon entering a new professional group treatment session, and to begin defining PGC’s limited group process: free leader-to-member/s and member/s-to-leader interactions, while the group observes these interactions. The Questions and Comments component of the Mini-Lecture is the patients’ chance to “give” in return, and thus more actively participate in the PGC group process, which is based on patients voluntarily self-disclosing thoughts and feelings by answering specific questions while their peers listen. The leader pays particular attention to how each group member responds to the leader’s invitation to contribute to PGC’s group process by saying in a few words what they honestly think and feel as they occur in the “here and

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now.” The leader uses the Mini-Lecture Question and Comment component to try to assess whether patients are not complying with the leader’s directives because they are unable to, or are choosing to be uncooperative and noncompliant for psychological reasons.

Mini-Lecture Content The content the leader chooses for the Mini-Lecture is intended to prepare patients for the psychological exercises that will follow, and provide them with helpful information and complimentary material. For example, in the Plan described earlier, the topic presented for the day’s session is “accepting help from others.” The Mini-Lecture will thus focus upon issues around patients accepting both physical and psychological help from others, over their life span. Since accepting help from others is an interpersonal event and is necessary for a human being’s survival and development, the leader defines the word interpersonal, and discusses how this word relates to accepting help from others. The leader also uses some of the Mini-Lecture time to explain and define any new or unfamiliar words or psychological concepts which the leader will be using throughout the session.

Preface to the Mini-Lecture Prior to presenting the actual Mini-Lecture, the leader informs patients of its purpose and what they can expect to gain from listening to it. Usually by this point, patients are sitting in their seats and looking at each other and the leader. Although they are physically in the room, they may not be “psychologically” in the room. That is, their attention may be focused upon other important personal concerns and problems. The leader might say something like this: Leader:

The reason I prepared this Mini-Lecture is to define and clarify the psychological words and concepts that will be used in today’s session, to provide some information that I hope will be helpful, and to warm up for the Psychological Exercises that will follow. Just as it is helpful to warm up before doing physical exercises, so is it beneficial to practice listening, selfreflection, receiving the thoughts of others, and giving verbal expression of one’s own thoughts and feelings to others. It might also give you some time to settle down and become more

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focused, and make it easier for those patients who arrive after the group session begins to ease into the room. The first three points are particularly helpful for the leader to articulate in the preface to the Mini-Lecture, with the hope that they will serve to demystify and demonstrate to both nonreluctant to very reluctant patients that this group method has been thoughtfully and carefully constructed to meet their specific needs. Throughout a typical PGC session the leader informs patients of the beliefs underlying the PGC method and why they are being asked to follow the leader’s directives.

Part I. Mini-Lecture, 5–10 Minutes To help limit the writing on the blackboard, the leader will at times not write the complete topic on the blackboard, but will verbally elaborate on the written topic as a means of beginning the Mini-Lecture. Another way for the leader to begin the Mini-Lecture is by altering what is written on the blackboard, in this case, inserting the words “focus on interpersonal behavior” before the words “accepting help from others.” The leader then begins the Mini-Lecture by pointing to the word “interpersonal,” and proceeds to define this term by giving examples of how the word relates to chemically dependent patients. Below is an abbreviated sample of what the leader might say in the Mini-Lecture: Leader:

Interpersonal behavior is defined as behavior that occurs between two or more people. For example, me lecturing to you is an interpersonal event because the lecturing behavior is occurring between me and all of you who are listening. All of you who choose not to listen are also involved in this interpersonal event because inattention, also interpersonal, has an effect upon the person who is speaking, as well as other people in the room who are listening. We all have had the experience of some one—let’s say a friend, lover, mother, boss, etc.—who may have become upset and angry with us because we were not paying attention or listening to them when they thought we were. Most people can relate to that experience. Therapists are trained not to get upset or angry when patients do not listen. We are trained to be curious instead. Therapists are trained to understand but not judge patients’ behavior,

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especially behavior that is self-defeating like not listening to this Mini-Lecture. Now some of you may not be listening for different reasons: perhaps you can’t hear because of some physical problem or you may not be listening because you have a lot on your mind right now, making it difficult for you to focus on what I’m saying. This could be labeled a psychological problem, which we all have from time to time, especially when we are going through major life changes and become preoccupied with our problems, which then makes it very difficult to listen to others even when it would be in our best interest to listen. Listening to others can help provide a little vacation from being too self-involved, which at times can be harmful. Another benefit which is unique to group compared with individual treatment is that we get to see and experience how—when it comes to psychological problems—we are all more alike than different. This realization can lead us to feel less alone in the world, more connected to others, and more hopeful about relying upon psychological methods to cope with all the changes you will need to make to free yourself from chemical dependency.

New Arrivals While the leader is in the middle of the Mini-Lecture, a new patient, smiling, enters the room, and casually looks around before recognizing and nodding to a few patients. The leader immediately welcomes the newly arrived patient: Leader:

Welcome to PGC. I’m Ms. Jones, a clinical social worker, and I’m in the middle of the Mini-Lecture [pointing to the PGC Plan on the blackboard]. Please take any available seat of your choice.

The new arrival pauses, looks at the blackboard, and then slides into an empty seat. Still smiling, he makes direct eye contact with the welcoming leader, turns slowly to face her, and in one fluid motion he raises his hand to be sure to get her attention. In a strong soothing voice the patient declares, with emphasis on the word you: New Group Member:

Have you ever been addicted to cocaine?

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If unexpected questions such as this occur, the leader is free to use the time that is planned for the Mini-Lecture to take advantage of this occasion and pursue other potentially more achievable therapeutic objectives. Although ideally the Mini-Lecture serves the purposes of focusing the group’s attention on the session’s topic, covering all of the planned content is not necessary because unexpected events can sometimes provide more dramatic and memorable teaching opportunities. This new group member, in a quick role reversal, has asked a simple question that has managed to quiet the room and has probably stimulated the curiosity of many group members, especially since some of them may have had enough lecturing. Everyone is now concentrating on how the leader reacts and responds to this question. This is a pregnant moment. How should the PGC leader react to this “unexpected” event? Lectures are experienced by many patients as being talked at, rather than to. If at this time the leader happens to be ready to relate differently, then he or she might feel grateful for the interruption, particularly since this new patient’s question and delivery has very effectively focused the group’s attention upon a potentially more interesting and productive member-toleader and leader-to-member interaction. How the leader responds to this unexpected question could provide a chance to increase the groups’ trust and acceptance of the leader and this group method. But to deliver the most effective response, the leader would be wise to give some consideration to a number of questions before responding: Why was this specific question asked now rather than later? Why is the patient smiling? What does he hope the leader’s answer will do for him? Which is more important to him, a truthful answer or the content of the answer? Does he plan to help the leader if the answer is yes, or to avoid her? Is he also interested in the leader’s other psychological, physical, interpersonal, or existential worries, or just in his or her chemical dependency problems? Is his question a request or a demand? What effect will the leader’s response have on the group? The leader has two decisions to make. The first is whether to ask the patient to wait until the next component of the Plan where group members are invited to respond to the Mini-Lecture by asking questions and/or making comments, or whether to answer immediately. In PGC, one of the skills each patient is asked to practice is waiting, and many patients are told that they can benefit from improving this important social skill. However, some patients who ask the leader a question may expect and/or demand an answer immediately. The second decision the leader has to make is whether or not to selfdisclose if she has or has not been addicted to cocaine.

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Leader Decides to Ask the Patient to Wait In this situation, based on the leader’s clinical judgement, she decides to postpone answering the question by asking the patient to wait until the end of the Mini-Lecture (please see Chapter 7 for alternative ways PGC leaders typically respond to demands/requests for self-disclosure). The leader looks directly at the patient who asked the question and says: Leader:

Please tell me your name.

New Group Member: Leader:

Gerald.

Gerald, I want to welcome you to PGC. If you look at the blackboard, you will see that this is a different group method than your other group treatments. This group method is planned and has three parts. You just came into the Mini-Lecture part [leader can point to the outline on the blackboard]. I am about half-way through. I want to finish the other half, which will only take a few minutes, and then I will invite each group member to ask questions and contribute comments. I prefer and look forward to answering your question at that time. However, I want to thank you for asking your question because it gives me an opportunity to inform the group that after we complete each part (Mini-Lecture, Psychological Exercises, and the Final Questions/Comments) I will be asking all of you whether you have any questions and/or comments. I appreciate your willingness to wait until I finish the Mini-Lecture because the more each patient cooperates and complies by following the Plan, the more each group member will get from this experience.

The Leader Continues the Mini-Lecture The leader now continues the Mini-Lecture by writing the word “intrapersonal” on a blank portion of the blackboard, pointing to the word, and saying the following (abbreviated sample): Leader:

Intrapersonal behavior is behavior that occurs with only one person, that is, yourself. For example: you are alone in your room thinking about what treatment plans you should make

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for when you finish this program, and whether you should accept future professional treatment or not. This would be an example of an intrapersonal event. It is also called “self-talk.” The reason psychologists have created these terms interpersonal and intrapersonal is to help simplify human communication which is very complex. Interpersonal conflicts are a function of miscommunications and differences between human beings. One way to reduce interpersonal conflicts is to reduce miscommunications. Miscommunications are more likely when we are unable to focus our attention thereby interfering with our listening ability. It takes commitment and effort to listen to another human being. The better we are at listening, the less likely it is that we will have conflicts with others because of miscommunications. When I go around and ask each one of you if you have a question or if you would like to make a comment about what I have just presented, that is the time for you to practice your listening skills by paying attention to each group member’s response.

The Leader Stops Lecturing The leader decides to end the Mini-Lecture at this point. Once the leader stops lecturing, the objective is to begin to engage each group member by using the “going around technique.” Up until now, the leader has welcomed some group members opportunistically, as they entered the group. However, this is the first invitation that each group member receives to contribute directly to PGC’s group process, and the first time the leader will systematically and individually engage all group members. Forming and maintaining a therapeutic alliance with each group member, establishing rapport, and encouraging active participation in the PGC group process now becomes the leader’s primary therapeutic objective. Thus, all of the leader’s responses to group members’ questions and comments are to serve this therapeutic goal. The leader is mindful that for some patients, engaging in a dialogue with the leader while fellow group members listen can be very stressful. The leader makes every effort to minimize this stress, and protect group members who are attacked by other group members who, for a variety of reasons, wish to make critical comments regarding the verbal responses of others. How patients respond to the leader’s first invitation to participate in the PGC group process provides the leader with information on how cooperative

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and compliant the patient may be with the group tasks that will follow. For example: Do patients understand what is being requested of them? Do they immediately Pass? Do they repeatedly ask numerous questions and contribute unending comments? Do they relate to the leader as if only they and the leader were in the room? Does their verbal and nonverbal behavior communicate that they welcome the chance to have this limited dialogue, or the opposite? How group members react (verbally and nonverbally) to the leader’s request for questions and comments determines how the leader responds to them in the present, as well as how the leader will interact with them later in the session when the leader asks group members to make another contribution to the group process in the Plan’s next component, the Psychological Exercise/Word Association task. The leader is most interested in how patients relate to the leader, how they are responding to the method, and how receptive they are in general to receiving professional group treatment. The leader responds to each question and comment as supportively and empathetically as possible. How patients formulate their responses is treated by the leader as inconsequential (grammar, word usage, slang, idiosyncratic words), because the leader does not want group members to think that their language skills are more important to the leader than their desire to communicate their questions and comments honestly. If a patient uses words and phrases in ways that are unfamiliar (“street language”) or incomprehensible to the leader, the leader respectfully acknowledges not understanding what is being said, and asks the group member to define the words or phrases, to help the leader better understand what the group member is trying to communicate, and thanks the group member for any explanation of unfamiliar words and phrases.

Leader Asks Group Members for Their Questions and Comments The leader introduces the Questions and Comments component of the plan by addressing the group as follows: Leader:

Please take some time to think about everything I have just said in the Mini-Lecture, because I am going to ask each of you whether you have a question and/or a comment about anything you heard. Now, if you do not wish to ask a question and/or make a comment, you may pass. In PGC you may always pass whenever I ask you a question; you never have to answer any question I may ask.

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It is important to note that in the above directive the leader does not ask “do you have any questions and/or comments” (plural), for two reasons. First, depending on the number of patients in the room, roughly 15–20, permitting each person to ask multiple questions and make multiple comments may take more time than the leader plans to devote to this component of the Plan. Second, the distinction between one and many questions and comments can make a very important difference in the group process, especially in situations where patients are very reluctant to accept professional group treatment. They may attempt to change the goals of PGC and inhibit the PGC Plan from going forward by intentionally seeking to alter the group process by making multiple comments and asking many questions instead of just one. If you ask the first group member “do you have any questions or comments,” whatever number of questions and comments they make may influence how many questions and comments the next group member will make and how many questions and comments each subsequent group member may feel entitled to make. The group process will then ultimately be determined by group members rather than by the leader. The leader needs to control the group process so that 1) she can more readily determine how much time will be needed to complete this group task (Question and Comment component of the Mini-Lecture); 2) each group member will have a more or less equal opportunity to respond to the leader’s question in the Mini-Lecture; and 3) she will have the freedom and flexibility to determine which group members may need to have an unequal amount of time (in seeming contradiction to #2) to answer the leader’s question. For example, some patients reduce anxiety through excessive talking and may need more time as well as more of the leader’s attention and support to adjust to the basic PGC task of making brief verbal comments and being patient while listening to others respond. These patients are not intentionally uncooperative or noncompliant; they are anxious. However, limiting the number of questions and comments each group member may wish to ask is only done to ensure that each group member has an opportunity to ask a question and/ or make a comment. The leader can always decide to permit additional questions and comments after each group member has had their turn. Here is another example of how the leader may ask for Questions and Comments: Leader:

Please take some time to think about a question and/or a comment you wish to make. Try to choose the single most important question and/or comment you would wish to make on anything I have just said in the Mini-Lecture. The reason

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I am asking you to limit yourself to only one question and/or comment is so that I will be able to give everybody a chance to participate. Now if you do not wish to ask a question and/ or make a comment you may Pass. In PGC you may always Pass whenever I ask a question; you never have to answer any question I may ask. When it is beneficial to the individual member or the group as a whole, the PGC leader will offer the reason or reasons whenever patients are asked to restrain or limit their behavior, and the leader should try to do this in a sincere and respectful manner. The leader decides when to provide the explanation for why patients are being asked to restrain or limit their behavior. It could be done as suggested in the above directive, or the leader may choose to wait until a group member starts asking more than one question. Either way is acceptable; it is a question of timing.

Question and Comments: Group Members’ Responses During the Questions and Comments component of the Mini-Lecture, each group member is not only asked to self-disclose by means of a question and/ or comment, they are also being asked to trust that the leader will use the response in a way that will be helpful and not harmful. The leader treats all patients’ verbal responses to the leader’s questions with respect and as significant contributions to the PGC group process. The leader perceives and receives them as “gifts”: the seeming appropriateness or value of the offering is not more important than the giving. The leader praises group members for restraining themselves by waiting for their turn and listening to others. The leader’s use of the “going around technique” places all patients in a potentially interpersonal risk situation, since they now have to make a choice as to how to react to the leader’s instructions, and this reaction is going to be the focus of the group’s attention. Not knowing how each individual or the group as a whole will react creates a certain amount of interest and excitement among the group, and serves to focus the group’s attention upon each dialogue as it occurs. The leader should always anticipate a variety of responses, as it would be very atypical if all group members responded by precisely following the leader’s directive to ask one question and/or make one comment. The following is a representative sample of responses (8 out of 15–20) that PGC leaders might expect to receive regarding the Mini-Lecture.

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The Leader Begins The leader looks directly at the first group member, and in a friendly manner says: Leader:

Please say your first name to the group. Do you have a question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

The leader then looks to the entire group (to observe how many of the group members are paying attention to the leader’s first encounter with a group member) and then back again to the first group member to receive his response. Group Member #1:

Jim. I have nothing to say.

Leader’s Response Options No matter what the response, the leader responds to each group member by respectfully receiving and thanking him for his contribution to the PGC group process. If the group member asks a question, the leader responds by answering the question to the best of her ability. If the group member responds with a comment, and the leader chooses not to comment on or question the group member’s response, she would just thank the group member for their contribution and then move the Plan forward by continuing the “going around technique” with the next group member, since GAT is essential to move the PGC Plan forward. The other choice the leader has before moving the Plan forward is to respond to the group member’s comments by making additional comments which are ideally designed to be helpful to both the individual group member and the entire group. The decision whether to make additional comments, how many, and for how long, is based upon the therapeutic goal that the leader perceives as being achievable in that moment. Additional comments by the leader serve a number of useful therapeutic purposes: 1) they provide an opportunity for the leader to describe how this group treatment method is similar to or different from other professional and self-help experiences; 2) they inform group members as to what is expected of them; 3) they help explain why members’ participation is needed and provides the means for reinforcing PGC’s directives and norms, e.g., discouraging discussion between group

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members, group members commenting on others’ responses or lack of response, and speaking out of turn; 4) they provide the leader with the means to deliver supportive, protective, and empathetic comments throughout the session; and 5) in the case of a Pass response, they permit the group leader to be free to fashion a response that converts a group member’s Pass response into something which is acceptable and perceived as a positive contribution to the PGC group process. The leader’s additional comments are conceptualized to serve multiple communication purposes: 1) communications directed to benefit the entire group; and 2) indirect communications to help those very reluctant group members who would find it very difficult to tolerate and accept a direct challenge and/or confrontation from the leader, i.e., members who choose to pass for defensive reasons. For example, the leader might respond to Group Member #1 who has made the above comment and say: Leader:

Thank you for your contribution, Jim. The Mini-Lecture gives me a chance to describe some psychological concepts which I hope will be of some help to you to avoid relapse. However, my good intentions are not enough because human communication is a complex process. So to make sure that I have been understood, I need you to respond to what I have said because that is the only way I can know that what I intended to communicate has been communicated. The reason I bring this up is to point out that it is very easy for miscommunications to occur and for conflicts to follow them.

The leader then turns to the next group member, and continues the “going around technique.” Leader:

Please say your first name to the group. Do you have a question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

Group Member #2: Leader:

Pass.

Please say your first name.

Group Member #2:

Roger. Pass.

A Pass response does not have the same meaning for all group members, and therefore the leader’s observations of each individual group member’s

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behavior will affect the leader’s interpretation of the Pass response, and how she might respond. For example, prior to the beginning of the session, the leader may have observed that this group member was initiating conversations with and offering advice to other group members, and that he was paying particularly close attention to the leader’s behavior after giving a Pass response. The leader’s initial tentative interpretation of this behavior is that although this group member may have questions and comments to contribute to the group process, he is potentially withholding and distrustful, and might plan on testing the leader by using a Pass throughout the session. Instead of immediately moving the Plan forward, the leader decides to make some additional comments: Leader:

Thank you for your response, Roger.

The leader pauses, and then turns to look at the entire group to observe how attentive they are to the member-leader interaction and how much they appear to be looking forward to their turn to express themselves: Leader:

I hope that what I presented in the Mini-Lecture is clear and understandable. The only way for me to know this is if some of you choose to make comments and ask questions. This group method is similar to other group treatments you may be receiving in that the more each group member contributes to the group process, the more each group member can benefit from the experience. When group members withhold everybody loses but that is OK since until you feel or believe you can get something by participating you should withhold your thoughts and feelings.

In the above option the leader, when speaking, should not directly look at the group member who just used a Pass, because this is not a direct confrontation or challenge to this group member, it is an indirect communication. The leader is grateful to this group member for providing the opportunity to make this comment to the group; thus, the above option is to be presented by the leader in the spirit of sincere appreciation. The leader then turns to the next group member and says: Leader:

Please say your first name to the group. Do you have any question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

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Group Member #3: Leader:

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William. Half of the people I know aren’t worth listening to.

Thank you for your response, William. William makes an important point, because we all have to make judgments regarding whom we should listen to. We do not always know that what people are saying is truthful or is going to be helpful, and we’ve all had life experiences where people have told us things which have turned out not to be true or helpful. Some things people say are even hurtful. So listening to others is a more complex process and experience than it appears to be on the surface.

After completing her comments, the leader turns to the next group member, group member #4, and says: Leader:

Please say your first name to the group. Do you have a question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

Group Member #4:

[does not speak]

This group member does not speak, does not Pass, and seems to be only partially aware of what is expected of him. A group member not saying “Pass” and remaining silent is an unusual behavioral response in this group setting. It occurs rarely, usually with those who are very defiant and are refusing to cooperate or comply with the group leader’s instructions. But in this case, the leader has observed that this group member is withdrawn, mostly isolated from and avoided by other group members, and has occasionally been muttering to himself. The leader tentatively interprets this patient’s behavior as profound self-absorption and preoccupation with his internal mental experiences, and concludes that this patient may be unable to formulate a question and/or contribute a comment and likely needs the support and protection of caring others. If, in the leader’s judgment, the patient is not in severe emotional pain or potentially harmful to himself and/or others, the patient’s behavior is treated the same as any other group member during the session. Unexpected and very different group member responses can help to focus the group’s attention, and stimulate increased interest in what the leader will say and do. Therefore, the leader perceives unusual and very unexpected responses as providing a very valuable contribution to the PGC group process because the group is

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now more focused on the group task which is to listen and observe others as well as pay attention to their own reactions to other’s behavior. The leader begins by very carefully and sensitively attempting to engage the group member in a therapeutic dialogue to determine whether this group member becomes more or less agitated and disturbed by the leader’s attention and attempts to engage him in the group task. The leader can ask the patient to supply his name, or ask other group members whether they know the patient’s name and whether they are willing to volunteer it to the leader. If this group member shows signs of greater agitation, then the leader would immediately choose to move the Plan forward by thanking the group member for being in attendance and for his acceptable nonverbal response (silence). This would be recommended to avoid creating any more stress for this group member. The leader positions this response to the group member as not preferred but still a positive contribution to the PGC group process. [Important Note: If upon careful observation the leader sees that this patient is responding by not speaking throughout the entire session, and if the patient also appears consistently distracted and/or disoriented, at the conclusion of the session the leader would further evaluate the patient’s mental state and—if necessary—escort the patient to the appropriate treatment staff for additional treatment]. If, however, the leader’s attempts at a therapeutic dialogue seem to have an observable positive effect upon the patient’s behavior by diminishing his agitation, then the leader might continue to engage the group member by making additional comments. The reasons for this are as follows: 1) although this group member’s silence is a very different and unusual response, it is acceptable and has therapeutic value for both this group member and the group; 2) moving the Plan forward could lead group members to the conclusion that this group member has nothing to offer and should therefore be avoided; 3) it could reinforce this patient’s feeling of having failed to live up to others’ expectations and having nothing of value to contribute to others; 4) this group member’s not speaking does not threaten to change the PGC group process or its core therapeutic objectives; 5) it gives the leader an opportunity to accept and accommodate the patient’s silence into the group process. Some additional comments the leader might make are: Leader:

In PGC, the leader interprets a nonverbal response as a Pass. Not speaking is an acceptable response in PGC; there are times when for biological and/or psychological reasons our ability to attend and relate to others may be profoundly compro-

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mised, and that is when we need to be even more related to others because we will need their support and protection. There is a social and psychological benefit to just sitting in a group with others who are concerned about you and who will support and protect you. And that is why [leader looks at patient who is not speaking, and uses his or her name] is in the right place right now, that is, in a professional group treatment session, because if [patient’s name] needs additional treatment he will receive it when the session is completed. After making these comments, the leader turns to the next group member and says: Leader:

Please say your first name to the group. Do you have a question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

Group Member #5: Leader:

Lawrence. Why is it important to know the difference between intrapersonal and interpersonal?

From a psychological point of view, it’s important to know the difference because with intrapersonal problems the person ultimately has the ability to solve the problem themselves, whereas with interpersonal problems, because they are occurring between you and another person or persons, you can’t solve the problem without their cooperation. For example, if you’re trying to get back with a significant other, they may have to forgive and forget some of your past behavior. If they are not able or willing to forgive and forget because they’re afraid of being hurt again, you may have to live with their rejection. Whereas, you can always forgive yourself for some of your past behavior.

The leader then turns to the next group member, and says: Leader:

Please say your first name to the group. Do you have a question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

Group Member #6:

Paul. Pass.

The leader observes that this group member is aware of what is expected of him, but that he is quiet, speaks softly, has few interactions with other

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group members, and that his body posture, eye contact, and manner of relating appears shy and/or defensive. The leader interprets this Pass as avoidance behavior, and hypothesizes that some possible explanations for this group member’s behavior is that he fears being criticized, humiliated, and/or behaving foolishly; that he may not be comfortable with being the object of the leader’s attention in front of other group members; that he may be unaccustomed to expressing thoughts and feelings, especially in a group situation; that he may not be ready to engage in professional group treatment; or that he does not value his own thoughts and feelings and believes he has very little to offer others. For some patients, avoidance is one of their major defensive coping mechanisms. To help some very reluctant patients tolerate being less able to defend themselves, the PGC leader is very sensitive to their responses to the leader’s directives and to the PGC group process, and will quickly make very supportive and empathetic comments concerning each patient’s right not to answer the leader’s questions. Not answering a question by saying “Pass” is unconditionally accepted and permitted in PGC, because for some patients just being in the group can be very stressful, and they may not be ready to directly benefit from a PGC group session. In this situation, the leader can choose to move the Plan forward by thanking the group member for his contribution to the PGC group process, and moving on to the next group member. The other choice the leader has is to make the following comments before returning to the “going around technique”: Leader:

Thank you for your response, Paul.

The leader pauses, since during this pause some group members will replace a Pass response with a question and/or comment, thereby making their first self-disclosure to the group. The leader then turns to look at the entire group, to observe how attentive they are to the member-leader interaction and how much they appear to be looking forward to their turn to express themselves. The leader then continues: Leader:

I want you to know that honestly expressing your thoughts and feelings to others is not something most of us are used to doing, and many of us, at times, have difficulty with permitting ourselves to become more aware of certain thoughts and feelings. Plus, for many of us to experience certain feelings is not easy, and it is sometimes difficult to distinguish our different

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feelings and even find the words to identify and express them to others. Human behavior is complex. But, the good news is that we all can learn to become more aware of our thoughts and feelings with practice. The PGC group method gives each of you a protected opportunity to increase your awareness of your thoughts and feelings and to practice self-disclosing. I hope that you will benefit indirectly from the PGC session since this group method is based upon the belief that by watching others’ behavior we can often learn important things about ourselves and others indirectly, and we can sometimes gain very useful information when we least expect it. Following these comments, the leader turns to the next group member and says: Leader:

Please say your first name to the group. Do you have any question you wish to ask and/or a comment you would like to make about anything I have just said in the Mini-Lecture?

Group Member #7:

My name is Juan. [very lengthy response]

Whenever the leader is listening to a group member who appears to need more time than other group members to complete the group task, the leader will have to make a judgment regarding when to interrupt and what comments would be the most appropriate to make. However, sometimes before the leader makes this decision to interrupt, an “unauthorized coleader,” that is, another group member, will—out of personal frustration and/or wishing to help the leader to move the Plan forward—preempt the leader and interrupt the lengthy responder: Group Member #8:

Juan is taking too long to make his comment! He always talks too much. It’s time to go to the next person!

This remark could easily result in a conflict should the lengthy responder take offense and make a counterattack, because the more anxious he becomes the more he will speak, and it is possible that this patient may not be used to controlling and censoring his thoughts and feelings. Conflict usually gets the group’s attention. The leader wants to get and keep the group’s attention focused on each group member’s interaction with the leader, as well as avoid

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conflict since this method is not designed to explore and resolve conflicts and does not depend upon this to foster interpersonal learning. Preventing this situation from developing into a conflict requires the leader to act very quickly by immediately addressing the interrupting group member—ideally before the lengthy responder has a chance to attack or defend himself. But many times this may not be necessary, since often lengthy responders are oblivious to the effect their endless answers are having on their audiences and/or they don’t care. In this example, the lengthy responder—after making eye contact with the complaining and interrupting group member—continues speaking as if he did not hear the comment. This behavior gives the leader the ideal opportunity to confront the interrupting group member and redirect the criticism to where it actually belongs, which is to the leader and away from the lengthy responder. Since the leader did not interrupt this group member’s endless response sooner, she is therefore responsible for unintentionally creating a situation whereby other group members were expected to be patient while they listened to the lengthy responder’s questions and comments. This may be asking too much from some group members, especially those who have difficulty with waiting and listening. Immediately following the interrupting comment, the leader might move slightly away from the lengthy responder and closer to the interrupting group member to get a better look at and/or engage this group member. It is the leader’s judgment that determines how close or far away to stand from each group member. Since individuals from diverse cultural backgrounds experience physical proximity differently, and since moving closer can be threatening and moving away can be experienced as rejection, caution is advised. Thus, it is important for the leader to carefully observe the group member’s reactions to the leader’s movements, whether it is towards or away. While moving about, the leader is also looking at the entire group to observe their reaction to the change in group process, since it now has a member-to-member component. How the group as a whole responds either verbally or nonverbally to the interrupting group member’s unsolicited criticism of a fellow group member gives the leader some information to assess whether or not the interrupting group member is speaking for the group as a whole, or just for himself. The answer to this question helps the leader to decide what response will best serve the group’s needs at this time. Since one of the leader’s goals is to protect all group members from unsolicited criticism of their contributions (responses to the leader’s questions) to the group process, the first thing the leader chooses to do is to defend and protect the lengthy responder from the unsolicited criticism of the interrupting group member. One way to achieve this is by reframing the

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behavior as a learning opportunity for both the criticizing member and the lengthy responder. The leader might say: Leader:

Sometimes it is not easy to listen to people who require many words to express themselves, and learning to tolerate and accept others who often need to use a lot of words may be difficult for some of us. However, to get along with certain family members, bosses, and other coworkers it is necessary for all of us to learn how to cope with this behavior. PGC gives you many opportunities to practice these important skills: listening, and refraining from complaining.

After hearing the leader say the above, the complaining group member, as well as those members who believe the complaint is warranted, may feel that the leader is blaming the “victim.” So, it is wise for the leader to immediately support the complaining group member by turning and directly looking at the criticized member, and saying the following: Leader:

I’m going to request that you make every effort to shorten your replies, and that you accept my need for you to shorten your response in order to give others an equal opportunity to respond. This may be difficult for you, and I am sorry I have to ask you to do this, but it is necessary, because your efforts and success in giving briefer responses will be helpful to you and others in the group. If you can learn to do this here in PGC, it can improve your relationships with others (family, friends, and coworkers). We are not perfect, and we all have ways of communicating and protecting ourselves that others may not like or accept, but that is why you are here today, to learn more about ourselves, to become more tolerant and accepting of others, and to change those behaviors that can be harmful to our valued relationships outside and inside this group.

GROUP PROCESS: MINI-LECTURE The above scenario is one example of how a specific leader-to-member/ member-to-leader interaction can be influenced and sometimes determined by the behavior of the remaining group members. The nonverbal and verbal behavior of all remaining group members can be conceptualized on a contin-

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uum from having a minimal to overwhelming effect upon the leader’s and/ or the group member’s behavior who is engaged with the leader, and this can happen at any time during the leader-to-member interaction. The PGC leader is constantly scanning the group to assess how other group members are reacting to what is happening. The dialogue between the leader and an individual is integral to the total group experience and is the focus of attention for the entire group. While the leader asks the question and then listens to each member’s answer, the remainder of the group is expected to listen and learn from what occurs. The other group members’ observed listening behavior and their spontaneous verbal and nonverbal reactions will influence the leader’s behavior, may alter the group’s process, and sometimes provide the leader with an ideal opportunity to introduce and explore important psychological concepts.

DETERMINING THE LENGTH OF THE MINI-LECTURE Ideally, the time allotted for the Mini-Lecture is approximately 10 minutes. The actual time will vary depending on the following major factors: how many group members choose to pass; how many need or want to give lengthy rather than brief responses to the leader’s questions; and the leader’s judgment regarding how engaged group members are and how much they appear to be benefiting from the leader’s continuing the didactic experience beyond the planned 10 minutes. If the leader observes that group members are very restless and are eager to be engaged, the leader could choose to divide the Mini-Lecture into two parts and at the end of each part ask group members for a question and/or comment. In this case, the leader would then repeat the going around procedure by asking the first person to the right or left “any question or comment on anything I have just presented.” Once each group member has had the opportunity to respond, the leader would then proceed to the Psychological Exercises. The leader’s assessment of what would be best for this particular group of patients always determines the length of the Mini-Lecture, and how much content should be covered. Although the length of time that is scheduled for the Mini-Lecture is estimated to be about 10 minutes, it is the leader’s clinical judgement that is the most important variable in ultimately determining its duration, which can always be modified to meet the needs of patients in different clinical situations. This also holds true for the other components of the PGC Plan. Because the leader never knows upon entering a new group whether group

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members will welcome the leader and the Plan, or whether there will be insufficient cooperation and compliance to permit the PGC Plan to move forward, the leader always has the freedom to determine which therapeutic objectives to pursue, and within what time frame, in order to remain committed to providing a harmless to helpful group treatment experience for all. If during the Mini-Lecture group members are attentive, are following the leader’s directives, are positively responding to the opportunity to ask questions and make comments, yet appear equally ready and able to benefit from PGC’s next component—the Word Association Exercise—the leader will in most instances move the Plan forward as suggested, or even accelerate the Plan beyond the Mini-Lecture, if the leader senses that group members are eager to be more actively engaged. However, the leader can also enter a group representing the other end of the continuum. For example, in some very rare and unusual clinical situations in the treatment of chemically dependent and MICA patients, a leader may encounter a large proportion of patients who are very distrustful, rebellious, hostile, and critical of other group members, some of whom are also verbal, intelligent, creative, and energetic. These patients possess highly developed social and antisocial leadership skills, as well as a deep prejudice towards mental health professionals, and a generalized distrust of authority figures. Many of these patients have little or no reservations, and a few will have no inhibitions, about offering unsolicited thoughts and feelings in the “here and now” as they occur about the leader’s Plan for the day, for example, that they do not want to listen to a Mini-Lecture, especially from a professional, and that they have little desire to follow the Plan. Many of these group members will express their discontent by quickly passing, leaving only a few group members to ask questions and comments. Or, some of these responders will try to change what is supposed to be a therapeutic dialogue with the leader into a personal conversation by continuing to ask numerous personal questions while ignoring the group. Meanwhile, the remaining group members will nonverbally express gratitude for obtaining what has become an opportunity to spend the remainder of the session in peaceful inattention. Patients who are this reluctant, rebellious, hostile, distrustful, and critical make moving the Plan forward potentially risky, and the execution of the total Plan too ambitious. In this case, the leader could choose to continue in the didactic role and devote the full session to the Mini-Lecture in order to maintain maximum control over the group and to provide the most protection for all group members. Although not preferred, it is still beneficial to continue to engage them and to make the most of what the didactic technique has to offer.

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HOW PATIENTS RESPOND TO THE MINI-LECTURE Group members’ reactions to a PGC leader’s Mini-Lecture will vary. The quality and quantity of questions and comments, and the way the patients relate—that is, whether the group member moves “towards” or “away” from what the leader is requesting—will differ. The leader has the opportunity to observe how each group member reacts to both the Mini-Lecture and the PGC group process. All group members also have the chance to see how the leader responds to each patient’s reaction, and how the leader relates to them individually and collectively. Listening to the questions and comments of their follow group members provides each group member with the means to compare how their reactions to the content of the Mini-Lecture is similar to and different from other group members, and how each relates to the leader, in terms of how trusting, cooperative, and compliant they are with the leader’s directives. The questions and comments the leader receives will inform the leader of how well the essential ideas in the Mini-Lecture have been communicated, and gives the leader the occasion to correct any miscommunications that may have occurred and to make a general assessment of how many group members were listening versus how many were not. Listening behavior can be expected to increase during the Question and Comment section of the Mini-Lecture. One reason may be that patients’ curiosities are aroused when they have an opportunity to see how other group members are perceiving the leader’s behavior and whether or not fellow group members are cooperating with the leader’s directives when the leader begins to engage each group member individually.

EXITING THE MINI-LECTURE AND ENTERING THE PSYCHOLOGICAL EXERCISES Preface to the Psychological Exercises After welcoming each group member in the Mini-Lecture, the leader is primarily relating to each patient as would a teacher, and asks them to assume the role of “students.” They are encouraged to participate and engage in a didactic psychoeducational group treatment experience, and their role is limited to listening, asking questions, and contributing comments restricted to the material the leader has selected and presented. Similar to the Mini-Lecture, the leader continues to be responsible for selecting the material that is presented to all patients when they begin the

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Psychological Exercises; but now the leader behaves differently in two important ways: 1) the leader changes the way she relates to the patients by relating to each patient in the more traditional role of a very supportive group therapist/counselor, while encouraging and expecting (but not requiring) group members to assume the role of a cooperative, responsible patient, and to assume more responsibility for the group process by making more of a personal contribution; and 2) the leader asks patients to do something different—and for most patients, something new. In the following two psychological exercises (the Word Association and the Psychological Question), the leader asks each patient to self-disclose subjective, personal reactions to specific questions by verbalizing their responses to the leader while the group listens. The leader writes their verbal responses verbatim on the blackboard for all to see. As in the Mini-Lecture, the leader asks each group member to comply with and accept the leader’s directive “to please not comment on any group member’s responses.”

Part II. Psychological Exercises, 30–35 Minutes (Including the Word Association and Psychological Question) The leader introduces the exercises by first erasing everything from the MiniLecture that was written on the blackboard, and then saying: Leader:

Just as it is important for us to do physical exercises to maintain our strength and to be able to cope with the physical demands of living, so also do we benefit from doing Psychological Exercises to maintain our self-esteem and to better cope with the psychological demands of living and relating to others. At times we all have thoughts and feelings which are unwanted and potentially harmful, for example, thinking that your chemical dependency is only a temporary problem, and that once you gain some control over your life and solve some of your most pressing problems you will be able to return to controlled usage once again. Whenever you are thinking this way you will need to cope with these thoughts and the consequences of acting upon them. We are less likely to act upon our harmful thoughts and feelings if we are aware of them, if we can communicate them to others who care about us, and if we permit others to help us not act upon them. Thinking you will be able to control your chemical usage in the future is a thought which you will have to decide whether

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is harmful to you and those people you care about the most. For many patients controlled usage is not an option and you may have to accept that you are one of those people. If you don’t accept that controlled usage is not an option for you, then it will only be a matter of time before you have to decide when and how much to use. Therefore, accepting the extent of your chemical dependency problem is only part of your psychological challenge; the other part is that you have to accept all the help you will need to free yourself of being chemically dependent and all the problems that are related to it. I interpret your being here today in this room with me as a sign of some acceptance that you are chemically dependent and require professional help. I don’t know how much you fully accept this, but I believe that you deserve respect and to be praised for being here today. To be a patient in this detox program is a responsible act on your part because you are exposing yourself to professionals who have made your personal problem our professional problem, that is to help you identify and make all the necessary changes to free you of your chemical dependency problems. All exercises in PGC are very carefully selected to help each patient become more aware of their perceptions, emotions, thoughts, and actions, and if they choose, to learn ways of experiencing and behaving without harming themselves or others. There are no trick questions, and they do not have right or wrong answers. The leader asks for “brief and honest” answers, which are written verbatim on the blackboard. If a member chooses to Pass, “Pass” is written as their response. The leader interprets the “Pass” response to the group as the member’s acceptable and authentic behavior: better to Pass than to respond dishonestly, since practicing honest communication is one of PGC’s goals. When a member repeatedly Passes, or a pattern of Passing is observed, the leader may choose to “confront” the member if, in the leader’s judgment, the member can tolerate and potentially benefit from additional attention. Then, the leader will continue to engage the member in a therapeutic dialogue, to better understand their behavior. For example: Leader:

You have repeatedly Passed. I am curious, are you Passing because you are not ready to say what you think and feel, or

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do you have some other reason? [After a slight pause, the leader continues.] Of course you do not have to answer this question, you can choose to Pass again. If the member responds with another Pass, the leader can then say: Leader:

Good, it is always up to you to decide when and how much to contribute to this group, and always better to Pass, than make up some response.

Word Association, 10–15 Minutes After each group member has been invited to ask a question or make a comment about the final portion of the Mini-Lecture and all have responded, then the leader can introduce the next component of the PGC Plan, the Word Association exercise. Leader:

I want to thank all of you for your questions and comments, because when each person contributes something, this increases the effectiveness of this group method. The more you contribute, the more material will be available for you to learn, and I would like you to learn as much as possible today. I am now going to write a word on the blackboard and I will also say the word. [This is for the benefit of those group members who have visual difficulties or who may not want to look at the blackboard.] What I would like you to do is become aware of the first word that comes into your mind when you see and/or hear the word. I’m also going to write what you say on the blackboard. Please do not say the word aloud, but you can say it to yourself, and please remember the word because I am going to ask each of you to tell the group what the word was. And remember there are no right or wrong answers to this question; different people can have different word associations to the same word.

The leader turns to the blackboard and writes the word HELP, and turns to the group and says that the word is “help.” The leader then turns to the group member on the right or left to begin the “going around technique” and says:

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Please say your first name and then tell me the first word you became aware of, or which came to mind, when you saw or heard the word “help.”

Group Members’ Responses The following is a representative sample of responses (10 out of 20–25) that PGC leaders might expect to receive to the Word Association exercise: Group Member #1:

More than one word came to mind. I don’t know which was first.

This group member’s response is expressed in an annoyed tone of voice. Whenever a patient gives an unexpected response, the leader pauses to reflect upon the different possible meanings of this unexpected reply. The leader needs some time to consider and decide which therapeutic response would potentially yield the most benefit to the individual and the group in this interaction. Here the leader’s pausing behavior can also provide an example of an alternative way of coping when one encounters confusing or unclear communications from others. Being able to restrain oneself from reacting to others’ requests and demands is an important social skill. The PGC leader does not need to hurry to any predetermined destination because the process of listening and trying to understand what another is communicating takes priority in the PGC group method. Leader:

See how our minds can differ? For some of you, it may be difficult to determine which word came into your awareness and you may have to choose among a few of them. Please say your name, and pick the one that is most important to you and tell us that one.

Group Member #1:

Jim. I can’t, they’re all the same to me. Why can’t I give you all of them?

Without waiting for the leader to respond, the group member says in a strong voice: Group Member #1: Leader:

Lend a hand, A. A., and stupid.

OK, that’s fine. You can give me more than one word. Thanks!

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The leader then writes “Jim” on the blackboard, and next to it writes the response verbatim, thus: Jim. Lend a hand, A. A., and stupid. It is very important that the leader write all group members’ responses verbatim. It is not advised that the leader ever change what the group member has said without first asking and receiving permission from the group member to edit the response. It is recommended that editing be restricted only to save time or space on the blackboard. The PGC leader treats all patients’ responses with maximum respect and is grateful for their cooperation and compliance with all directives, especially their verbal contributions. Although this group member does not comply with the leader’s specific directive, “please give one word” but instead offers three responses, the leader readily accepts the group member’s response for the following reasons: 1) this group member cooperated and complied with the basic request; 2) the additional two responses can be readily assimilated into the group process, since these additional few words take up little time and space on the blackboard; and 3) this group member is unaccustomed to permitting a stranger (the leader) to define and control how to communicate to others, especially in the presence of his peers. The leader could also speculate that this group member is testing the leader to see whether the leader is willing to accommodate the patient’s need to give more than one response to the leader’s question, and whether the leader accepts the fact that the group member refuses to pick one word, claiming he can’t rather than he won’t, and insists upon giving all three. It is important to note here that when the leader asks Group Member #1 to choose the most important word, the leader is asking the patient to selfreflect, make a choice, and then tell the group which of these three responses is most important to him, which in essence is asking the patient to make an additional self-disclosure. The additional request “choose the most important word” could be perceived as a more personal request since in being asked to tell the group the most important word, the patient may not be ready to freely tell the leader and the group what is most important to him. This may be one possible reason the patient gives three words rather than one in response to the leader’s request. The leader continues the Word Association exercise by looking at the next group member, Group Member #2. Earlier in the group session, the leader observes that Group Member #2, who is next in sequence to be called upon, is approached by another patient and is welcomed to the group (this welcoming

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patient has been previously assigned to welcome and help orient new admissions). The leader perceives this new member reacting very cautiously and tentatively to being welcomed but also tries to please the welcoming group member by behaving in a self-effacing manner. Therefore, the leader’s interpretation is that this patient is shy, fearful of being in a group of strangers, and wants to please others. This previous observation and interpretation influences how the leader engages this group member: Leader:

Please tell me your first name.

Note that the leader does not make the usual request “please say your first name” (i.e., say to “the group”), but instead requests that the patient “tell me” your first name, that is, tell the leader. The leader at this time has decided to emphasize the patient’s relationship with the leader, and de-emphasize this patient’s involvement in the group, by asking the group member to give the response directly to the leader and indirectly to the group. Asking a patient to deliver his response directly to the leader is a different interpersonal transaction from asking the patient to speak to the whole group and the leader. Here, the leader is purposely permitting the patient to avoid and delay self-disclosing directly to the entire group because the leader wants to minimize the pressure that the patient may be experiencing to make selfdisclosures he or she may not be ready to make. Sometimes self-disclosures can be made prematurely in an attempt to please others and gain their acceptance, rather than because the patient is ready and believes that there is a benefit to self-disclosing. Especially with patients who are eager to please, the leader should be very careful not to take advantage of the inherent social pressure these patients might experience, such as their desire for group acceptance, to get patients to self-disclose prematurely. When the leader looks directly at the patient and says “tell me your name” (rather than the group), the leader effectively uses the leadership role to invite the patient to respond only to the leader, thus indirectly signaling to the patient that he can avoid looking at the entire group by looking at the leader instead. Ideally, the leader prefers to have all patients deliver their self-disclosures to the group. This is because being able to self-disclose to a group is an assertive social skill which can permit patients to better communicate their needs (on the job, in the family, and in other social situations). However, in PGC it is not expected or required. Therefore, the leader has encouraged this group member to do less (tell me rather than tell the group) to potentially gain more honest and authentic responses in the future.

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Roger. I don’t know.

Thank you, Roger.

The leader then writes “Roger” on the blackboard, and then next to it writes the response verbatim. On the blackboard we now have: Jim. Lend a hand, A. A., and stupid. Roger. I don’t know. While writing the response on the blackboard, the leader says: Leader:

Self-reflection is not something most people are accustomed to doing. Becoming more aware of our personal and private reactions requires practice, and sometimes it is difficult to describe our subjective experiences to others.

The leader turns to Group Member #2 and says: Leader:

If later you do know and want to give your answer you can.

The leader immediately turns to the next group member and says: Leader:

Please say your first name and then tell me the first word you became aware of or which came to mind when you saw or heard the word “help.”

Group Member #3: Leader:

Please tell us you first name.

Group Member #3: Leader:

Pass.

William.

Thank you, William.

The leader then writes “William. Pass” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. I don’t know. William. Pass. While writing the response, the leader may turn and look at the entire group and then say:

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In PGC “Pass” means you have an answer but you would rather not reveal it at this time. It is always better to Pass than to give a false answer, and you should not share your subjective, private experiences until you believe it is in your best interest to do so.

The leader immediately turns to the next group member and says: Leader:

Please say your first name and then tell me the first word you became aware of or which came to mind when you saw or heard the word “help.”

Group Member #4: Leader:

Pass. Thomas.

Thank you, Thomas.

The leader then writes “Thomas. Pass.” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. I don’t know. William. Pass. Thomas. Pass. While writing the response, the leader is silent and then turns to the next group member and says: Leader:

Please say your first name and then tell me the first word you became aware of or which came to mind when you saw or heard the word “help.”

Group Member #5: Leader:

Lawrence. Pass.

Thank you, Lawrence.

The leader then writes “Lawrence. Pass.” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. I don’t know. William. Pass. Thomas. Pass. Lawrence. Pass.

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While writing the response, the leader is again silent and walks towards the middle of the group and says: Leader:

It is always better for group members to pass than to be dishonest or inauthentic, and it shows good judgment and that you are capable of assuming responsibility for not selfdisclosing because you fear the consequences. Whenever we self-disclose we are taking a risk, so playing it safe in here may be the best thing for you to do today; only you know for sure. And since I want all of you to have a harmless to helpful group treatment experience today the more times group members “Pass,” the safer the group experience. But I also want you to learn something today that will help you to better cope with your chemical dependency problems. How much you will learn today depends somewhat on how much each of you is willing to risk by contributing your associations to the word “help.”

The leader turns to the next patient in sequence, but before the leader has a chance to ask the question, Group Member #6 voluntarily states: Group Member #6: Leader:

My name is Paul. “Don’t trust” came to mind when you said the word “help.”

Thank you, Paul.

The leader then writes “Paul. Don’t trust.” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. I don’t know. William. Pass. Thomas. Pass. Lawrence. Pass. Paul. Don’t trust. While writing the response, the leader is silent and then turns to scan the entire group. When he looks at Group Member #2, Roger says: Group Member #2:

I now know what the word was. It was “fear.”

The leader returns to the blackboard and erases the “I don’t know” response, replaces it with the new response “fear,” and says:

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Thanks for your additional response, Roger.

The leader turns to the next patient in sequence, Group Member #7, who is sleeping. Group Member #8 who is next to him starts (in a caring way) to wake him up. The leader immediately says to Group Member #8: Leader:

Please don’t wake him. I know you are doing this to be helpful to him and to the group and I appreciate your intentions, but it is OK if he sleeps. Of course, it would be better for him and the group if he were awake so he could get more help and be helpful to others, but right now being able to sleep in the safety and care of all of us is what he may need most. Perhaps he will wake up later, but thanks again for your efforts.

Sleeping may be caused by physical side effects of medications, psychological reasons, or sleep deprivation due to emotional conflicts. If necessary, the leader would wake the patient up at the end of the session and assess his or her treatment needs. This sleeping behavior would then be reported to the appropriate treatment staff immediately following the session. In PGC, the leader conceptualizes and interprets sleeping behavior as a profound form of inattention, which may be serving psychological defensive functions and thus could be influenced by the psychosocial therapeutic factors inherent in the PGC group method. It is a common observation to see initially sleepy and sleeping patients fully awake and engaged by the end of a PGC session, while the opposite is a very uncommon occurrence. The leader asks the entire group if anyone knows the sleeper’s name. While the leader is asking this question, the sleeping patient appears to be waking up when a few group members answer the leader and say loudly, “Juan.” Juan wakes up and looks at the leader, who then says: Leader:

Juan, what was the first word you became aware of or which comes to mind when I say the word “help?”

Group Member #7: Leader:

A. A.

Thank you, Juan.

The leader writes “Juan. A.A.” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. Fear.

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William. Pass. Thomas. Pass. Lawrence. Pass. Paul. Don’t trust. Juan. A. A. The leader then turns to the next group member who voluntarily says: Group Member #8: Leader:

Jose. Just what I need.

Thank you, Jose.

The leader then writes “Jose. Just what I need.” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. Fear. William. Pass. Thomas. Pass. Lawrence. Pass. Paul. Don’t trust. Juan. A. A. Jose. Just what I need. While writing the response the leader is silent. The leader turns to Group Member #9 who is looking out the window and who communicates through facial expressions and body posture that he has no interest in participating in this group task. Leader:

Please say your first name and then tell me the first word you became aware of or which came to mind when you heard or saw the word “help.”

While continuing to look out the window, Group Member #9 says in a parrotlike manner, obviously mimicking Group Member #8’s response, and smiling mischievously while turning to look at the group: Group Member #9:

Just what I need.

The leader observes some group members ignore this group member’s response, while many others laugh, at which point Group Member #9 smiles in return, as if to communicate his ability to provide some humor to the

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group experience that was up until now serious and guarded. The leader looks at this group member, smiles, and says: Leader:

Please tell us your first name.

He laughingly says “Jose” but immediately retracts his answer and in a more serious tone of voice says: Group Member #9: Leader:

My name is Roberto.

Thank you, Roberto.

The leader then writes “Roberto. Just what I need.” on the blackboard, thus: Jim. Lend a hand, A. A., and stupid. Roger. Fear. William. Pass. Thomas. Pass. Lawrence. Pass. Paul. Don’t trust. Juan. “A.A.” Jose. Just what I need. Roberto. Just what I need. The leader then walks towards the center of the group and while scanning the group says the following: Leader:

Earlier I made the comparison of our need to do Psychological Exercises and how we can benefit from doing them. We can even think of this group session as giving us the opportunity to work out psychologically. Psychological Exercises are similar to physical exercises in two ways: first, because just as with physical exercises, the more you practice the more you will gain from the experience, and second, no one can do the exercises for you. Trainers and coaches can demonstrate, guide, and encourage you, but in the end you must do the work to benefit. However, there is a very important difference between physical and Psychological Exercises. They differ in the following way. For example: let’s say you are in a gym with a trainer with others watching you; this is an interpersonal event. Your

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behavior is public, directly observable, objective, and easily measurable. For example, if the exercise requires you to do 25 sit-ups and lift 150 pounds, all can see just how many situps you actually completed and how much weight you actually lifted. You can’t fake it! Now, of course, intelligent and creative people can probably find a way to fake some physical exercises, but it will require effort and it is not easy, whereas you can easily fake your responses to some Psychological Exercises, and that’s the big difference between them. For example, in this Word Association exercise which is a Psychological Exercise and which focuses upon an intrapersonal event—that is, your private, not directly observable, subjective experience that cannot be directly and easily measured—only you know whether your response is sincere and authentic. Anyone in this group who is not ready to or does not want to contribute self-disclosures but wants to appear as if they do, could decide to repeat another group member’s response and falsely present it as their own. And we would not be able to know the difference. In PGC your not being ready and/or willing to self-disclose is respected and accepted. I want you to have the opportunity to practice direct honest communication—that is why you are encouraged to Pass rather than give false responses. But of course for you to Pass means you need to trust me to see if I live up to what I say. So, you will have to take the chance to see whether I can be trusted, or whether you decide to continue to misrepresent yourself to protect yourself. The leader is using this last member’s response to communicate to the entire group, not to put pressure on this group member to give more authentic responses. The leader is actually grateful to have this opportunity to make the above comment. The leader initially assumes that all group members are contributing honest authentic responses, until they prove otherwise. The leader’s above response can easily be seen as an indirect communication to the last group member who gave the identical response as the previous group member. If the leader believes that this identical response is inauthentic and that the patient could and would likely benefit from being confronted, then the leader would make a direct communication to the group member. If in this situation, this group member takes offense to what the leader says, because he believes the leader is saying it only for his benefit, then the leader

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would use this as an opportunity to say that all group members’ responses verbal and nonverbal are used by the leader to provide psychological information that will hopefully be helpful to all group members. The leader turns to the next group member and says: Leader:

Please say your first name and then tell me the first word you became aware of or which came to mind when you heard or saw the word “help.”

Group Member #10: Leader:

Martin. What the hell does this have to do with my addiction?

This is what you immediately became aware of when I said and wrote the word “help” on the blackboard?

The leader asks this question out of sincere curiosity and not out of disbelief. Group Member #10: Leader:

Yeah!

Thank you, Martin.

The leader silently writes “Martin. What the hell does this have to do with my addiction?” on the blackboard, thus: Jim. Lend a hand, A.A., and stupid. Roger. Fear. William. Pass. Thomas. Pass. Lawrence. Pass. Paul. Don’t trust. Juan. A.A. Jose. Just what I need. Roberto. Just what I need. Martin. What the hell does this have to do with my addiction? The leader then walks towards the center of the group, and after scanning the group, looks directly at Martin and says the following: Leader:

If this is your honest reaction to the word help—which since I don’t know you and have no reason to believe it is not, I will assume it is—I want to thank you twice. First, for your

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contribution because you did the Word Association exercise, and second, for voluntarily communicating your honest, doubtful thoughts, which is additional. Honestly and directly, communicating your thoughts as they occur in the now, while the group listens, is a basic PGC group task. And even though you weren’t specifically asked to do this in this exercise, you could have just as easily Passed but you did not. The leader does not answer the question “What the hell does this have to do with my addiction?” but treats it like all other responses given to the Word Association exercise, hoping that as the group progresses the answer to his question will become evident to this doubting patient. The above ten responses are a representative sample of what a leader can expect to receive during the Word Association exercise. The leader continues this exercise following the identical procedure until all group members have had an opportunity to contribute a response.

Word Association Analysis After all responses have been recorded on the blackboard, the leader begins the content analysis of the Word Association exercise by saying: Leader:

I want to thank all of you for your responses. The PGC group method is most potent when all group members contribute to the group process. The responses on the blackboard provide us with unique material; although another group of patients may give some similar responses, they would not be identical. One way to analyze these responses is to see how we are similar and different.

At this point, the leader thoughtfully looks at the responses on the blackboard and gives an analysis of what she sees. The leader addresses the entire group and points to the following similarities: 1. All group members were able to complete the task. That is, everybody was able to associate another word with the word “help” and some came up with a number of words. 2. Some had the same word association. This happened in 2 responses.

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3. We see in this exercise that we all share a common mental ability, to associate one word with another. Some of us associate words with phrases or with a question. The leader could also contribute additional associations. For example, the leader might say that in other groups of chemically dependent patients, she got some of these responses: weak, dependent, vulnerable, children, sick, helpless, etc. The leader does this to enrich the group experience and explains that “different people give different answers, but that our associations are not that different since often the word help has negative associations for many of us, especially our need for psychological help.” The leader concludes by saying: Leader:

At times throughout our lives, we all require both physical and psychological help from others. Knowing when you need help and accepting help is the sign of psychological development and competence because it permits our survival. Before we go on to today’s main psychological exercise, does anybody have any questions about the Word Association exercise? Please raise your hand so I can call on you.

Only one group member (Martin, Group Member #10) raises his hand. Leader:

Yes, Martin?

Group Member #10:

What the hell does this have to do with my addiction?

The leader scans the entire group to see the group’s reaction. Some laugh, some appear annoyed, and others appear indifferent. The leader’s recommended response: Leader:

Well I guess what I have said and done so far may not seem very related to your chemical addiction, but it is. And rather than try to explain it to you now, I’m asking for you to trust me and give me the chance to show you, because this would be better for you and all other group members who also may be wondering about what this group treatment method has to do with relapse prevention. So, what I would like to do is not answer your specific question right now, and if by the end of today’s session I have not answered your question, you can

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ask me again in the final Question and Comment section of the PGC session. Here the leader can point to the blackboard to show Martin and the other group members where Final Questions and Comments fits into the PGC session. Leader:

But, I would like to know if anyone else has any other questions about what I have presented in the Word Association exercise. If so, please raise your hand.

Questions and Comments (Optional) The leader always has the option of allocating more time to this exercise by asking each group member (using GAT) whether they have any questions and/or comments on anything regarding what the leader has just presented in the Word Association segment of the PGC session. The leader briefly answers whatever questions are asked, and listens and briefly responds empathetically and supportively to any comments they might have.

Exiting the Word Association Exercise and Entering the Psychological Question Exercise The leader turns to the blackboard and thoroughly erases all names and previously recorded responses. This is done for the practical purpose to make room for the responses that will be recorded in the next exercise, but more important, to remove a potential distraction as well as to communicate indirectly that group members’ responses will not be saved for the leader’s future use and that each exercise is an independent learning experience. Therefore, it is possible to enter the group at almost any time and function as a contributing group member.

Preface to the Psychological Question Exercise Approximately 20 minutes have passed, but the leader can still expect more latecomers, perhaps one or two. The leader needs to be prepared to sincerely welcome additional patients at almost any time; however, sometime after

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about 20 minutes the traffic in and out of the group treatment room usually diminishes and comes to an end (medical clinic procedure sometimes requires patients to leave psychological treatments to go for scheduled medical tests and treatments). Patients who enter late are greeted by a welcoming professional, who interrupts the group’s activities to usher them into available seats and thank them for coming because they are needed to make this group treatment more beneficial. These latecomers often react with surprise and disbelief at receiving such a welcome in the middle of a group session, and many of the observing group members appear equally perplexed by such professional leadership behavior. What hopes to be communicated through both words and actions is the leader’s dedication to providing immediate exposure to what the PGC method has to offer, no matter when patients arrive. Each time someone new arrives, the leader seeks to immediately assimilate the patient into the group’s procedure and expects that person to make whatever contributions they can to the group. An example of how a leader accomplishes this follows in the Psychological Question exercise below. Leader:

One of the purposes of the Word Association exercise was to reveal how our minds function. Words are connected with other words, phrases, thoughts, and feelings. Now, the really interesting part is that these associations can exist without our being aware of them. And if we are not aware of them, we would not know which different words, thoughts, and feelings are related, and even more important, how these connections can influence our behavior outside of our awareness. For example, if your past experiences have taught you that to need and request help is a sign of weakness, and if when people saw that you were in need they were quick to take advantage of you, needing and asking for help could now have some very negative associations for you. Therefore, accepting help could be another problem for you because you want to avoid experiencing the unwanted thoughts and feelings associated with your past experiences of needing help. The reason I am telling you this is to let you know that these negative past experiences can get in the way of your accepting help, so for some of you not only do you have to struggle with accepting your chemical dependency problems, you may also have to deal with your not wanting to accept help, even though you know you need it. Therefore, some of you have two major problems: chemical

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dependency and trouble accepting all the physical and psychological help you may require. For many people, one of the reasons why solving their chemical dependency problems is so difficult is because they do not accept all the help they may require. Since you have not been able to solve your chemical addiction problems through all of your own efforts, it is in your best interest to receive professional help; it shows your good judgment. Now, some of you may be angry at yourself for having become chemically dependent, and for not being able to solve your problems by yourself. And if your needing and accepting help happens to be associated with past negative experiences, then you might have a negative reaction to this group treatment. Therefore, you may wish to avoid this group experience and may even become annoyed or angry when you are expected to participate in today’s topic of accepting and receiving help from others. Now for some of you the opposite can also be the case, for example, if you have had the good fortune to have people in your life who—when you needed and asked them for help—they reacted to your situation in constructive ways, your reaction to the PGC group method and today’s topic might make you more tolerant and open-minded. For those of you who are not angry at yourselves and who have had neutral to positive experiences with asking for and receiving help, this group treatment may be more interesting and hopefully helpful to you. The leader often makes extensive comments to transition between exercises, to focus the group’s attention, and to give information that they may find interesting as well as helpful. After the leader makes these extensive comments, and before moving the Plan forward, the leader can always ask the group “Do you have any questions about what I have just said?” Whether the leader chooses to do this depends upon the leader’s assessment of nonverbal cues regarding how the group has reacted to the extensive comments. If these comments appear to stimulate some group members, and the leader observes that they seem to want to express their reactions, then the leader could entertain a few questions and give brief answers. Or, if it seems to focus their attention and have a quieting effect by making group members more pensive and receptive, then the leader could choose to forego giving

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the group a chance to ask questions, and instead move directly into the next exercise—the Psychological Question—to take advantage of the group’s seemingly more compliant mood. Endings and beginnings of each component of the PGC Plan is when the leader makes the most behavioral requests and gives directives. Therefore, it is during these transitions that the leader has the opportunity to observe any changes in the cooperation and compliance of each individual and the group as a whole. Often by this time, 20 minutes into the session, the group as a whole may be more receptive to the leader’s requests. However, in some clinical situations, the leader needs to be more psychologically prepared to cope with some very reluctant patients who at any time may behave in ways that directly challenge and test the leader’s sincerity and competence. One way for the leader to be prepared to cope with this possibility is to expect reluctant and very reluctant patients to challenge the leader regularly. The leader should anticipate and be alert to the higher probability of being challenged when asking questions and giving directives. If the above does not occur, any of the following speculations may account for the group as a whole behaving in a more cooperative and compliant manner: 1) a significant portion of the group is beginning to trust the leader and is becoming more interested in the proceedings; 2) a subgroup of more reluctant group members sense the larger portion of the group would not welcome their challenges and confrontations if it stopped the group from moving forward, because this larger portion of the group is now more curious and willing to give the leader a chance to lead the group; or 3) reluctant and very reluctant group members are tired, and have decided the best way to cope with this unwanted situation is to use passive and indirect means to communicate their thoughts and feelings. Any combination of the above speculations may account for why, in our clinical experience, we have observed many patients becoming receptive and accepting PGC’s norms in a relatively short period of time. .

Psychological Question, 20 Minutes (Including Analysis and Questions/Comments) The leader turns to the blackboard and writes the session’s Psychological Question, saying each word after it is written. When the entire question is completely written on the blackboard, the leader turns to the group and repeats the entire question, as follows:

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Leader:

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Why should you not accept professional help for your chemical dependency problem?

The leader places a strong verbal emphasis upon the word “not.” Leader:

Please take some time to reflect on this question. [pause] What answer or answers do you come up with? [pause] If you become aware of more than one answer, think about which one is the most important to you. [pause] Please remember there are no right or wrong answers to this question and you may always Pass rather than say your answer to the group. And please do not comment on each other’s answers. Before we hear your answers and I write them on the blackboard, I want you to know that I believe each one of you should accept professional help because you have all suffered enough and other people with similar problems have been helped by professionals. One of the goals of this group is to convince you to consider accepting future psychological group help, as well as self-help and religious groups, if needed, to achieve your independence from the chemicals you have become dependent upon.

The following is a representative sample of responses (10 out of 20–25) that PGC leaders might expect to receive to the Psychological Question. The leader begins the “going around technique,” again in a clockwise manner beginning with the first person on the leader’s left, and asks each group member to state their name and answer the Psychological Question. The advantage of using GAT uniformly is that it is a more orderly and predictable procedure which is easier for patients to follow, and which helps them prepare to respond. The leader turns to the first group member and says: Leader:

Please say your first name again.

Group Member #1: Leader:

Jim.

Thanks, Jim. [pauses, looking at him] Jim, why should you not accept professional help for your chemical dependency problems?

The leader emphasizes the word you as well as not when asking the question.

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Group Member #1:

They are only in it for the money.

The leader observes that he gives his answer in a matter of fact tone of voice. Leader:

Thank you, Jim.

The leader then writes Jim’s name and response on the blackboard, thus: Jim: They are only in it for the money. Using the patient’s first name is an attempt on the leader’s part to communicate that the leader in this moment is completely focused upon asking the question to this individual, and is professionally very curious about the answer. The leader believes that the answer to this question has varying levels of significance for each patient. The leader expects patients to take the question very seriously and to give truthful answers, and hopes that their answers will lead to their learning something about themselves that will contribute to their goal of avoiding relapse. The leader turns to the next group member and says: Leader:

Please say your first name.

Group Member #2: Leader:

Roger.

Thank you, Roger. [pause] Roger, why should you not accept professional help for your chemical dependency problems?

Group Member #2:

I should accept professional help.

Roger answers very quickly, and looks away from the leader. The leader adds Roger’s name and his response on the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. The leader turns to the next group member and as soon as their gazes meet, Group Member #3 does not wait for the leader to ask the question, but instead answers: Group Member #3: Leader:

William. Pass.

Thank you, William.

The leader adds his name and response to the blackboard, thus:

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Jim: They are only in it for the money. Roger: I should accept professional help. William. Pass. This psychological exercise is meant to be a therapeutic dialogue between the leader and each group member while their fellow group members listen. When asking the Psychological Question, the leader looks directly at the group member and always uses his or her first name in an attempt to create a more personal experience that occurs between both the leader and the patient. (In many clinical settings, it is customary for staff to call patients by their first name. The opposite—patients calling the staff members by their first names—is also a common practice). The leader purposely erases all group members’ names at the completion of the Word Association exercise. Asking each patient to repeat their names in the Mini-Lecture, Word Association, Psychological Question, and Final Question/Comment may seem redundant and unnecessarily time-consuming. However, from the PGC leader’s perspective this is a very important procedure for the following reasons: 1) since the PGC method seeks to be maximally inclusive, each component of the PGC plan is designed to accept and assimilate patients whenever they arrive. Asking new patients to say their names if others do not would stand out, and this would emphasize individual group members as latecomers, and would be in opposition to PGC’s therapeutic objective of making all patients feel welcome whenever they arrive; 2) asking each group member to repeat their name provides the leader with objective assessment data. By asking group members to repeat their names, the leader uses this interaction as a baseline for comparison. For example, does the patient have to always be asked to say his name prior to answering the leader’s question? Does the group member begin saying his name voluntarily, which helps the PGC Plan to move forward more quickly? And does this group member appear increasingly more comfortable and willing to comply with this directive as the session progresses? For example, in the above interaction William responds by giving his name and his answer before the leader asks the question. When we compare how William reacts to the Word Association exercise and how he reacts to the Psychological Question exercise, we observe two differences: first, this time he says his name first before answering the question, and second, he volunteers his response. Here he demonstrates greater compliance with the leader’s directive and his behavior has the constructive effect of moving the Plan forward. The leader can only speculate on what this different behavior means for this individual, but the leader hopes that William’s different behav-

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ior signals more receptivity to some of what this group experience has to offer and that he is beginning to benefit from the therapeutic factors previously discussed and described by Yalom (1995). As each group member’s participation in the PGC group tasks and process increases, the group as a whole can benefit. The leader then turns to the next group member. Leader:

Please say your first name.

Group Member #4: Leader:

Thank you, Thomas. Thomas, why should you not accept professional help for your chemical dependency problems?

Group Member #4: Leader:

Thomas.

They have never been addicted. All they know comes from books.

Thank you, Thomas.

The leader adds Thomas’s name and response to the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. The leader turns to Group Member #5. Leader:

Please say your first name.

Group Member #5 immediately says: Group Member #5: Leader:

Lawrence. Because they can’t be trusted.

Thank you, Lawrence.

The leader adds Lawrence’s name and response to the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. Lawrence: Because they can’t be trusted.

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The leader turns to Group Member #6: Leader:

Please say your first name.

Without delay, Group Member #6 says: Group Member #6: Leader:

Paul, because they are not there when you need them.

Thank you, Paul.

The leader adds Paul’s name and response to the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. Lawrence: Because they can’t be trusted. Paul: Because they are not there when you need them. The leader turns to Group Member #7, who is now fully awake. Leader:

Please say your first name.

Group Member #7: Leader:

Juan.

Thank you, Juan. Juan, why should you not accept professional help for your chemical dependency problems?

Group Member #7 smiles and says: Group Member #7: Leader:

I have AA and my higher power.

Thank you, Juan.

The leader adds Juan’s name and response to the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. Lawrence: Because they can’t be trusted.

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Paul: Because they are not there when you need them. Juan: I have A.A. and my higher power. The leader turns to the next group member. Leader:

Please say your first name.

Group Member #8: Leader:

Thank you, Jose. Jose, why should you not accept professional help for your chemical dependency problems?

Group Member #8: Leader:

Jose.

I don’t know.

Thank you, Jose.

The leader adds Jose’s name and response on the blackboard, thus: Jim: they are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. Lawrence: Because they can’t be trusted. Paul: Because they are not there when you need them. Juan: I have A.A. and my higher power. Jose: I don’t know. Leader:

I want to thank all of you for your cooperation and responses so far. You have given plenty of material to be analyzed at the end of this exercise. I especially want to thank you for not commenting on anyone’s answers.

The leader turns to Group Member #9. Leader:

Please say your first name.

Group Member #9: Leader:

Thank you, Roberto. Roberto, why should you not accept professional help for your chemical dependency problems?

Group Member #9: Leader:

Roberto.

I don’t need it.

Thank you, Roberto.

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The leader starts to add Roberto’s name and response to the blackboard. Before the leader finishes writing his response, a group member who has not had their turn (Group Member #12) says in an angry voice: “That’s a stupid answer!” The leader immediately turns to Roberto, looks directly at him, and says: Leader:

Roberto, your answer is not stupid because there are no smart or right answers to the Psychological Question. I want to thank you again for your answer, and would you please not respond to Group Member #12’s comment, so I can continue giving each group member a chance to respond to the Psychological Question, because otherwise our time for this exercise may not be sufficient.

After conversing with Roberto, but before resuming the exercise, the leader immediately turns to and looks at Group Member #12: Leader:

I would greatly appreciate your not expressing your thoughts and feelings toward other group members’ responses, and I know this may be difficult for you to do. You are certainly entitled to your thoughts and feelings regarding other group members’ responses, but for this group method to be effective [leader now shifts his gaze to the entire group and moves more toward the center of the group] I need all group members’ cooperation. I am asking all of you to direct and restrict your comments and questions to me only. And although I am asking you to restrict your communications to me only, what you say to me is totally unrestricted. And I also ask you to wait until the end of each exercise when I will ask you whether you have any questions or comments on this part of the session. Then, in the last part of the session, the final Questions and Comments [leader points toward the blackboard] you will have the opportunity to tell me what you think and feel about anything I have said or done while leading the group. The reason I am asking you to do this is so each of you will not have to be concerned about being criticized for your responses. Remember there are no right or wrong answers to the Psychological Question. This group method does not offer you the benefits of receiving feedback from your fellow group members. This is a disadvantage of the PGC method, but for those of you who are not ready

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or have difficulty with receiving even constructive criticism it may be an advantage because all criticism is discouraged in a PGC session. This group method is designed to complement your other group treatments where you will receive the benefits of constructive criticism from your fellow group members. The leader then finishes writing Roberto’s response on the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. Lawrence: Because they can’t be trusted. Paul: Because they are not there when you need them. Juan: I have A.A. and my higher power. Jose: I don’t know. Roberto: I don’t need it. The leader turns to Group Member #10. Leader:

Please say your first name.

Group Member #10: Leader:

Thank you, Martin. Martin, why should you not accept professional help for your chemical dependency problems?

Group Member #10: Leader:

Martin.

They may not be around when you want them.

Thank you, Martin.

The leader adds Martin’s name and response to the blackboard, thus: Jim: They are only in it for the money. Roger: I should accept professional help. William: Pass. Thomas: They have never been addicted. All they know comes from books. Lawrence: Because they can’t be trusted. Paul: Because they are not there when you need them. Juan: I have A.A. and my higher power. Jose: I don’t know.

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Roberto: I don’t need it. Martin: They may not be around when you want them.

Analysis of Responses to the Psychological Question After thoughtfully looking at the blackboard, the leader turns to the group and says: Leader:

I want to thank all of you for your participation in this Psychological Exercise. You responded to the specific question that I asked. Your answers to the Psychological Question do not say whether you want or will accept help in the present and/ or the future. Earlier in the session you permitted me to introduce and conduct two Psychological Exercises. In fact, right now, you are all accepting professional help as I speak, because you are listening to a group leader in a professional group treatment session designed specifically for chemically dependent patients. And isn’t it very interesting to see all the reasons written on the blackboard for why you should not be listening to me. Yet you are! See how complex human behavior can be? See how we can think and feel, tell what we think and feel, and then do exactly the opposite of what we think and feel? This is one way how we can recognize our conflicts: when we think or say one thing, and then do the opposite. To be conflicted and not be aware that we are behaving in a conflicted way is not an uncommon experience. We are all capable of being conflicted about many different things in life. What makes us all alike is that we can be conflicted. It is a common human experience. How we differ is what actually causes our conflicts. What we all seem to share is a dislike of being conflicted, so much so that we often pretend to ourselves, as well as others, that we are not. Another interesting occurrence is that it is frequently easier for us to recognize other peoples’ conflicts than our own. This is one of the advantages of group treatments: other group members can help each other identify their unwanted conflicts. Three of the reasons for avoiding acknowledging and accepting that we are conflicted are: 1) we think we don’t need to acknowledge it; 2) we are not ready to; and 3) we fear the process of change itself. You see how complicated human behavior can be?

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Notice how many of you had no difficulty in answering the Psychological Question. Many of your answers were given quickly and seemingly required little effort on your part. This suggests that accepting and receiving professional help may be difficult for a number of you. The reason I choose this particular question is because it allows patients to express thoughts and feelings that reveal the conflict some may have regarding accepting help. This Psychological Question can also identify those of you who may be ready, willing, and able to accept all the help you may need. Here are some optional additional comments the leader can make: I asked this question to help you become more aware of your thoughts and feelings related to accepting professional help. I did not ask this question to judge which of you are or are not conflicted about receiving professional help. You may need to look at some of your negative thoughts and feelings regarding accepting professional help. Certain thoughts can be irrational, and some feelings can be harmful to your avoiding future relapses. Thinking “once addicted, always addicted” and feeling you are hopelessly addicted are examples of very harmful thoughts and feelings. Other caring people are needed when we have such destructive and hurtful thoughts and feelings. I believe that because of the severity of your chemical dependency problems, it would be best for you to receive all the help you can get. But it is not what I believe that is important; what is most important is what you think and feel because that is going to influence the judgments you make regarding your future treatment needs. The PGC method is designed to increase your awareness. Increased awareness can lead to better life choices. This is directly related to relapse behavior. Many patients say they don’t want or intend to use alcohol and other drugs, but then find themselves doing the opposite by drinking and drugging again. And of course, when they tell people what happened, they often receive very little empathy for their truthful explanation. Not being aware of thoughts and feelings that lead to relapse is no excuse for the relapse behavior, but it is an explanation. The reason it is not an excuse is because as

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adults we are all held responsible for all of our actions. Harmful thoughts and feelings outside of our awareness can influence our behavior. To reduce the possibility of acting out these unwanted thoughts and feelings, we need to increase our awareness of them. The PGC group method is created to help you become more aware of your wanted and unwanted thoughts and feelings. The more aware you are of them the less likely you are to act upon them. Relapses are common because it is very difficult to change behavior that has become habitual. Habitual behavior is automatic. Until you appreciate and accept the complexity of your situation, and how complicated it can be to transform harmful habitual behavior into helpful behavior, you will be less likely to see why it is in your best interest to seek and receive help from caring and competent others.

Questions and Comments (Optional) After the Analysis is completed, the leader always has the option of asking the group as a whole whether there are any questions and/or comments on anything regarding what has just been presented in this segment of the PGC session, and if so, to raise their hands. The leader briefly answers whatever questions are asked and listens, and briefly responds empathetically and supportively to any comments they might have. However, if the leader determines there is not sufficient time for these optional questions/comments, the leader can instead inform the group that it is preferable to move to the Final Questions and Comments segment, where they will be systematically invited to ask questions and make comments about anything that has been covered in the day’s session.

Part III: Final Questions and Comments, 15 Minutes The leader’s first individual dialogue with each group member is at the completion of the Mini-Lecture when the leader asks each group member in sequence if they would like to ask a question and/or contribute a comment. The leader’s last conversation with each group member occurs in the third and final part of the plan, the Final Questions/Comments. At the end of Part I, the Mini-Lecture, and Part II, the Psychological Exercises (the Word

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Association and Psychological Question) all patients are invited to give their reactions to the material presented by the leader. Patients are asked to restrict their questions and comments to only what the leader presents and what occurs in that part of the Plan which has just been completed. During these Questions/Comments, the leader might choose to respond to a group member’s questions or comments with additional remarks if the leader thinks they are potentially helpful to the individual, as well as to other group members. The Final Questions and Comments distinguishes itself by serving three additional therapeutic purposes. The first is to end the session by allowing the leader to express appreciation for all patients’ efforts to participate and contribute to the PGC group tasks. The second is to let group members have the “last word” by giving each of them the opportunity to ask a final question or make a final comment. Here, the leader uses the “going around technique” for the last time. But this time, the group members are encouraged to ask their final question and/or comment concerning any portion of the day’s session. The PGC method is provocative, and going around systematically allows each patient to leave the session having had the “last word,” and the leader can use this as a last chance to make parting supportive, helpful, and empathetic statements concerning their experience and participation in the day’s session. The leader thanks them for attending, cooperating, complying, and for contributing their personal responses in the two Psychological Exercises (Word Association and Psychological Question), and for their final question/comment. The third distinguishing factor of the Final Questions/ Comments is to permit the leader to obtain some assessment information by specifically asking each group member, as part of their final comment, to give honest and direct feedback to the leader regarding the PGC session’s content, the group’s structure, and the leadership. PGC accepts limited therapeutic objectives, and each session’s exploration of a specific topic is restricted. The PGC experience can stimulate patients’ curiosity, but may also leave some patients with incomplete answers to important questions. If, in the Final Question/Comments section of a PGC session, patients express disappointment because the day’s session raised some incompletely answered questions, the leader acknowledges that similar to all group treatments, PGC has its limitations, and that at times this method may raise some questions that are not fully explored or answered. The leader informs the disappointed group members that their disappointment has a psychological value, namely, the patient’s disappointment reveals that the patient was sufficiently involved in the session and is now taking an active, assertive approach towards receiving treatment. The leader praises

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these patients for experiencing and identifying their unwanted feelings of disappointment, as well as directly and verbally expressing their disappointment in the “here and now.” Although it is the leader’s hope that these patients might benefit from being congratulated for successfully completing one of PGC’s basic group tasks, these patients may still want and need more complete answers. In this case, the leader responds by suggesting that these patients consider accepting more responsibility for determining more of their own answers. The leader uses the patients’ disappointment to suggest that they bring their incompletely answered questions to their other treatments for further exploration and discussion. This also permits the leader to encourage them to take greater advantage of their other treatments: group and individual counseling and therapy as well as self-help and religious group experiences. Patients are told that professional group treatments can be most helpful when patients use them in combination to meet their individual needs. To take advantage of PGC’s tendency to raise unanswered questions, treatment staff might want to consider scheduling PGC groups early in the day. That way, patients have a less restrictive opportunity to continue exploring the topic and any unanswered questions raised in PGC in their other group treatments.

How Patients Respond to the Final Questions/Comments For patients who have participated in the first and second parts of the PGC Plan, the Final Questions/Comments will be the fourth time the leader has asked them whether they would like to ask a question and/or make a comment. By this time, many patients have learned to anticipate when it is their turn to respond and will voluntarily say their name prior to responding. The leader interprets this behavior as representing patients’ acceptance of and cooperation with the leader’s instructions. The leader can also compare how each group member’s response is similar to or different from the three previous times the group member was asked to respond to the leader’s invitation to participate by asking a question and/or contributing a comment. The leader can expect to observe some dramatic changes with reluctant and very reluctant patients, because, if and when they decide to be more compliant and accepting of the PGC method and leadership, their behavior will obviously be very different from their initial responses. Their behavior becomes more similar to nonreluctant group members who follow the leader’s directives and participate to the best of their abilities. The response patterns tend to distribute

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themselves into three major categories: 1) criticisms and complaints concerning the leader’s behavior and the group method; 2) “Passes”; and 3) testimonials. Criticisms and Complaints. A very small minority of patients offer responses that fit this first category. A few will voice dissatisfaction with the leader’s discouragement of members freely interacting with each other. The following three speculations are offered to explain their dissatisfaction: 1) unfulfilled expectations due to previous group treatment experiences and/or media-influenced perceptions of traditional group therapy; 2) the patient believes himself or herself to be ready and able to benefit from the more demanding models of interpersonal learning; and 3) very reluctant patients quickly can identify the limitation that in PGC group members do not freely interact, and use this specific limitation to justify and excuse themselves from participating in the group treatment process. This very small group of patients can further be divided into two groups: the larger of these two groups are patients who, for characterological or situational reasons, have an intense need to control others and/or avoid being controlled, who may be anxious tolerating the level of control the leader is exerting, but who will nevertheless continue to participate. To help this larger group, it is especially important that the leader repeatedly make empathetic comments and praise them for their decision and determination to tolerate their anxiety. The smaller of these two groups are those who eventually reject and/or prematurely terminate all treatment modalities offered to them in the treatment program, including, but not limited to, PGC. Passes. A small minority of Passing responses can be expected. The leader respects these patients’ inability or unwillingness to self-disclose. After receiving a group member’s Passing response, the leader praises the group member with the same enthusiasm as the leader does for members who choose to self-disclose. In a single-session intervention, the leader usually refrains from interpretation so that group members do not mistakenly perceive the leader’s interpretations as criticism for not offering the group a more personal response. Testimonials. A consistent majority of group members respond to the Final Questions/Comments with testimonials. These testimonials come from the highest and lowest functioning group members. While recognizing that the number and quality of these testimonials could be inflated because of the inherent bias of the leader (staff member) asking for feedback, we believe that a variety of other factors strongly contribute to these positive results, including: 1) all patients are treated in an equal manner as much as possible, and all levels of group members’ participation are respected and accepted;

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2) the leadership is protective and very supportive; 3) the group structure promotes a calm, orderly, interesting, and safe interpersonal environment where all patients can be listened to while their fellow group members listen and/or observe, and where they consistently receive hopeful and empathetic statements from the leader. Thus, patients’ basic need to be appreciated and affiliated in a secure setting are being met (Maslow, 1970).

PGC IN CHEMICALLY DEPENDENT/MICA SHORT-TERM INPATIENT AND LONG-TERM OUTPATIENT REHABILITATION PROGRAMS Multiple Sessions What has just been described is the application of PGC in a one-week detoxification treatment program for chemically dependent and MICA patients on a medical ward. This gives patients a “sample” experience of the PGC group method and potentially makes it easier for them to transition into other affiliated programs where multiple PGC sessions are offered. In a short-term inpatient, long-term outpatient, or residential program, PGC is conceived as a multiple-session intervention that is offered as an additional and/or alternative group method to complement and support all the other interdisciplinary treatments that are being offered. PGC’s adaptability permits treatment staff to determine and to freely change the number of sessions that best meet the needs of their patients and programs. PGC sessions can be scheduled on an as-needed basis, weekly, a few times per week, or even daily—for example, if the staff chooses to use PGC to provide patients with a commonly shared therapeutic theme for the treatment day.

Membership Criteria PGC leaders use the same minimal exclusion criteria in short-term inpatient and long-term outpatient PGC groups as they do for a one-week detoxification program. Screening conducted by the intake staff is sufficient for patients to enter an inpatient or outpatient PGC group, requiring no further screening by PGC leaders. If the leader observes that there are any acute patients requiring either immediate psychiatric care and/or detoxification, these patients can then be referred to other program treatment staff.

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Patient Composition In the one-week inpatient detoxification program, the majority of patients are equally unfamiliar with the PGC method, the only exception being patients who have relapsed and are returning to the detoxification program. In the short- and long-term inpatient or outpatient rehab programs, the patient composition is more complex. Some patients have had prior exposure to PGC, while others have not. For example, a patient attending the shortterm inpatient rehab program may be directly referred, with no prior exposure to PGC, or they may have been oriented to PGC through the one-week detoxification program. Likewise, a patient attending the long-term outpatient program may be directly referred, or have some experience with PGC in either the detoxification or short-term inpatient rehab program. As a result, the leader needs to be aware of subgroups that may form, which can happen among the “regulars” or new patients entering the group, and which might potentially lead to conflict. Any time two or more new patients enter the group at the same time they can be viewed as being a new subgroup. Although they immediately become a part of the existing group physically, they are not yet psychologically integrated into the group. The leader wants each new group member to feel welcomed, accepted, and integrated into the total group as soon as possible. However, new group members may often behave very differently than “the regulars,” i.e., experienced PGC group members who now accept the method and are active participants. Experienced PGC group members can and often do help to facilitate new group members’ compliance with the PGC group norms. When nonreluctant and experienced group members observe some new group members being uncooperative, some will often generously offer spontaneous testimonials and encourage new group members to cooperate and comply. However, many reluctant new group members are very independent thinkers, so when it comes to evaluating a new leader and group method they will often need to test the leader themselves. The PGC method is designed to minimize the possible negative effects of a newly arrived and very reluctant subgroup that seeks the approval of the subgroup’s “leader” who may be behaving noncompliantly, rather than from the PGC leader and the group as a whole. This creates the potential for direct conflict between the new subgroup and the “regulars.” However, since new patients are asked to speak only and directly to the leader, this helps to redirect any potential hostilities towards the leader and away from group members.

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Returning Group Members Relapse is the usual reason most patients return to treatment programs. Returning patients deserve a sensitive and caring welcoming back to an ongoing PGC scheduled session, because some are often demoralized, very angry, and disgusted with themselves. It is recommended that the leader direct as many very hopeful, supportive, and empathetic responses as appropriate to the returning group member throughout the session, and at the end of the session might even consider spending a few minutes with the patient to reinforce and praise the patient’s decision to return for professional treatment. This also gives the leader an opportunity to make a brief assessment of the patient’s emotional condition. Most returning group members may receive some greetings and welcoming remarks from some other caring “regular group members” whom they already know. It is recommended that the leader permit these brief spontaneous member-to-member interactions to occur whenever they may happen if the leader believes the relapsed patient could benefit from this additional attention. For example, if a regular group member enters the session late and recognizes the return of a recently relapsed patient in the room and greets him warmly and caringly in the middle of an exercise, the leader might choose to interrupt the Plan and observe this interaction and wait for it to have its positive effect on the patient before moving the Plan forward. This also provides an ideal opportunity to praise the group for being flexible, tolerant, and accepting of this brief interruption and to inform them that giving patients additional attention for returning to receive treatment is deserved because of their renewed effort and courage to change harmful chronic habits.

Attendance As a multiple-session, open-ended, continuing group treatment intervention, PGC is particularly well-suited to equally accommodate noncompliant patients with time management problems and irregular attendance patterns, as well as compliant, regularly attending patients. There is no seniority in PGC, that is, the leader does not award group members special privileges for regular attendance and compliance. For example, it is common for regularly attending group members to form preferences for certain seats in the treatment room. When the leader observes that “the regulars” expect to sit in their preferred seats, the leader is quick to remind the group that in PGC there is no “seniority”

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and that equal participation for all group members is a basic PGC objective. However, the leader frequently looks for opportunities to acknowledge and praise group members whose attendance and participation has improved.

Welcoming Group Members In outpatient settings, the leader never knows exactly who will enter any scheduled PGC session because newly admitted patients to the program may be entering the group for the first time, and because some previously assigned patients do not attend regularly. Therefore, it is especially important that the leader prepare the room in advance to permit all arriving patients to sign their names on a sheet of paper before taking their seat in the treatment room. Ideally, a small table placed at the front of the room between the entrance door and the blackboard will permit the leader to ensure that all entering patients’ names are recorded before the leader welcomes them into the group and helps them to find a seat. This arrangement is very important because this permits leaders to introduce themselves, to welcome all entering patients into the group session, and to begin forming a therapeutic relationship with new group members whose identities are previously unknown. This also has the advantage of encouraging more responsible behavior, because it prevents patients from remaining anonymous. How patients react to the leader’s request that they sign their names also provides potentially important information regarding how cooperative and compliant these patients may be.

Content of Sessions The PGC leader intentionally does not reveal the day’s topic until the time of the session. This gives the leader maximum flexibility to determine and to change the topic. The leader is free to select any Plan that may better address the most current needs of both the patients and the program. In interdisciplinary inpatient milieus and residential programs, there can be miscommunications and differences at any time that might explode into conflicts between patients and/or staff. This creates an easy and tempting way for some patients to avoid working on their own personal problems by solely focusing their attention on the complexities of the unresolved conflicts, which can dominate the therapeutic agenda. However, all of this provides group leaders—in treatments where patients are encouraged and expected to learn from freely interacting, as well as in PGC—with excellent here and now “grist for the mill.”

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The PGC leader’s clinical judgment always determines which topic would be the most helpful to both patients and staff. For example: a patient is minimally compliant, frequently makes critical but accurate comments about how the program could be improved, and is quick to find faults with the staff’s imperfect behavior. This patient also expresses his anger by verbally making statements that some other patients and/or some staff members perceive as “threatening.” The staff becomes divided on whether or not this patient should be prematurely and immediately discharged. Whatever course of action the staff takes will have an impact on the entire therapeutic community. In situations such as these, the leader can try to help resolve whatever conflicts have arisen by selecting a topic directly related to the presenting problem, or to choose an indirectly related one.

VARIOUS USES OF PGC WITH CHEMICALLY DEPENDENT/MICA PATIENTS Orientation/Assessment/Transition Group One of the most valuable uses of PGC is as an orientation and assessment tool. Participation in PGC facilitates the transition of newly admitted patients into a program, while at the same time allowing staff to assess patients’ abilities to comply with the behavioral expectations and demands of other group treatments for which they are being considered or have already been scheduled. Because of PGC’s realistic, practical, and flexible approach, its active and directive leadership, and the very supportive and protective learning environment that it provides for group members (for example, by accommodating lateness, irregular attendance, early departures, and varying group size), PGC serves as a pleasant welcome to the treatment program. PGC also provides the leader with an opportunity to systematically observe how well these members comply with the method’s minimally demanding group tasks. This can have important predictive value; for example, part of any treatment program’s screening procedure could include multiple PGC sessions as a way of evaluating patients’ abilities to meet the behavioral requirements of a proposed “closed” 16-week relapse prevention group of 8–10 members where a commitment to regular attendance is expected and needed to maintain group cohesion. If it happens that a patient is consistently late and/or absent or frequently needs to leave the PGC session early, this behavior would need to be reviewed by the staff to determine whether it is appropriate for the patient to make the proposed transfer, rather than remain in regularly scheduled PGC

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groups. If the staff decides that the patient is not ready for the transfer, then PGC could be used as a transitional group treatment until the time when this patient better demonstrates the ability to meet the requirements of the closed group treatment.

PGC as an Alternative to Existing Group Treatments PGC is designed to be acceptable to the widest possible variety of patients. Because PGC makes relatively few behavioral demands compared with existing professional group treatments, it offers another treatment option to interdisciplinary programs that are seeking to provide the most comprehensive range of services possible. PGC is an ideal alternative approach for those reluctant high-risk patients— potentially suicidal, violent, binge drinkers, and illegal drug users—who, whether voluntary or mandated to receive counseling, are uncommitted to attending their regularly scheduled group treatments. PGC can be offered as an alternative drop-in, open-ended, ongoing group treatment for those patients who are not ready for or reluctant to accept existing professional treatments, but who need to be professionally monitored in order to provide preventive, efficient, and economical treatment whenever needed. For high-risk patients, irregular attendance is preferred to no attendance because at least they remain in the health-care system, are known to the staff, and can be quickly referred for additional appropriate treatments when needed. This may save patients’ lives as well as save the administrative costs of repeatedly readmitting and reprocessing patients into treatment programs.

Chapter

Seven Responding to Noncompliant Behavior, Suicidal and Homicidal Thoughts and Threats, and Requests for the Leader’s Self-disclosure

In order to conduct a PGC session with maximum benefit, the leader needs the cooperation and compliance of as many group members as possible. To accomplish this, the leader is required to ask all group members to focus their attention upon the leader’s directives by asking them to become more aware of their thoughts and emotional reactions and to report their reactions directly to the leader while their fellow group members listen. Nonreluctant patients can be defined as those patients who enter the group willing and able to readily comply with the leader’s directives because they believe that they can benefit from what the leader is offering and because they desire the approval of the group leader and/or fellow group members. Nonreluctant patients regularly ask reasonable questions and/or contribute comments which are relatively related to the material that has been presented. They not only accept the limitations of the PGC group process, but at times even praise the PGC method. In general, they demonstrate an interest in helping the PGC Plan to move forward, and appear sincerely interested and curious in other group member’s responses to the group’s tasks. 145

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We also perceive that nonreluctant group members tend to give more honest responses. Our perception is usually reinforced by other group members, who are acutely sensitive to inauthentic behavior. Although group members are advised and encouraged not to comment on the veracity of another group member’s response, that does not mean they can always refrain from moans, groans, and very expressive facial expressions when they perceive another member’s response to be of questionable honesty. Each group member and the group as a whole benefits more when each member responds honestly. The leader seeks to create an interpersonal environment which fosters honest self-disclosures but does not expect or require them. Direct, brief, honest self-disclosures are always conceived as an ideal to be achieved. In PGC, if a lack of honesty is revealed, it is not punished; instead it is explored and interpreted. Reluctant patients can be defined as those who are able but unwilling to comply because they are convinced that what the leader is asking and offering is not going to be helpful to them and because they do not desire the approval of the leader and/or fellow group members. Reluctant patients vary in their intensity of feelings, the rigidity of their thinking, and their manner of selfexpression: passive and/or aggressive. Reluctant and very reluctant patients can be categorized as those who are social or antisocial, leaders or followers, as well as those who are assertive, passive, passive-aggressive, or actively aggressive. Those patients who fall into the antisocial, actively aggressive, leader category, especially those who are very intelligent and creative, pose the greatest potential hindrance to the leader’s attempts to engage the other group members in the PGC Plan for the day. Patients in all other categories will at worst slow down the forward movement of following the proposed Plan, but will not usually inspire the leader to eliminate most of the Plan’s other components, thus encouraging the leader to focus and depend upon only one component of the Plan to achieve PGC’s core and supplementary therapeutic objectives. The leader explores a reluctant patient’s behavior from the perspective that this behavior is motivated by fear and ignorance. The PGC leader perceives this reluctant behavior as self-defeating, as well as potentially harmful to other group members’ psychological well-being and development, albeit in varying degrees. For example, less harm is done when a reluctant patient chooses not to participate in the group treatment process because this selfdefeating behavior is limited to this patient, who is being deprived of the benefits of professional group treatment. But much greater harm can occur if this patient uses his leadership skills to encourage others not to participate and/or to join him in rejecting what the leader is offering the group. This

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distinction influences how the leader responds to individual group members’ uncooperative and noncompliant behavior, and how challenging and confronting the leader chooses to be. Subgroups of very reluctant patients intentionally making dishonest responses in a PGC session are accepted by the PGC leader, because they have still made the choice to attend a professional treatment session, rather than face prison time (in some cases), demand an early discharge from the program and accept the consequences, or leave against medical advice and return to those environments and social groups which exploit their chemical dependency problems. In PGC, a patient’s presence and coping defenses—such as a misrepresentation of their honest thoughts and feelings—are accepted, but what a PGC leader does not accept is that a group member is incapable of, and not responsible for, more direct, honest communication. The above two definitions describe patterns of behavior which represent extreme ends of a continuum. The leader is concerned with helping all individuals at any point on this continuum to accept the PGC norms, group process, and content, because this can help them regain more control over their harmful thoughts, feelings, and actions and help free them from continuing to depend upon legal and illegal chemicals. Since leaders never know how much noncompliant behavior they will need to address in any given session, they always need to be prepared to slow down and temporarily stop the Plan from moving forward. Cooperation and compliance allow the Plan to move forward, but it may be inauthentic: leaders never know for sure if patients are just going along with them to gain their approval, rather than the patients believing that guided self-exploration can lead to greater control, freedom, and responsibility. Since one of PGC’s main therapeutic objectives is to encourage all patients to remain committed to accepting and receiving all the treatment they require, the PGC leader takes a very flexible, tolerant, and patient approach toward all defiant and noncompliant behavior to achieve this objective. However, since fellow group members may not be as accepting and accommodating as the leader, the leader has a dual role to play. The first is to try to win the very reluctant patient’s voluntary compliance with PGC norms and group tasks. The second is to continue to move the Plan forward to enable nonreluctant patients to benefit from the various parts of the PGC Plan. The leader also needs to be aware that nonreluctant group members can at times behave in noncompliant and harmful ways when they become intolerant of some of their rebellious group members’ behavior, and decide to “help” the leader by angrily confronting these rebellious group members in a punitive manner. Whenever the group leader is lecturing or replying to group members’ questions, comments, and answers to the psychological exercises, all group

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members are instructed to listen and wait their turn. Reluctant patients who are actively defiant and not compliant present the leader with continuous and ready-made “grist for the mill” because what they are communicating is more likely to be an honest expression of what they really think and feel about what the leader is asking and offering. How each patient reacts to this directive provides the leader with a meaningful sample of each individual’s behavior and the group as a whole. For example, from their perspective, why should they not speak to each other whenever they want? Ideally, the leader’s therapeutic task is to assess, accept, assimilate, praise, understand, interpret, support, challenge, and address this question in such a way as to win the voluntary cooperation and compliance of all patients who continue to defy this or any other directive. However, this is an ideal, and when necessary, the leader may need to confront this behavior. Very, very, reluctant patients can always frustrate a therapist’s professional efforts because under certain circumstances, these patients behave in ways that are harmful to themselves, such as terminating the treatment they need. When a seriously chemically dependent patient leaves treatment prematurely, the patient loses an opportunity to benefit from treatment, and the group is deprived of this patient’s contributions. This is why noncompliant behaviors are to be expected and treated with more care because these behaviors can have a significant impact on other group members, and may require heightened sensitivity and effort on the leader’s part to assimilate the potentially disruptive behavior into the group process.

NONCOMPLIANT BEHAVIORS Noncompliant patient behaviors that create special challenges for the PGC leader are: 1) not speaking; 2) lengthy responses; 3) speaking out of turn; 4) member-to-member interactions; and 5) verbal abuse toward the leader. Suicidal/homicidal thoughts and threats, and requests for the leader’s selfdisclosure may also create special challenges for the leader. All of these behaviors can be expected in treatment programs that are designed to treat both chemical dependency and psychiatric patients. Psychiatric patients who display some of the above behaviors may be frightening to other patients, particularly nonpsychiatric patients who are in treatment for the first time. The typical self-protective behavior is to avoid patients who are behaving in unusual ways, which unfortunately adds to the alienation and social isolation that many psychiatric patients experience. Some of the behaviors described above can increase anxiety in patients who may already be anxious about entering a new treatment program; therefore, the

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leader needs to quickly intervene to ensure a harmless to helpful group treatment experience for all patients. The PGC leader relies upon very protective, supportive, therapeutic interventions for three reasons: 1) to protect the patient who is exhibiting these behaviors, particularly the most disturbed and defended, from becoming alienated or more alienated from fellow group members; 2) to safeguard other group members who may be disturbed by these unusual behaviors; 3) to prevent the specific noncompliant behavior from becoming the major focus of and distraction from the group’s tasks. The leader always considers the first and second reasons as more important than completing the group tasks or moving the PGC Plan forward. To achieve these objectives, the leader interprets and reframes these behaviors.

Not Speaking In a typical single-session PGC session, previously described in Chapter 6, the leader invites each patient to speak four times during the session, and each time the response is observed by all attentive fellow group members. If each time the response to the leader’s invitation is not to speak, the leader has to make two assessments: first, is this patient not capable or not willing to speak, and second—assuming the leader believes an inquiry is therapeutically advantageous—how much of an inquiry into the patient’s silent response is necessary. In the moment, the leader may judge the silence response as not preferred but acceptable, and believe that a therapeutic investigation, challenge, or confrontation of the patient is not beneficial. However, this does not mean that the patient’s fellow group members share the leader’s belief, and feel as accepting of this behavior as the leader does. That is why the leader may need to interpret and reframe the silent behavior by offering therapeutic comments to all group members, thus making it less disturbing to others, as well as to communicate to the silent patient that silent behavior is not only acceptable, but actually adds to the PGC group experience. If the nonspeaking response occurs over the course of multiple sessions, this can usually be interpreted as a means to avoid self-disclosure for selfprotective purposes, assuming that there is no physical reason for this behavior (e.g., a hearing disorder). The leader needs to communicate this empathetic interpretation to the group to help preempt the group from reacting suspiciously and angrily toward this group member’s silent behavior. Therefore, the leader’s basic therapeutic tasks are to establish the patient’s trust and to help encourage the patient to risk self-disclosure and avoid the possibility of becoming a scapegoat. In this case, the leader can be more active and engaging,

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while remaining supportive and empathetic, for the purpose of helping the patient to verbalize a response, i.e., at the very least, say “Pass.” The leader might make the following comment: Leader:

I see that you are attentive to what we are trying to accomplish here today, so I don’t understand why you are not making a verbal contribution, and I want to remind you that a Pass is very acceptable behavior and so is your not speaking. But your saying Pass instead of me saying it for you would be better because I really do not like speaking for you, especially when I think you are quite capable of speaking for yourself, so I would appreciate your thinking about it and maybe the next time I come around you can say “Pass” yourself. I value you as a group member. I do believe you are learning by observing and I am eager to see you also learn by doing, but I want you to understand it is OK for you to remain silent as long as you need to, and I am glad you are here today.

There may be times where the leader perceives the patient’s silence not as an intense fear of self-disclosure, but rather as a passive-aggressive communication, and as deviant, distrustful, or rebellious behavior. In this case, the leader might hypothesize that the patient is doing some of the following: passively rejecting all professional treatment; testing the leader to see how accepting and accommodating the leader is; seeking attention and wanting to have some fun; acting in a leadership role with other patients, and signaling and encouraging other reluctant and very reluctant group members to rebel and reject the leader’s directives; hoping the leader will join other professionals in prematurely terminating him from the treatment program. In this situation, the leader might challenge the silent response: Leader:

In PGC the leader interprets a nonverbal response as a Pass. Now when people do not verbalize what they think or feel because they are unable to do so due to physical difficulties (hearing impairment), mental distractions (hears voices), or does not wish to, we can only guess or interpret what their nonspeaking behavior may mean, and different people will interpret the nonverbal responses in different ways. For example, some people interpret others who are less verbal compared with themselves as a sign of being stupid, while others may interpret the same behavior as being withholding and angry.

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And to add to the complexity of human communication, in some Asian cultures, for example, people using few words when relating to others is valued, and is interpreted as a sign of wisdom and self-control. The leader makes the above response to support and protect the group member who does not comply with the group task, which is to make a brief verbal contribution to the group process by asking a question and/or making a comment regarding the Mini-Lecture, or to say “Pass.” In terms of leading the group, it does not matter whether the patient is unwilling or unable to comply with the group task; what is crucial to communicate to each group member and the group as a whole is that noncompliance is acceptable, and rather than disturbing or inhibiting learning, it can help the leader understand why patients are behaving in ways that are not helpful to themselves and others. Here is another example of how the leader might challenge the silent response: Leader:

I see that you have been attending this group regularly which is in your best interest. You appear very aware of all that we are doing, and yet you have repeatedly chosen to respond by not speaking. I believe that what we are doing here is helpful to you because it offers you the opportunity to learn by observing your fellow group members but you are denying yourself the opportunity of learning by doing. I believe that you have much to offer but for some reason you are not ready or do not want to at this point. It would be helpful for me to know which it is: are you not ready to make a contribution, or is it that you don’t want to?

If the patient answers either one of these questions, then the leader says: Leader:

Thank you, I appreciate your answer.

The leader makes no further comment, and immediately moves on to the next person. If the patient remains silent, the leader says: Leader:

Well I hope you think about what I just said and perhaps the next time I go around you will choose to say “Pass.”

If multiple challenges similar to the above example are employed and are ineffective, and if the leader continues to perceive this patient’s not speaking

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as a form of passive-aggressive communication, the leader might determine that it is time to confront this group member, but only if the leader believes that the patient’s defenses are sufficient to receive the leader’s direct confrontation, and if at this time other group members are more likely to perceive the confrontation as a sincere attempt on the leader’s part to engage this patient to achieve further therapeutic ends. The PGC leader relies upon confrontational techniques only when—in the leader’s judgment—there is a very high probability it will be effective, and only after other therapeutic strategies have been exhausted. However, there are situations in which other group members will voluntarily and all too willingly confront a silent group member, preempting the leader’s confrontation. Since the leader wishes to avoid this, the leader may at times be forced to confront a group member sooner than would be ideal to protect the patient from receiving unsolicited, punitive, and angry confrontations from fellow group members. Leader:

Your regular attendance in this group demonstrates that you are committed to receiving psychological treatment. You appear alert and aware of what others are contributing to the group. I am glad to see that you may be learning indirectly from observing others. But until you speak we have no way of knowing for sure. Your behavior is self-defeating because you are limiting your learning and the group does not get to learn from your experiences. What is essential is that you learn to verbalize your thoughts and feelings rather than withhold them from others. Your silence may be misunderstood, which can cause other people to become angry, and to fear and/or avoid you. In a professional group treatment session such as this your behavior is acceptable; we are here to try to understand your behavior, not to judge it, but in other social situations such as jobs, family, etc., your verbal withholding could cause others to reject you.

The following additional comment could be made if the leader perceives that the patient who is being confronted is reacting very negatively to this confrontation and/or if the leader also wishes to use the opportunity to simultaneously and indirectly confront other group members who are also communicating passively: Leader:

I know I just made a lengthy comment. I did it because I thought that maybe it would encourage you to take the risk of trusting

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and making some self-disclosures, and in this way I could help you get more out of being here. But I also did it for another reason, and that is to help more of you in this group because I believe that what I just said goes for a number of your fellow group members as well as you, and I believe that you are not very different than some [or many] of your fellow group members who are not contributing all that they are capable of but who—like you—are withholding and just giving minimal responses to appear more cooperative and compliant than they really are.

Lengthy Responses To establish a protective group process, the leader requests that patients speak only to the leader while the remainder of the group listens. The leader is repeatedly asking group members to listen to these brief transactions and to give their own brief comments when called upon. This presents all group members with the opportunity to practice and improve their listening and speaking skills. Listening to others and learning to speak briefly may be a particularly difficult skill for some patients to acquire. Because the PGC method seeks to give each group member an equal part in PGC’s group process, group members whose responses dominate the group’s attention requires the leader to quickly, actively, and directly support and protect these group members from the possible attacks of some of the other more assertive or aggressive group members. The leader needs to win the lengthy responder’s cooperation and compliance with the group task, that is, to make briefer responses. Some patients who are anxious and dependent, who have a profound need for attention, are chronically self-absorbed, and who have undeveloped selfcontrol use constant verbalizations to reduce anxiety. These patients might depend upon others to reduce feelings of insecurity, helplessness, and dissatisfaction, and/or hold strong feelings of entitlement to others’ unconditional appreciation, concern, and help. In this case, the leader might intervene by making the following comment: Leader:

I need to limit your questions and comments because I want to give everyone as much as possible an equal chance to ask questions and make comments. I am sorry that I have to ask you to stop speaking because I know that you have a lot to

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contribute and we are not going to be able to benefit from what you have to offer. This is one of PGC’s limitations; group members do not always get the time they need to express themselves. Or: Leader:

This is not what I like to do which is to shut people up because patients need to talk and be listened to, but I need to do it, to give each patient more or less an equal chance to express themselves. This is one of PGC’s limitations; group members get only a limited amount of time to speak, but this is not unlike other professional treatments and nonprofessional group experiences, because in these other groups members also do not always get as much time to speak as they desire. I really need your cooperation on this because I need you to stop speaking and I don’t want to cut you off in the middle of expressing your thoughts or feelings. I would be glad to use any additional time we may have at the end of the session during the Final Questions and Comments to let you make additional comments, if you still need to.

Or: Leader:

It is not easy for some of us to use only few words to express our thoughts and feelings when we are anxious, especially if you haven’t done this in a while, because in your recent past you have been mostly with chemically dependent people who didn’t care how much you spoke or what you said and there were no penalties attached to using many words to express yourself. However, in family, work/vocational training, and school situations we all have to use fewer words than we may want to at times, so there is a real benefit for all of us to learn how to use fewer words because when we use many words people may stop listening to us because they become impatient. I really need your cooperation because this group method is most effective when everybody contributes to the group process and I want to give all of you a more or less equal opportunity to express yourselves, so I am sorry but I need to go on to the next person.

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In contrast, if a patient is observed to be highly intelligent, extroverted, verbally gifted, creative, and humorous, and if this patient enjoys relating to others and seems to possess leadership skills, the leader might interpret that this patient is very fearful of depending on others, rebellious and very reluctant, and that the behavior is more likely attributed to him being distrustful of all professionals and others in a position of authority. This particular patient might easily present himself as needing attention and demanding additional time to respond for disingenuous purposes, that is, to lead the group away from cooperating and complying with the leader’s directives. He might also seek and hope to demonstrate to the group that the leader is not to be trusted and is incompetent. A patient such as this might also not be totally convinced that he is chemically dependent and could benefit from professional help. Patients such as these who are accustomed to speaking when they want to, or for as long as they want, may be very reluctant to make the effort to shorten their replies, especially if their social behavior is highly motivated by self-interest and/or the desire to dominate the group process. The leader has the responsibility to find a way to win the patient’s cooperation and compliance in another way: Leader:

Speaking briefly permits more group members to participate, which makes this group treatment more potent because you will get to see how you are alike and different from others. Now it may not matter to you today whether your fellow group members approve of you, but if some day you wish to obtain the approval of an important person in your life, being able to express yourself using only a few words will not only be appreciated, but what you say is also more likely to be believed, and this may be in your self-interest, especially if you are speaking to someone whose approval you want, for example your boss or your parole officer. So please shorten your answer so I can give the next group member a chance to respond.

Or: Leader:

You seem to be having difficulty with giving brief answers each time it is your turn to ask questions and contribute comments. Your questions and comments are valuable, but what I find very interesting is that your fellow group members do not seem to care how much you speak and they seem content to listen

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to you and me indefinitely. Now this is very unusual because in other PGC groups where the group members value the experience, the group starts to complain that I am spending too much time with one patient and they encourage me to end the conversation and move to the next patient. So I would interpret the group’s behavior right now in two ways: one, that the group is avoiding the group’s task, and second, that they are letting you take the blame because “you always talk too much,” therefore it is your fault they don’t participate, but they are not assuming responsibility for their nonparticipation and are avoiding saying what they really think and feel about participating in this PGC session. This is typical acting out behavior, and so you and I are both the scapegoats. Now, it is perfectly OK to give lengthy responses because you haven’t learned yet how to say more with less words, and this is one of the social skills PGC lets you practice. But now I am going to ask you to stop speaking so I can ask the next patient to answer. Or: Leader:

The number of questions you are asking and comments you are making can be very helpful to others, and helping others is a positive and constructive act on your part and I am sure in your other group treatments you offer a lot to the group, but unfortunately in PGC “less is more,” and that is a limitation of this group method, because it forces me to ask you to please sum up so I can go on to the next group member [pause]. I don’t want to cut you off because it would be better if you chose to stop speaking [pause] and I don’t want you or the group to think that my having to interrupt your questions and comments means I don’t appreciate what you have to say. I am sorry that I have to invite you to complete your response now, but I want to remind you that you will be given other opportunities to ask questions and make comments later in the session.

Regardless of what might be motivating a patient to give lengthy responses, and what the leader’s interpretation of this behavior may be, moving the Plan forward requires active intervention by the leader for group members who

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do not stop asking questions and making comments on their own, and who appear unaware and maybe uncaring about how others are reacting to their lengthy responses. These group members require the leader’s help in controlling their self-defeating behavior, because this type of behavior often causes others to avoid or attack them. If the leader does not stop patients from continuing their excessive verbalizing and from dominating the group’s attention and the group process, other group members will! Since this behavior is frequently experienced as selfish by other group members, some group members will feel justified in becoming angry and attacking group members whose lengthy verbal contributions to the group process deny other group members from benefiting from asking questions and making their own contributions to the group process.

Speaking Out of Turn The leader can initially expect some patients not to wait for their turn to ask questions, make comments, and provide answers to the leader’s questions. This group of patients fits into the following categories: 1) they do not hear the leader’s directive because they are not listening or they are distracted when the leader asks for each group member’s cooperation by waiting for the leader to call on them before speaking; 2) they are in the habit of speaking whenever they wish because in their other group treatments they are encouraged to express themselves freely and the “going around technique,” if used at all, is only selectively used; 3) they do not wish to comply with the leader’s directive, for a variety of personal reasons, for example, a patient who is most comfortable when controlling others and who wishes to lead rather than follow others. Patients who comprise the first two categories will usually cooperate and comply with the leader’s directive after the leader repeatedly reminds them and gives an explanation for why they are being asked to wait their turn. Here the leader is primarily dealing with an orientation and educational matter, especially if these patients’ other group treatment experiences have been much less structured, do not stress the “equal” time norm, and expect patients to provide and be responsible for the content of the session. Patients who comprise the third category are those who need/desire to monopolize the interactions and dominate others, and who become very frustrated when they are expected to follow the leader’s directives, especially sharing the group’s time “equally.” These patients present the leader with some of the most trying challenges: how to obtain voluntary cooperation, compliance,

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and acceptance from patients who refuse to accept the PGC method as is, and who want to change it. For example, imagine the following scenario. A leader encounters an angry, very verbal male group member who is highly intelligent, well educated, and socially competent, and who very convincingly and eloquently expresses to the leader while the group listens that he does not want to wait his turn to speak and that he is not benefiting from this group. This patient then proceeds to accurately describe some of the limitations of the PGC method and tells the leader that he needs to lead the group differently, namely, to stop restricting patients who need to speak and allow group members to freely communicate with each other. To make the matter more complicated, the leader observes that this patient appears to be representing a small subgroup of patients who cheer him on as he confronts the leader. However, the leader also perceives that the remaining group members (a majority) have become quiet, attentive, yet unconcerned that the Plan has been interrupted and that they are being denied their chance to respond to the leader’s questions. They appear curious to see how the leader will deal with the confronting patient’s criticisms of the PGC method and leadership. Since the leader wants to be helpful to all patients in this group, the leader makes a greater effort to engage this dissatisfied patient. The leader tries responding by carefully and patiently listening to all of the criticisms. This requires patience on the part of the leader as well as the observing group members, because the patient may restate several of the criticisms to emphasize his beliefs and gain additional gratification from being the center of attention. As the patient continues to control the conversation with the leader, he becomes more relaxed. By now, this confrontation has gotten most of the group’s attention and aroused their curiosity, which is beneficial. Once the patient is finished speaking, it is recommended that the leader pause before responding, because this is likely to increase the group’s attention even further. The leader’s therapeutic decision is to continue to deny the patient’s requests/demands, and anticipates that this response will be better received by the majority of the group than by the dissatisfied patient and the subgroup he is representing. If this patient is ultimately unwilling to accept the leader’s directives and is determined to change and control the group experience to meet his special needs, when he realizes that his needs are not going to be satisfied he may further communicate his dissatisfaction by rejecting this group treatment method and walking out of the session. Given this possibility, the leader attempts to directly engage and placate him by honestly, respectfully, and

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genuinely agreeing with those criticisms which are accurately stated, as well as voicing acceptance and appreciation of the patient’s thoughts (criticisms) and feelings (anger) concerning his noncooperation. If this accepting and empathetic reply to the patient’s requests/demands further angers him, it is likely that he does not want a therapeutic listener, he wants an obedient one. In this case, attempts to further directly engage the patient are not recommended, but the leader can make the following comment to the entire group: Leader:

It is never my intention to purposely frustrate and anger patients and I am sorry that some of you find this group method unhelpful and even unacceptable. I appreciate your honesty and respect your criticisms and feelings, but all group methods have limitations and that is why this program offers a variety of group treatments, and many group treatments require that a patient attend a number of sessions and stay for the entire session because for many group treatments it is necessary to attend a number of sessions before you realize the benefits. It’s like taking antibiotics; your body needs to be exposed to this medicine for a number of days, and that is why you are expected to take it for a prescribed number of days before you know whether it is going to help you. So that is why I encourage all of you to be more patient and see if with more exposure to this group method you may begin to see some benefit for yourself. It is self-defeating to not give yourself a chance to benefit from participating in this group treatment. One of the contributing factors as to why relapses can occur is that many patients do not realize the different kinds of treatments they need and how long they may need them. It is one thing to accept that you are chemically dependent, but it is another to accept the different kinds of treatment you may require to free yourself of your chemical dependency problems.

The above comment may have little effect on the complaining and dissatisfied patient, but it does serve to communicate to the entire group some information regarding group treatments. The majority of the group will have to judge for themselves whether to trust the leader or the dissatisfied patient to define the purpose and process of professional group treatment. Fortunately, it is our experience that the majority of group members decide to trust the professional. Usually, after such an encounter just described group members

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often respond by being more cooperative and compliant with the leader’s directives and a few will sometimes voluntarily praise the group method.

Member-to-Member Interactions Although in PGC the leader asks all group members to temporarily stop their spontaneous speaking with other group members, the leader expects that member-to-member interactions will commonly and spontaneously occur, especially in groups comprising many new group members. When these interactions occur, the leader has repeated opportunities to assess and utilize them to serve the group’s therapeutic objectives. The leader relies upon three basic strategies to deal with these spontaneous interactions: Ignoring, Complaining, and Confronting.

Ignoring The leader is responsible for being attentive to all significant transactions that occur between group members. When group members engage with each other in either a harmless or helpful manner, the leader is advised to “ignore” this behavior whenever possible because being tolerant, accepting, and patient can frequently be effective, and when ignoring is successful, the leader has accomplished a major PGC goal, which is to enlist each patient’s voluntary participation in the group method. Constructive spontaneous therapeutic transactions are appreciated and accepted, even if at times they necessitate a slowing down and/or temporary interruption of the Plan’s forward movement. The fewer directives the leader delivers—while maintaining a calm, secure, and protective interpersonal learning environment—the better. For example, if during the Mini-Lecture the leader’s attention is minimally distracted by a conversation between two group members where one is giving helpful information to another and the receiving group member appears grateful for the information, the leader could “ignore” this behavior and continue with the lecture, because this interaction is therapeutic for both group members and does not rise to the level of slowing down the Plan. In addition, there are no group members complaining about this behavior and the group as a whole does not appear to find it distracting. To cope with this distraction, the leader may need to make a greater effort to stay focused, but this is a small price to pay for the professional pleasure of observing two patients already benefiting from attending the day’s session by being involved in a spontaneous, helpful interpersonal transaction of giving and receiving.

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However, “ignoring” should never be confused with the leader being negligent or avoidant. It is very important that those group members who are cooperating with the group norms know that the leader is aware of the uncooperative behavior of some group members and that the leader is making a leadership decision to ignore it. A simple way to achieve this is for the leader to recognize it nonverbally by interrupting the lecture for only enough time to directly look inquisitively at the group members who are communicating with one another and then back to the entire group to see if they are aware of what the leader is doing. Once the leader sees that a significant percentage of the group has observed this nonverbal communication the leader could then resume the lecturing, even if it means that the interacting group members have not finished speaking with one another and the leader, for a limited time, has to speak a little louder. When the “ignoring” strategy is successful, it relieves the leader from having to rely upon other options such as complaining and confronting, which can be equally effective, but take much more effort and time than “ignoring.”

Complaining Unexpected therapist behavior can get attention. From the patient’s perspective, professionals are expected to listen to their complaints, not the opposite. When a leader complains, patients will listen and many often respond positively as long as the complaint is honest and fair. When some very verbal group members seem to be unable to resist the temptation of continuing to speak to one another, thus distracting the leader and their fellow group members who are trying to listen, the leader is now in a position to complain: Leader:

When you talk to one another, I get very distracted and I can’t deliver what I need to cover to make the remainder of the session meaningful to you. I spent 30 minutes before this group planning this very brief lecture material specifically for this group session. I need all of your attention. This is a planned psychological group method which depends on your cooperation with each part for it to be effective. I need your help.

When saying the above, the leader looks at the cooperative, rather than the uncooperative, group members. The leader is not confronting, but rather complaining about a problem of being “unable to handle the distraction” and thus “asks for help.” This communication is educational. The leader is

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informing patients that a great deal of thought has been given to them prior to this session (the leader cares); that this specific lecture material was prepared for their benefit (the leader did something); and that the leader is now trying to do something more to help them, that is, deliver “psychological information.” However, for this specially selected information to enter patients’ consciousness and to be most effective, group members need to listen. After saying this, the leader immediately resumes lecturing, remaining as focused on the lecture material as is possible, should some group members continue to talk to one another. This complaining strategy does not always have an immediate effect, and sometimes depending on the group, the leader may be required to repeat the above comment periodically throughout a session.

Confronting When reluctant group members do not accept the leader’s directive to speak only to the leader, they are denying themselves the maximum benefit of the leader’s taking them through the stated Plan written on the blackboard. When their behavior disrupts the Plan from moving forward, their fellow group members are also prevented from the possibility of profiting from the stated Plan that appears on the blackboard. All behavior that brings the PGC Plan to a halt gives the leader a chance to present to all group members an ideal vicarious learning opportunity: to identify self-defeating actions, thoughts, and feelings in themselves and others. The PGC leader is psychologically prepared to divert from the blackboard Plan at any time, because the leader anticipates that certain group members will not always follow directives and participate in the Plan. Therefore, the leader is always ready to use this noncompliant behavior as “grist for the mill.” Whenever group members disrupt the leader’s blackboard Plan to such an extent that the leader decides it is not worth pursuing because there is an insufficient amount of cooperation from the group, this impasse almost certainly focuses the group’s attention on how the leader will respond to these rebellious group members. The PGC leader can readily use a confrontation strategy with individuals who have well developed leadership skills, and who wish to test the sincerity of the leader’s commitment to helping them by behaving in ways that will try the leader’s tolerance, flexibility, and patience. Some defiant group members will purposely behave in provocative ways to “force” the leader to react. How the leader reacts becomes the focus of the group’s attention. The behavior that begs to be addressed is when a small group of patients, usually led by

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informal leaders of the larger group, decide to have their own “leaderless mini group treatment session” in which they freely interact while the leader is trying to lecture to their fellow group members. In this scenario, a diversion from the blackboard Plan is advised. To win patients’ trust and compliance, the leader needs to demonstrate acceptance and empathy. The leader stops the Plan, moves closer to the group member who is the most verbal and appears to be the informal leader, looks directly at that individual and says: Leader:

I have been observing your continuously speaking to other group members. I had hoped that by ignoring your behavior that you would eventually stop and then after complaining a number of times about my need for all group members to restrain from speaking to each other that this might encourage you to stop speaking to other group members. I need your cooperation. But, you just keep on talking. Now, I don’t believe you have an undiagnosed hearing problem. So, I am beginning to wonder, is it that you can’t stop talking or you refuse to stop talking. If you can’t control yourself because of some physical problem and/or perhaps because of some very rare neurological disorder then I will need to alert the staff and ask the physician to examine you and see if perhaps you may require a neurological examination as well. Now I really hope that this is not the case because then the best treatment I can offer you today is to refer you to other treatment staff which I don’t want to do because then you would be denied benefiting from and contributing to today’s group session. I want and need your cooperation and I look forward to the contributions you have to offer the whole group. I believe you can benefit from and need all the treatment that you can get, because being chemically dependent is a very serious problem; it is a problem that some patients have resolved by accepting all the treatment they require. I don’t believe you have a physical problem. I believe that the reason you are uncooperative is because you refuse to cooperate which is a psychological problem!

At this point, the leader looks at and moves toward the center of the group and addresses the following to the group as a whole:

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And that is why you are all together in this room today—to learn that when you don’t verbalize certain thoughts and feelings, you may act them out in ways that can harm yourself and others. From a psychological perspective, uncooperative behavior in a PGC session can be seen as self-defeating, harmful, irrational behavior. It is similar to a medical patient not taking their prescribed medicine for a serious condition. Now sometimes patients have good reasons why they might not take their medicine; one might be they do not trust the physician or believe the medicine can really help them because they believe they are hopeless. If you do not trust me and/or have some doubts about following my instructions please tell me this when I ask you “do you have any questions and/or comments about anything I have said,” and please say it to me directly, but please wait until it is your turn to speak.

After saying all of the above the leader may postpone moving the Plan forward to give any and/or all of the confronted group members a chance to respond. In this case, the leader tells the remainder of the group that what would be best for the whole group at this time is for the leader to give these (confronted) group members an opportunity to tell the leader how they honestly feel about the PGC group method and its goals, at this moment. If the noncompliant group members replace their acting out behavior by listening, waiting their turn to speak, and then briefly and honestly verbalizing their thoughts and feelings directly to the leader as they occur while their fellow group members listen, then the leader will have achieved one defining major therapeutic objective. The other equally important major therapeutic objective the leader will have achieved is making their previously uncooperative, noncompliant behavior more understandable and acceptable to the remainder of the group members, thus avoiding potential interpersonal conflicts. To achieve this the leader has to be as accepting, supportive, and empathetic as possible. There are some patients whose commitment to accepting and receiving professional treatment may prove to be insufficient to meet the requirements and demands of the treatment program. But a proportion of these patients do not know this is the case until they begin attending the various assigned treatments. These patients will often terminate their treatment programs prematurely, and—for a variety of reasons—some of them will excuse their behavior by attempting to externalize the blame to fellow patient and/or staff

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behavior, program regulations, etc. Some of these individuals are often very skillful at provoking others to reject them. Since the PGC group method relies upon didactic techniques—the content and Plan are explicit and group members are told how to behave, as in “speak only to the leader”—patients seeking an excuse to leave the program conclude that a way to get rejected from such a group treatment is to break all the perceived “rules.” But the only PGC rules that require enforcement are the prohibitions against physical violence, which is absolutely not acceptable, and verbal abuse of fellow patients, which is not tolerated. If an individual is not able or willing to conform to the relatively minimal behavioral demands of a PGC session, then the patient is encouraged but never forced by the leader to voluntarily leave. Although this is certainly not a preferred option, at times it may be a necessary one, because the leader does not wish to be responsible for creating an interpersonal situation in which the patient has to increase the self-defeating behavior as a means of avoiding remaining in the treatment session. In fact, the leader hopes that by helping the patient leave the session prematurely, he or she will help the patient not leave the program prematurely. When a leader is faced with having to confront a patient who is attempting to stimulate an anger response on the part of the leader by behaving uncooperatively, the leader can accommodate the patient’s hidden desire to be rejected and ejected from the group session by gracefully helping the patient choose an early departure from the session: Leader:

I have been observing your continuously speaking to other group members. I had hoped that by ignoring your behavior that you would eventually stop and then after complaining a number of times about my need for all group members to restrain from speaking to each other that this would encourage you to stop speaking to other group members. I need your cooperation. But, you just keep on talking. I believe you are purposely choosing to ignore my instructions and I feel that you do not trust me enough to even try going along with what I am asking you to do. But, I am just speculating; I really don’t know why you are being uncooperative, only you know why, and I am sure of one thing: you must have some good reasons for your behavior. I believe you need to benefit from all the treatment that you can get, because being chemically dependent is a very serious problem.

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You may not be ready to receive what this group has to offer you today, but I want to thank you for making a contribution to the session today, because your uncooperative behavior gives me the chance to remind all of you that PGC was created equally to accommodate and include individuals who are ready and not reluctant to participate, and those who are not so ready and reluctant. That is why all patients are welcomed to PGC whenever they arrive, and they may leave when they choose. You would all be exposed to more of what this group has to offer if all of you could get here on time and stay for the entire session, but that is your responsibility and choice. Plus, the more group members, the greater the potential contributions to the PGC group process: all contributions are of value. The more each group member contributes the more potent the treatment session. I would really prefer that you stay for the remainder of the session. I really need your cooperation. But this is not what you may need today. So it’s your decision whether you stay or go. However, I want to remind all of you that you are always welcome to return to any PGC session as long as you are a patient in our program. If the patient gets up to leave, the leader may decide to add the following as the patient is leaving: Leader:

I am sorry that this group method was not what you may have needed today and I hope wherever you are going will be of greater help to you than staying with us. And if you just want to get out of the room for a few minutes to take a walk and think a while, and then decide you want to come back today, you would be very welcome back.

The leader encourages each patient to determine when to attend and how long to stay in a PGC session. This is done to demonstrate respect and to empower all patients. The leader invites patients to collaborate in their own treatment process, and to share the responsibility for how much they benefit from a PGC session. Patients’ voluntary and full participation in all PGC group tasks is what the leader strives to accomplish in every session. The leader communicates respect for each patient’s desire and decision regarding

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which professional treatments they are willing to accept, while actively encouraging each patient to take advantage of all offered professional treatments, self-help, and religious experiences.

VERBAL ABUSE TOWARDS THE LEADER The PGC method seeks to be as inclusive as possible. In order to achieve this objective, at times the leader must be able to tolerate and accept verbal abuse from group members. This therapeutic acceptance of verbal abuse is not to be confused with condoning or approving of insulting behavior. The leader accepts this self-defeating behavior as an initial step in helping the patient change this potentially harmful and maladaptive behavior. First, the leader has to determine if the patient is aware that what is being said may be very offensive and insulting to many people: is the offensive language intentional or is it the way the patient has learned to express certain feelings such as frustration and anger? The leader’s task is to try to understand the behavior in order to help the patient voluntarily change it. For example, is this patient using verbal abuse with the hope of being prematurely discharged from the program by staff members? In this case, the patient might be hoping that the leader will overreact to the verbal abuse, supporting other staff members’ opinions that the patient is unsuitable to remain in the treatment program. Or, is this a case in which the patient is unaware that they are using verbal abuse as a way to get people’s attention and respect, and to be taken seriously? To make a determination, the leader needs to engage the patient in a therapeutic dialogue. What follows is how the leader might respond to the latter scenario: Leader:

What you have said to me is very offensive but I accept it; not because I believe it is true or I believe that your using offensive words is justified, but because I am not here to judge your selfdefeating behavior. I am here to understand it. For example, I don’t know if you are aware that what you said is offensive or how offended others might be by what you said. Some patients will use offensive words as a reaction to being offended. So in trying to understand your behavior I ask myself did I do or say anything to you that offended you? Please tell me. Offending others can lead to physical conflicts in other social situations, for example in the family, on the job, etc. Learning to express ourselves without offending others is an important

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social skill. PGC is designed to give each of you an opportunity to freely express your thoughts and feelings to me while your fellow group members listen. However, as an adult you are responsible for what you say and how you communicate. Because PGC is a psychological treatment group, behavior that would normally be rejected is accepted because it gives all of us an opportunity to learn how to improve the way we communicate with each other. In PGC verbal abuse is not conceptualized as being identical to physical abuse, because they are only words, which can be changed. “I am sorry for what I said” (in the case of verbal abuse) can potentially repair a relationship, but “I’m sorry for what I did” (in the case of physical abuse) cannot physically restore someone who has been maimed or murdered through an act of violence. Verbal abuse is never excused: it is treated psychologically. By discouraging member-to-member interacting, the leader protects patients from the potential of being exposed to the direct verbal abuse of other patients. However, that does not protect them from indirectly experiencing it, if they have formed a positive identification with the leader when the leader is under attack. Caring and protective group members will often spontaneously verbally attack a group member, who they do not fear, when that patient is verbally abusive towards the leader. When this occurs the leader needs to quickly come to the defense of the verbally abusive group member, with the explanation to the leader’s “protector/s” that in PGC the leader gives all patients permission to honestly say what they think and feel to the leader, and that it is the leader’s therapeutic objective to avoid a potential conflict from arising between group members.

SUICIDAL AND HOMICIDAL THOUGHTS AND THREATS When a patient verbally expresses suicidal and/or homicidal thoughts and/ or threats in a PGC session, the leader treats them with the utmost seriousness. This therapeutic strategy is chosen to 1) safeguard the patient from the possibility of acting out these thoughts and threats; 2) enable the leader to determine what, if any, additional treatments are required, for example referral for a psychiatric evaluation; and 3) communicate to the group that expressing suicidal and homicidal thoughts has very serious treatment consequences. The leader first needs to find out whether these thoughts pose an immediate danger to the patient and/or others. But before this inquiry can occur the

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leader has to decide who is going to conduct it and where is it going to be conducted. The leader has several options to choose from. The first is for the leader to immediately end the group session and accompany the patient to the psychiatrist on staff for an evaluation, but in interdisciplinary programs where sufficient staff is available, the common practice is for the leader to ask another staff member to accompany the patient. The second option is for the leader to interrupt the Plan and begin the process of trying to determine from the patient if an immediate danger exists. In this case, the leader asks the patient some of the standard psychiatric questions related to suicidal and homicidal thoughts and threats. This latter option is recommended for the following reason: if at any time during the leader’s inquiry it appears that a psychiatric evaluation is going to be required, option one can always be immediately implemented. In other words, if at any point the leader believes that the patient is in genuine crisis and requires medication (or additional medication) and/or possible protective confinement and immediate psychiatric attention, the patient can then be escorted to the appropriate psychiatric staff member on duty. However, it is not helpful for the leader to prematurely draw the above conclusion from the expression of these disturbing thoughts and threats. Fortunately, some patients who chronically present suicidal and/ or homicidal thoughts are often more troubled by the lack of attention and care they need or want at that moment, as opposed to their distress over their actual destructive thoughts and feelings. When these patients receive the attention and protective treatment services they need and/or desire, the possibility of these dangerous thoughts and feelings being acted out are substantially diminished. If the leader perceives that this may be the situation, then one useful strategy is for the leader to—upon hearing a patient express destructive thoughts—immediately interrupt the Plan and directly engage the patient while the group listens as to whether the patient is requesting/demanding a need/desire for attention, or if indeed the patient requires additional treatment services. The leader’s swift action hopefully signals to the patient and the group that what the patient has communicated is very serious and that the patient deserves immediate attention. The leader may have to ask the group for their cooperation, by requesting them to “please be patient because it is necessary to ask this patient at this time some assessment questions to protect the patient and/or others.” How the distressed patient reacts to the leader’s questions, concern, and commitment to protecting him will help the leader to evaluate how serious these thoughts and threats are and whether this patient needs a referral. If the leader’s inquiry reveals that there appears to be no immediate danger and the patient’s expression of suicidal and/or homicidal thoughts is

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determined to be an expression of the patient’s desire or need to receive special attention or monopolize the leader and the group’s attention, then the leader might say the following: Leader:

I am very glad that you chose to come to today’s session and that you felt safe enough with all of us to reveal some of your very personal disturbing and potentially destructive thoughts and feelings. The concerns you brought up are serious and I want to strongly encourage you to make sure you reveal them in your individual treatment as well as in your other group treatments where the leader encourages all patients to express freely to each other what they are thinking and feeling.

The leader would then turn to the center of the group and address the following to the entire group: Leader:

I want to thank all of you for being patient and listening to our brief interview which was necessary because I needed to give this patient some extra attention and to determine what would be the best treatment for this individual, at this time. I consider your cooperation as an act of caring for a fellow patient. We all require extra attention from time to time, and need to learn ways of asking for it without harming ourselves and/or others. One of PGC’s primary purposes is to complement all your other forms of treatment in this program. And sometimes what we explore here and what occurs can be disturbing to some group members. I encourage all of you to bring to your other treatments those issues that arise in a PGC session which are important to you and which you would like to explore in more depth.

It is not uncommon for some patients to regularly express suicidal and homicidal thoughts, but fortunately these thoughts do not often present an immediate danger. However, since these thoughts can always potentially be acted upon with lethal outcomes, it is prudent for the leader to reengage this patient individually at the end of the session to reassess the seriousness of these thoughts and/or threats and to advise all treatment staff of what has occurred in the session.

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REQUESTS FOR LEADER’S SELF-DISCLOSURE It is not uncommon for many chemically dependent patients to want to know whether the group leader has had personal experience with chemical dependency. Thus, during any of the Question/Comment components of the PGC plan when the leader encourages group members to freely communicate their thoughts and feelings as they occur in the “here and now,” some will seize the opportunity to ask the leader whether he or she has ever been addicted to alcohol, cocaine, or other drugs. The leader should also be prepared that some patients might not wait for the Question/Comment component to ask this question (as was the case illustrated in the Mini-Lecture in Chapter 6). When this question is asked it usually focuses the group members’ attention upon the leader’s answer. Therefore, leaders need to be prepared to respond to this question in ways that advance psychotherapeutic objectives. Since one of PGC’s goals is to reinforce honest expression of thoughts and feelings, this question gives the leader an opportunity to model honest communication regarding the privacy issues that requests for self-disclosure raise for all people. The crucial question is whether the leader’s answer will help group members accept treatment and change maladaptive behaviors. Different leaders will have diverse thoughts and feelings regarding when and what they feel comfortable revealing to patients. But what most leaders would most likely agree upon is that the leaders’ self-disclosure is to serve specific therapeutic goals and that the timing of self-disclosures is an important consideration. Thus, the leader first has to decide when to answer the question, and second how to answer it. What follows are typical leaders’ responses.

Leader Decides to Answer Immediately If the leader believes that the group’s therapeutic goals would be advanced by addressing the question right away rather than later, then the leader has to choose whether or not to self-disclose the truth regarding the question “have you ever been addicted to cocaine?” If the leader chooses not to self-disclose, she might say: Leader:

I prefer not to answer your question because in my professional judgment I am concerned that answering will not be as helpful as not answering, and I have been able to help many chemically

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dependent patients without ever answering this question. However, that does not mean you should not ask this question, if you think and feel it is necessary for you. Self-disclosure is a very personal matter. You are asking me to self-disclose, which I prefer not to do, and now I ask you to respect my right to decide when and what to self-disclose. I will always respect your right not to answer any question I will be asking you and all other group members later on in the session. Your question suggests to me that you are curious and that you may need to know more about me before you will trust me enough to let me help you. You have also demonstrated that you can assert yourself by asking a question directly to me. This gives me the chance to let you and the group know that you just completed one of the therapeutic tasks in PGC, that is for group members to directly and honestly say what you are thinking to me, the group leader, while your fellow group members listen. An optional comment the leader might make is: Leader:

Now, although I wish to avoid self-disclosing my problems or lack of problems with legal and/or illegal chemicals, I am very willing to briefly describe my past educational and professional experiences which are [the leader selectively volunteers her educational, training, and professional experiences, for the benefit of all group members].

Leader Chooses to Self-Disclose Leader:

No, I have never been addicted to cocaine. Now, I hope that my answer does not encourage you to not actively participate in this group treatment because it is led by a professional who has never been addicted to cocaine. There is psychological research that suggests that a patient such as yourself will be able to cope better with all of your physical, social, and psychological problems when you attend self-help and religious groups and receive all the necessary medical and psychological treatment you may require. Of course, each one of you is a unique individual but when it comes to being chemically ad-

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dicted, patients are more alike than different regarding their addiction behavior. Present research that I am aware of does not suggest that professionals who have a past history of chemical dependency problems are any more effective than professionals who have not. PGC is designed to help you become more aware of your perceptions, emotions, thoughts, and actions, and to identify which may be self-defeating and harmful to yourself and others. You will be given an opportunity to learn how to experience more emotions and to express them, as well as thoughts, without harming yourself and/or others. For example, if you think “only an addict can help another addict,” and you do not trust professionals who have never been addicted, then this thought and your feelings of distrust would be examples of harmful and self-defeating thoughts and feelings because they may cause you to not participate in today’s group session. This would deprive you of learning more about yourself, and it would even be more harmful and self-defeating if you used my answer to justify your not accepting what this treatment program has to offer. If you did that you would be acting out your thoughts and feelings, and these actions would be very selfdefeating and harmful to you because we only admit people to this program who are identified as needing all services that we have to offer. If what I described are some of the thoughts and feelings that caused you to ask the question, as long as you don’t act on them, they’re OK. Having doubt and distrust are very adaptive reactions to accepting help from unfamiliar staff. But if you use my “no” answer as a reason for not fully participating in today’s group treatment then I regret my decision to selfdisclose, because I could have just as easily chosen not to answer your question, which I sometimes choose to do in other situations. But with you, I thought the best response would be to self-disclose, and I hope that you will be able to respect our differences and still accept my help.

Chapter

Eight PGC Plans

The PGC leader is always responsible for the structure and content of the group experience, and for presenting the day’s Plan to the group. How group leaders arrive at the Plan and the content (i.e., the day’s topic) will influence their feelings about it; the more leaders are involved with the Plan’s preparation, the more enthusiasm they will hopefully bring to its execution. What follows are practical, easy to follow, useable PGC Plans divided into two categories: intrapersonal and interpersonal. To help leaders increase their involvement in the content selection, various options are presented, allowing leaders to have some opportunity to share in the creation and customization of the Plan. This has been done to enable leaders to freely modify the Plan according to their clinical judgment and unique clinical/ counseling situation. The more leaders are comfortable and familiar with the selected Plan and content, the easier it becomes to focus attention upon each individual patient’s reactions to the group’s tasks, and to create a group process that maximizes the unique advantages inherent in this group treatment.

Mini-Lecture Leaders can choose to present as much of the suggested content being offered in the Mini-Lectures as desired, and they may also choose to elaborate as much on each point as they would like. Leaders are encouraged to enhance this material by using their past educational and professional experiences and to use as many of their own clinical examples as much as possible. 174

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Leaders can also borrow the Mini-Lecture material to use in other parts of the group session, for the purpose of introducing timely and relevant psychological concepts. Certain psychological concepts are complex and may be unfamiliar to many patients; these psychological terms are followed by asterisks, suggesting that leaders define these terms and offer examples based on their own understanding of these concepts.

Psychological Exercises Word Association. For each Word Association exercise, a number of words are offered for leaders to choose from. Leaders should also feel free to select their own words. This gives leaders the opportunity to present the word they are most interested in exploring and analyzing with their patients. Psychological Question. There are two types of psychological questions being offered for each Intrapersonal and Interpersonal Plan. Both require group members’ attention, effort, concentration, and thinking. One is labeled “other directed,” and the other is called “inner directed,” which demands self-reflection and greater self-disclosure. Leaders are encouraged to select one question—either inner or outer directed—based upon their judgment of which question would best meet the needs of their patients on the day of the session. Usually, there is only enough time for one question, since it is important to leave sufficient time for the Final Question/Comment component of the PGC session. Further options the leader may want to consider are: When asking “why” questions (e.g., “Why do you think people do not accept themselves?”) leaders can instruct group members to please provide one or more reasons; when asking “when” questions (e.g., “When do you think other people do not accept themselves?”) leaders can instruct group members to please provide one or more circumstances. If the leader prefers each patient to provide only one answer to a question that can have multiple answers, the leader should inform patients to choose the one answer that they think is the most important, and to give this answer. Note: In this circumstance, the leader is asking the patient to make a judgement about which answer is most important, which is an additional psychological task. When asking paradoxical questions that contain the word “should” (e.g., “Why should you not accept yourself?”), the word “would” can be immediately substituted for the word “should” while engaging with certain patients who are having difficulty answering the paradoxical “should” question.

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INTRAPERSONAL PLANS Topic #1: To Increase Self-Acceptance Goal: to help patients identify those thoughts and feelings that are harmful and helpful to increasing self-acceptance. Acceptance of oneself does not mean condoning or excusing behavior that is harmful to oneself and others; these behaviors are never acceptable. Accepting that one is capable of these behaviors makes it possible for the person to confront them, while the denial and rejection of aspects of oneself makes it possible to continue to avoid confronting and changing harmful behaviors. Self-acceptance makes it possible for patients to accept the help they may need to confront their harmful behaviors.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Self: one way of thinking of the self is as a concept composed of three elements: biological = physical; social = others; and psychological = perceptions, emotions, and thoughts towards the self • Perceptions: Can be accurate or inaccurate. Example: “When we are very hungry, we can misperceive nonedible physical objects as something edible.” Or: “You see a stranger on the street whom you falsely perceive as being a close friend that you miss because they have died or moved away.” • Emotions: can be wanted (hope) or unwanted (fear) • Thoughts about the self: can be idealized, e.g., “I never lie” • The self develops from life’s experiences over the life span • As the self develops, it becomes more complex and can expand or contract. For example, a severely chemically dependent patient’s self is severely constricted; all of the other aspects of the former self are diminished or appear nonexistent due to chemical dependency preoccupations and a restricted lifestyle • The self changes: your self today is different than when you were a child • The self is made up of different parts and some of the thoughts and feelings compromising a part of the self can be outside of the person’s awareness • The different parts of the self can be in conflict, for example, your “ideal self” believes that you do not need to depend upon professional

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help to resolve your chemical dependency problems and that you can return to controlled usage again, but your “real self” is defined by what you actually do and not what you would like to be able to do • The self is greater than the sum of its parts: human beings are more than the sum of their behaviors and always have the potential to change dramatically. For example, a severely chemically dependent, uneducated, unemployed, and unloved patient today can become a chemically-free, educated, employed, and loved person in the future • Self-acceptance represents a greater degree of psychological development • The ability to self-disclose thoughts, feelings, and actions to others indicates a greater degree of self-acceptance

Part II: Psychological Exercises 1. Word Association: • Rejection 2. Psychological Question: • Other Directed Why do you think others do not accept themselves? When do you think others do not accept themselves? • Inner Directed Why should you not accept yourself? Why should you accept yourself? What do you accept about yourself today that you did not accept about yourself in the past? What have you not accepted about yourself today? What would you like to accept about yourself today?

Topic #2: Anger Towards Yourself Goal: 1) increase self-awareness of experiencing and expressing anger; 2) increase sensitivity to physiological and psychological functioning when having an anger reaction; and 3) encourage patients not to become angry at themselves and express anger towards themselves. A basic human developmental task for all people is to learn how to experience and express anger without harming themselves and/or others.

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In order to explore the topic of experiencing anger toward the self, it is first necessary for patients to be able to identify when they are angry. Some patients may have difficulty with experiencing anger altogether. Therefore, the topic will first focus upon the physiological and psychological indications of an anger reaction. All experiences and expression of anger towards the self are considered to be an unnecessary, harmful, and unwanted emotional experience that can frequently diminish self-esteem. It can be acted out by verbally abusing oneself, e.g. cursing oneself, calling oneself stupid, and physically abusing oneself, e.g., self-mutilation and suicide—which at the extreme, may represent the result of violent, destructive, murderous expressions of an anger reaction towards part of the self.

Part I: Mini-Lecture Following are suggested psychological concepts and terms: • Anger: a universal human emotional reaction • Physiological factors, e.g., hunger, sleep deprivation, alcohol and other drugs, and organic brain disorders influence the intensity of the experience of anger and its expression • The more a person is aware of what makes them angry and when they are experiencing anger, the more control they will have over when and how they express their angry feelings • Human anger-provoking events: your own behavior, other people’s behavior, and mechanical failures (TV set doesn’t work) • Theoretically, people are capable of an anger reaction to any event • Nonhuman anger-provoking events: storms, rain; for example, someone close to you dies in a sea storm or you plan an outdoor party and it rains • Varying intensity: from mild irritation to rage • What creates the “problem” is usually the intensity of the emotional response and how it is expressed • Extremely intense anger reactions are difficult for most people to keep private (voice and body language are difficult to control when people are enraged) • The external expression of anger can be objectively observed, quantified, and directly measured, e.g., blood pressure • The internal experience of an anger reaction is subjective, and can only be indirectly measured: what it feels like to experience an anger reaction may not be identical for each person

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• Our empathetic ability is based upon enough commonality to have some appreciation for when another person expresses anger in a way that is familiar to us • Defensive emotional reaction: physically energizes person to fight or flee • Expressions of anger vary from culture to culture, and person to person • Some modes of anger expression are learned: e.g., learning to throw or break your own and/or others’ personal objects; “silent treatment” • Unexperienced anger can cause psychosomatic* reactions • How frequently a person experiences anger can vary with the individual • Different people have common anger reactions to both similar and different stimuli • Anger reactions can increase and decrease over a person’s life span • Anger reactions are frequently correlated with other emotional reactions, e.g., frustration, disappointment, deception, etc. • Anger reactions can be instrumental in having personal and interpersonal needs better satisfied, e.g., a mother expresses anger toward her child to get the child to behave • For some people, having an anger reaction is a very unwanted and feared emotional experience • Other people are not responsible for your emotional reactions, but can be responsible for stimulating and encouraging you to react angrily

Part II: Psychological Exercises 1. Word Association • Anger 2. Psychological Question • Other Directed How do you know when other people become angry at themselves? Why do you think other people become angry at themselves? When do you think other people become angry at themselves? • Inner Directed How do you know when you are angry at yourself? Why should you get angry at yourself? When do you get angry at yourself?

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How do you perpetuate the anger you have towards yourself today? Describe something that in the past made you angry at yourself but does not make you angry at yourself today?

Topic #3: Identities Can Be Changed Goal: to help patients 1) increase their appreciation of the complexity of human identity issues; and 2) begin to consider accepting certain identities as well as making some identity changes; for example, it may be appropriate and adaptive to accept being a patient for as long as is needed, or to accept a new positive identity such as student and/or employee. Becoming chemically dependent is a learned activity. Others—family, friends, classmates, etc.—show us how to use and misuse the chemicals that are available in our society. Most people do not choose to experience the effects of alcohol and other drugs with the intention of becoming chemically dependent. It is a most unfortunate side effect causing enormous suffering and potential death to both the chemically dependent person as well as others, e.g., driving while intoxicated can cause lethal accidents. Excessive and chronic misuse of alcohol and other drugs can so consume a person physically, socially, and psychologically as to cause them to completely identify with their chemical dependency problems and its accompanying lifestyle. Therefore, chemically dependent people often respond to the identity question “Who are you?” by answering “I am an alcoholic” or “I am a drug addict.” The question “Who am I?” is an identity question. The answer to this question changes over our life span. Our choices influence our identities and adults are responsible for their choices. What we do and do not do contributes to our defining ourselves. Choosing to no longer depend upon chemicals may require making many new difficult choices, which may require that people accept more professional treatment than they expect and/or desire, as well as accepting all of the self-help/religious group experiences that may be needed for them to live their lives without depending upon alcohol and/ or other drugs.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • We all have past identities: for example, we were all infants and children • We all have present identities: for example, we are all adults • Your identity is initially defined by others

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• You can change certain aspects of your identity • We are born into our biological family, social and economic class, and cultural group (ethnic, religious, and values incorporated) • Identity changes over one’s life span, e.g., child, (pupil), adolescent (student), adult (unemployed vs. employed, single vs. married, etc.) • We can have identity problems, e.g., deciding whether to change religious beliefs or choosing a vocation • Sometimes we have identity confusion and conflicts, e.g., we are unsure whether to form an intimate relationship, assume the role of a parent, etc. • Sexual preferences are one aspect of our identity; we all have sexual preferences, e.g., same sex, heterosexual, bisexual • What people do and don’t do can be used to define their identities, e.g., people who do drugs/no longer do drugs; students/no longer students; etc. • You can define yourself, e.g., I am an artist, pool player, etc. • Others can define you, e.g., he is a criminal, she is sexy, etc. • Physical characteristics can be used to identify us, e.g., short, tall, skin color, etc. • Family relationships can define you, e.g., she is Kennedy • Social affiliations can define you, e.g., he belongs to the YMCA or to a gang • Political affiliations can define you, e.g., she is a Democrat • Employment can define you, e.g., he is a bus driver • Unemployment can define you, e.g., she is out of work and lives on unemployment benefits • Physical disabilities can define you, e.g., he is visually impaired • Psychiatric disabilities can define you, e.g., she is manic-depressive • Education can define you, e.g., he is a high school graduate; he is uneducated • How others (interpersonal) define us contributes to our self-esteem, and how we define ourselves (intrapersonal) also influences how we evaluate our self-worth • We inherit the majority of our physical characteristics, e.g., eye color and body type, but some of our physical characteristics we can alter, e.g., weight, hair color

Part II: Psychological Exercises 1. Word Association • Man • Woman

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• • • •

Alcoholic Drug Addict Student Mental patient

2. Psychological Questions • Other Directed How would others (family, friends, significant others) answer the question “Who are you?” • Inner Directed Who are you? Why should you be who you are?

Topic #4: Becoming More Independent Goal: to reinforce and encourage patients to continue their struggle with becoming more independent and to identify helpful and harmful dependent relationships and activities. Human beings’ independent functioning is a life-long physical, social, and psychological struggle. To survive and to maintain our security, it is appropriate and adaptive that our independent functioning be immediately replaced by dependency upon others at any time, e.g., heart attack, automobile accident, fire, etc. Becoming chemically dependent can lead to economic problems (loss of all assets and accumulation of debts), physical problems (cirrhosis of the liver, AIDS), social problems (alienation from family members, loss of friendships/significant others, divorce), and psychological regression (profound self-absorption, insecurities, lack of empathy for others, arrested emotional development) and psychiatric problems (depression, suicide). To become independent of chemicals patients need to transfer their dependency on chemicals to reliance on helpful, trusted others and constructive activities.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • We are dependent beings • In the beginning, we are completely biologically dependent upon our mother’s physical health when we are in her uterus

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• When we are born, we are completely dependent upon the nurture of others for survival, security, and satisfaction • It is a biological, social, and psychological achievement to care for oneself • The “in” in the word independence is always vulnerable to being erased; we can easily revert to dependent behavior when we are physically and psychologically compromised • There are helpful dependencies, e.g., depending on the dentist to regularly clean and care for our teeth can prevent the loss of teeth • There are harmful dependencies, e.g., chemical dependencies; psychologically, chemically dependent patients have less freedom, limited behavioral choices, can become alienated from all the caring people in their lives, and can psychologically regress • The term psychological regression refers to a concept in human development: human beings are capable of regressing in ways that are more typical of earlier stages of their psychosocial development; children who have not sucked their thumbs for years, do so after witnessing a traumatic event. Another example is becoming angry, impatient, or demanding when your physical and/or psychological needs are not being met • Dependency often has negative associations, e.g., weak, disabled, helpless • The question is not whether we are dependent or independent; the better question to ask is what are we dependent upon • Habits are patterns of behavior that we learn so well that not only do we repeat the learned behavior patterns automatically, but often very efficiently. For example, we learn to smoke cigarettes without burning ourselves. This becomes so automatic, we can then learn to smoke and perform other complex behaviors at the same time, e.g., smoke and drive an automobile • We can learn habits that promote independence and dependence • We are dependent upon other human beings to teach us to become human beings • How others relate to us is the model that we use to relate to others, e.g., if people who we have been dependent upon and have power over us regularly use this power for their own selfish reasons and therefore harm us, we may think that becoming dependent upon another is to be avoided • Paradoxically, to function more independently often means behaving more dependently for a limited period of time; for example, to reduce

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or eliminate dependency upon chemicals may require becoming dependent upon the services provided by chemical dependency treatment programs and self-help/religious groups • Self-help group experiences are one way for chemically dependent people to transfer their harmful dependencies to helpful ones, namely, depending upon attending regular meetings where caring, nonprofessional others with similar problems help each other to avoid misusing alcohol or other drugs

Part II: Psychological Exercises 1. Word Association • Dependent • Independent 2. Psychological Question • Other Directed Why do you think people do not want to depend upon other people? Why do you think people want to depend upon other people? • Inner Directed Why should you not depend upon others? Why should you not depend upon others, and who are the others? Why should you depend upon others? Why should you depend upon others, and who are the others? Who would you depend upon today? (helpful person) Who would you not depend upon today? (harmful person)

Topic #5: Speaking Honestly and Telling the Truth Goal: to encourage group members to honestly self-disclose more of their thoughts and feelings, and to discourage lying and deceitful behavior in all of their individual and group treatments sessions. Speaking honestly and telling the truth can be viewed as both an intrapersonal and interpersonal event. In order to simplify the exploration of this topic, it is better to limit the topic’s exploration to either interpersonal or intrapersonal. This plan focuses only upon intrapersonal aspects of this topic— what group members think and feel about speaking honestly and telling the truth—rather than what they say to others.

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The exploration of this topic is from a psychological treatment standpoint and not from a religious (moralistic) or legal point of view. It is important for group members to be informed that the leader will be using nonjudgmental techniques to better understand their behavior, rather than to judge it from a right or wrong perspective. The more group members understand and accept themselves, the more they will be better able to predict their future behavior and gain more control over those behavior patterns that are harmful to them, and which keep them chemically dependent.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Speaking dishonestly is a learned behavior, usually called lying, being deceitful, false • Speaking honestly is a behavioral choice since we can choose to speak dishonestly • Honesty and telling the truth can be dangerous behavior • When to tell the truth or to lie requires a judgment • We can choose how often to lie • We can choose to learn how to lie better • We can choose to tell or not tell the truth • To really tell the truth, we need to know what is true • Sometimes we do not know the truth about ourselves because we may have important thoughts and feelings outside of our awareness which can influence our behavior. For example, you can strongly believe and want very much never to use or misuse alcohol or other drugs again, which will cause you to say “I will never drink or drug again.” You believe this is a true statement, and so you end your treatment prematurely. But a month later, to your surprise and to the disappointment of significant others you may find yourself back in the detox program again. • We may think we know what is true and try to tell the truth as we know it, but end up not telling the truth. For example, someone asks you what time it is, and the time on your watch says 1:00 p.m., so you say honestly it is 1:00 p.m. However, you are unaware that your watch stopped working half an hour ago. This is an example of your being honest but not telling the truth. Another example: you think you are ready and can handle a very tempting high-risk relapse situation.

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Before going, you honestly tell a significant other (family member, friend, etc.) that you have absolutely no intention of using and that they have nothing to worry about. So you go to this high-risk relapse situation, and you discover to your surprise that you couldn’t handle the temptation and you resume using. • The more unwanted thoughts and feelings you become aware of regarding your drug usage behavior, and the more you accept them, the better you will be able to honestly and truthfully communicate them to trusted others (professionals and significant others), who will then be in a position to be your ally and help you to better cope with what you are experiencing • Honest and truthful statements regarding thoughts, feelings, and actions regarding drug usage help professionals better assess the kinds and lengths of treatments that would best meet your individual needs

Part II: Psychological Exercises 1. Word Association • Honest 2. Psychological Questions • Other Directed When do you think others lie? Why do you think others lie? Why do you think others should lie? When do you think others shouldn’t lie? • Inner Directed When do you lie? Why should you lie? Why should you not lie?

Topic #6: Accepting and Tolerating Professional Treatments Goal: to encourage patients to accept all the professional treatments, selfhelp, and religious experiences they may require and to help them become more aware of their need to tolerate and cope with the interpersonal conflicts that are very likely to occur sometime during the group treatment process.

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Accepting professional help is very difficult for many chemically dependent people. One way to make professional help more acceptable is for professionals to provide treatments that directly address their reluctance to accept professional services and to better educate and prepare patients to receive treatments.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Chemical dependency problems are treatable • Often there is a negative association to receiving physical rather than psychological assistance. Over our life span many of us will require medical attention periodically, which we are more comfortable accepting • It is adaptive to accept psychological help as readily as physical help • After patients have been detoxified from the drug/drugs they are physically addicted to, they then require primarily social and psychological treatments to avoid chemical dependency • Patients deserve respect for acknowledging their need for change, and for making public what needs to be changed • It is an indication of psychological strength and greater self-acceptance to acknowledge one’s need to change harmful behaviors and to accept the help of others to achieve these necessary changes • If chemically dependent patients accepted and complied with all of the demands of professional treatments they required—as well as the expectations of self-help groups and religious experiences—they would be able to avoid chemical dependency in the future • The more patients accept all the treatments they need, the more likely they will be able to achieve successful outcomes • Choosing to accept professional treatment is constructive, responsible behavior • Intrapersonal refers to our subjective, private experiences: perceptions, emotional reactions, thoughts, memories, fantasies, imagination, dreams, word associations, etc. • Interpersonal refers to our behavioral transactions with others, which are an objective public experience • Verbal communication—talking, speaking, singing, whistling, etc.—is a behavioral transaction. So is nonverbal communication: touching, looking, personal space (how close you stand to another person), etc.

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• Interpersonal conflicts in group treatment are caused by miscommunications and differences • Miscommunications in group treatment are inevitable and common, just like miscommunications in other social group experiences, e.g., your job. For example, your supervisor tells you over the phone that you are needed to be at a new job site at 8:00 a.m. You arrive at 9:30 a.m. thinking you are only a half hour late because you thought you were told to be there at 9:00 a.m. Your supervisor is angry and threatens to fire you because you are one and a half hours late! And you are just as angry because you remember hearing that you should be there at 9:00 a.m., and there have been times in the past when your supervisor has given you incorrect times to be at new job sites • Differences are also inevitable and common, e.g., you want to eat American soul food and your friend wants to eat Chinese food • Interpersonal conflicts are common because miscommunications and differences are inevitable, e.g., it is almost impossible in a competitive basketball game not to have occasional fouls occur. It is the same when relating to others: family, friends, schoolmates, coworkers, treatment staff, fellow patients. These miscommunications and differences are unavoidable; one way to think of them is as “interpersonal fouls” • To be able to accept group treatment, you also have to tolerate the possibility of being involved in conflicts with others • Interpersonal conflicts are often unintentional • Interpersonal conflicts can be intentional, e.g., some employees purposely get into conflicts with supervisors because they are tired of the job and wish to be let go rather than quit because they don’t want to be seen as a quitter

Part II: Psychological Exercises 1. Word Association • Help • Professionals 2. Psychological Question • Other Directed Why do you think some people do not accept professional treatment?

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When do you think some people do not accept professional treatment? • Inner Directed Why should you not accept professional treatment? Why should you accept professional treatment? When would you not accept professional treatment? When would you accept professional treatment?

Topic #7: Making a Commitment to Change Goal: to increase patients’ appreciation and understanding of how their commitments and lack of commitments can help them to avoid or better cope with their chemical dependency problems. What commitments to make, and when to make them, are important questions which may be difficult to answer. When people are considering major life changes, it is often necessary for them to review the role of commitments in their present life situations. Confusion and doubts about which commitments to keep and which to consider changing are commonly experienced by patients struggling with chemical dependency problems. A most important concern is whether patients commit to abstinence versus controlled usage goals. Because this topic will stimulate patients’ thinking and feelings regarding making and breaking commitments, it may also stimulate some patients’ guilt and anger towards themselves. Leaders need to be aware of this possibility and be ready to quickly provide supportive and empathetic comments when needed.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Making a commitment is a learned behavior • Commitments require you to accept that some of your behavior may not be determined by what you feel like doing or would like to do in the moment • Some commitments require us to abstain from the pleasures of the moment and to tolerate pain • Commitments prescribe and forecast our behavior in the now and in the future

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• Commitments can be made to yourself, e.g., “I vow to exercise more, eat better, relax, etc.” • Commitments can be made to others, e.g., “I promise you I will not drink and drug again” • Commitments can be broken • Broken commitments can be harmful to self and others • Not keeping a commitment to yourself (intrapersonal event) can cause you to feel guilty and angry towards yourself and also lower your self-esteem • Not keeping a commitment to others (interpersonal event) can cause them to verbally and/or physically attack and/or reject you • Feelings of revenge and hostility are often stimulated in people who have received false commitments from others • Commitments can vary in the length of time, e.g., one-week detoxification program, two-year residential program • Others can ask or demand that we make and keep our commitments • We can ask or demand commitments from others • Accepting a commitment from another is based upon trust and faith • Commitments are verbal, but what is committed to is often a description of a future physical behavior, e.g., you say that you will not drink and/ or drug today • Commitments can be made to not behave in a certain way, e.g., I will not drink or drug while I am attending the program • Commitments can be made to behave in specific and predictable ways, e.g., “I will attend all of my scheduled treatment appointments” • Adults are held responsible for and are expected to keep their commitments • Children are held less responsible for their commitments but are expected to learn how to keep them in the future • It is much easier to say we are committed to specific behavior patterns, but it is much more difficult to carry out the actions that demonstrate we are committed. It is easy to say “I will attend all of my scheduled treatment appointments,” but the reality is that few patients have 100% attendance records • We can make false commitments to others and the opposite is also true • When we are conflicted, it is more difficult for us to keep our commitments, because our other desires can sabotage our good intentions • If we are unaware that we are conflicted it is even more difficult to stay committed

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Part II: Psychological Exercises 1. Word Association • Commitment 2. Psychological Question • Other Directed Why do you think some chemically dependent patients break their commitment to not use alcohol and/or other drugs? When do you think some chemically dependent patients would break their commitment to not use alcohol and/or other drugs? • Inner Directed Why should you break your commitment to not use alcohol and other drugs? What makes you think that you will not break your commitment to not use alcohol and/or other drugs in the future? When would you break your commitment to not use alcohol and/ or other drugs?

Topic #8: Changing Harmful Behaviors Towards Ourselves Goal: to increase patients’ awareness of those subjective and objective behaviors that are harmful to them and/or significant others, and to encourage the acceptance of other constructive ways of coping, controlling, and considering which harmful behaviors they can realistically hope to eliminate at this time.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • We can change what we think and how we feel towards ourselves and others • To become more aware of our thoughts and feelings requires that we pay attention to our thoughts and emotional reactions • What we think and feel are private (subjective) behaviors • What we do that others can observe are public (objective) behaviors

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• Thoughts and emotions can be categorized into two groups: helpful and harmful. An example of a helpful (subjective) behavior is thinking that many other people with severe, chronic chemical dependency problems have benefited from professional treatment, so therefore, “I believe I can be hopeful about my ability to tolerate the treatment process” • An example of a harmful (subjective) behavior is thinking that you are so different from all other people that no treatment program could help you, and you feel very hopeless about your ability to tolerate the treatment process • When we are conflicted regarding how to behave, we may need others to help us become aware of those behaviors that may be harmful to ourselves • When we are confused we may need to ask others to advise and guide us to avoid behaving in ways that harm ourselves • It is much easier to identify harmful behaviors in others than in ourselves • It is much easier to identify our harmful behaviors than it is to change these harmful behaviors • Becoming more aware of our harmful thoughts and feelings is an indication of psychological change and greater self-acceptance • Harmful thoughts and feelings outside of our awareness can sometimes determine our actions and cause us to hurt ourselves • The more we are aware of the full range of our harmful thoughts and feelings the more potential control we have over the expression of them • Regret is the feeling that often accompanies the acknowledgement that we have harmed ourselves • Regrets are an indication that people have changed psychologically and that people have learned from some of their life experiences

Part II: Psychological Exercises 1. Word Association • Harmful • Self • Behavior 2. Psychological Question

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• Other Directed Why do you think some patients believe that sometime in the future they can return to controlled usage? When do you think some patients who complete the program will try to return to controlled usage? • Inner Directed Why should you try to return to controlled usage in the future? When would you try to return to controlled usage in the future?

Topic #9: Coping With Unwanted Emotions Goal: to increase patients’ awareness of their unwanted emotions and better ways to cope with them. All human beings are required to learn how to cope with a variety of emotional reactions in ways that do not harm themselves and/or others. This plan focuses upon emotions which many chemically dependent people would like to avoid experiencing. The leader seeks to help patients identify these emotions, and to encourage, support, and assist them in making possible beneficial changes in their lives.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • • • •

Coping is necessary for survival Emotions change Emotions influence our behavior Different emotional states may not be acceptable or easily tolerated by some people, e.g., one’s own experience of intense anxiety may be difficult to tolerate; or another’s expression of intense anxiety may be difficult for someone to tolerate • Unwanted emotions are those emotional states that we would rather not experience; often people refer to them as negative (bad) emotions. Those emotions we want to experience are often labeled as positive (good) emotions • The terms negative and positive are frequently used incorrectly because from a psychological perspective there are no positive (good) or negative (bad) emotions • The same emotional reaction can be judged and labeled differently— negative (bad), or positive (good)—depending upon the social/psycho-

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logical situation. For example: Increased hopefulness in the case of a depressed patient is perceived as a positive (good), helpful, needed emotion. However, in the case of a chemically dependent patient who continues in a very harmful relationship, feeling hopeful about this relationship is negative (bad) because this person will then continue to be influenced by someone who continues to tempt them into resuming use of alcohol and/or other drugs. In this situation, hopelessness would be a positive (good) emotional state and needed/desired in order to permit the person to end the destructive and harmful relationship Examples of common unwanted emotions are anger, anxiety (generalized* and social), sadness, guilt, shame, helplessness, confusion, inadequacy One way to learn to cope with unwanted emotions is by observing how others cope with these emotions Alcohol and other drugs are frequently used to cope with social anxiety, e.g., meeting and relating to strangers It is all right not to want to experience a particular emotional state, but is not all right to deny the emotional experience Becoming more aware of unwanted emotional reactions is an indication of being more self-accepting Often people fear that if they become aware of an unwanted feeling it will be necessary for them to express it to others Learning how, when, and with whom to express your feelings is a very complex set of social skills We physically (visibly) express intense, unwanted emotions even when we are unaware of them, e.g., voice changes, face gets red, etc. The more unaware you are of your intense, unwanted emotional reactions, the more likely you will “act them out” [leader to supply an example here] The term emotional “breakdown” or he “broke down” is often used to describe a person who appears to be overwhelmed by the intensity of a particular emotional experience and who expresses their emotional reaction in a public manner, e.g., grieving people might scream and shout Machines break down; people do not break down People express feelings according to cultural expectations, e.g., in some cultures, people are expected to restrain from any public expression of their grief At times, people are overwhelmed with severe, painful, and disturbing emotional reactions to events often outside of their control

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• It is not a “failure” when people have overwhelming emotional reactions. Machines fail; human beings express themselves • The way to fully experience your emotional response is to become aware of the response and how it influences your psychological and physical functioning • The more you are aware of your emotional responses, the better you are able to tolerate them • It is important to acquire socially acceptable ways of expressing emotions • What you become aware of today is not something you need to change today. What you decide to change in your life and when you decide to change it is a very personal decision, and it is your decision to make

Part II: Psychological Exercises 1. Word Association • emotions • “positive/good” emotions • “negative/bad” emotions 2. Psychological Question • Other Directed Which emotions do you think other people would not want to experience? Why do you think other people would not want to experience certain emotions? Which three emotions would you think many people would have difficulty experiencing? Please give one or more. Which three emotions would you think other people would have difficulty expressing? Please give one or more. • Inner Directed Why should you not want to experience certain emotions? Which emotions do you wish not to experience? Are you now struggling with unwanted emotions? If yes, please name one or more emotions. Which three emotions would you have difficulty expressing? Please give one or more.

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Topic #10: Increasing Wanted Emotions Goal: to increase patients’ appreciation of how responsible we are for determining our emotional reactions; how we all learn to experience and express our emotions in specific ways; and how to increase their wanted emotional experiences. Emotional experiences are constantly being influenced by a complex combination of factors: environment, biological processes, social relationships, and psychological factors. This plan focuses on how one’s thinking and actions (behavior) can help to increase and maintain experiencing more wanted feelings.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • A quick and potent way to change from unwanted emotional states to wanted emotional experiences is to consume alcohol and other mindaltering drugs • Some of the most important social learning occurs early in our human development • Most of our emotional reactions are learned • How we experience and express our emotions is very influenced by the people who raised us • One way we learn is by imitating the behavior of significant, nurturing others. For example, you might have observed that when your family member or members became angry, they expressed their feelings by raising their voices and threatening physical violence. Or, the opposite might have been true: they became very quiet, refused to speak (silent treatment), and withdrew from the situation. These behaviors can become the models that you have come to imitate and incorporate into your own behavior pattern • Although your emotional reactions are learned and have become automatic and may be outside of your awareness, as an adult you are responsible for how you express your feelings • BAD NEWS: other people, events, and situations are not responsible for your emotional reactions; you are! Example: “I feel angry,” rather than “you make me feel angry,” is the correct psychological description of your anger reaction

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• GOOD NEWS: the more responsibility you take for the experience and expression of your feelings, the more control you will have over your emotional experiences and the less control others will have in influencing your feelings. With increased responsibility comes greater freedom and less dependency upon others in experiencing wanted emotions • You are not responsible for other people’s emotional reactions, but you can be responsible for provoking and increasing certain emotional reactions in other people. Example: you encourage someone who is angry to stay angry and get even so a conflict will escalate into a physical confrontation, providing you and others with the opportunity to watch for amusement • You can hurt others psychologically by provoking them to have harmful emotional reactions, but you are not responsible for their emotional reactions, they are! Example: if you know that your friends enjoy feeling superior to others and need to be “right” all the time, and you have the opportunity to point out that they are “wrong” about something at which point they then become angry at you, they are responsible for their anger reaction, not you. You are only responsible for stimulating this reaction • It is more adaptive to laugh at our many harmless imperfections—which usually only cause minor inconveniences—than it is to become angry at ourselves • Once you have learned that you are the creator of your emotional reactions, you are more capable of changing and controlling the expression of your emotional experiences • One way to increase your wanted emotions is to reduce your unwanted emotional reactions, e.g., if you are experiencing an intense anger reaction to a situation or other person, it is very difficult to feel relaxed and at peace with yourself and the world • Many of our learned emotional reactions are outside of our awareness and occur automatically. Some of our emotional reactions are helpful, and some are hurtful to ourselves and/or others, e.g., some people will often say “this is just the way I am, I can’t do anything differently” after they just behaved in a manner that is self-defeating and hurtful towards another. When it comes to changing emotional experiences and modes of expression, it is most often you “won’t” make the necessary changes rather than you “can’t” • Changing our emotional reactions requires self-reflection • Sometimes it is difficult for us to change our own emotional reactions. This is when trusted, caring others may be needed to help you change

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• Changing your activities can change your feelings. Example: in the past, activities like walking, running, and dancing made you feel more optimistic and in control, emotions that you wish you could experience now. If you start to walk, run, or dance now, your emotions are very likely to change • Changing your activities can lead to changes in your emotional experiences, e.g., when a caring friend knows you are feeling sad and lonely, they might try to encourage you to go dancing or to the movies because they are hoping that if you dance or watch a movie, these activities will encourage and permit you to release yourself from your harmful self-absorption, at least for a little while

Part II: Psychological Exercises 1. Word Association • Emotions • Wanted Emotions 2. Psychological Question • Other Directed What three feelings do you think other people would want to experience more of? Please give one or more answers. What three feelings do you think other people would like to feel towards others? Please give one or more answers. What three feelings do you think other people would like to feel towards themselves? Please give one or more answers. • Inner Directed What are three feelings that you would like to experience more of? Please give one or more answers. What three feelings would you like to feel towards others? Please give one or more answers. What three feelings would you like to experience towards yourself? Please give one or more answers.

INTERPERSONAL PLANS Topic #1: Trusting Others Goal: to give all patients the opportunity to express their thoughts and feelings honestly and openly and to encourage them to increase their trust and depen-

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dence upon caring and competent mental help professionals, religious leaders, supportive family members, friends, and significant others. Many chemically dependent patients are socially isolated and alienated from their families, friends, and significant others because they have lost their trust. They may also deny their need for caring relationships with others by believing that “as long as I have my supply of alcohol and or other drugs I don’t need anybody.” The honest and open expression of thoughts and feelings is a means to regain the trust of family, friends, and significant others; however, forgiveness on their part may also be required. Forgiveness may not be forthcoming from some people because the only way they can guarantee and protect themselves from future hurt, deception, and disappointment is to never trust again. Therefore, it may not be possible for patients to regain the trust of some of the people they have hurt in the past. The loss of caring and supportive family members, friends, and significant others is one of the most unfortunate and destructive “side effects” of chemical dependency problems.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Very early in our human development (physical and psychological) we depended upon and trusted all people • We learn to be distrustful through our unfortunate life experiences with others • For some people physical intimacy (sexual contact) requires less trust than psychological intimacy • The only way you can know whether you can trust another person is to trust them • Trusting another person requires that you have faith • You are taking a risk when you trust another • Ideally, you should not risk what you could not tolerate to lose; however, we often do not know how attached we are to what we lose, and how dependent we are upon what we lose, until we lose it • If someone misuses your trust, you are not the foolish one, you are an injured party • The only way to avoid being misused or injured by another is to never trust anyone • If you decide not to trust others, you need to learn how to be alone and tolerate loneliness

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• The more someone knows how you think and feel, the more they can hurt and pleasure you • The more secrets you have, the less revealing you will be to others • Accepting psychological help requires trust • Fear of the consequences of trusting another often motivates social isolation • Honest expression of thoughts and feelings promotes trust in others

Part II: Psychological Exercises 1. Word Association • Trust 2. Psychological Question • Other Directed Why do you think people do not trust others? Why do you think people trust others? When do you think people do not trust others? When do you think people trust others? • Inner Directed Why do you not trust others? When do you not trust others? When do you trust others? Why should you not trust others? Why should you trust others?

Topic #2: Depending Upon Others Goal: to help patients become more aware of their thoughts and feelings about depending on others, and to identify those people they may depend upon to help them. Once a person has decided to let others help them with their problems, the question then becomes who is available for them to depend upon. Some chemically dependent patients need to first become less dependent upon and/ or may need to completely separate from the nonhelpful and even harmful people in their social world. For some patients, before they can fully benefit from depending upon caring and helpful others, they need assistance with rejecting and distancing

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themselves from family members, friends, and significant others who continue to tempt and enable them to continue remaining dependent upon chemicals.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Human survival requires dependence upon the care of others • Relating to others is a complex interpersonal activity which becomes more complex as we develop into adulthood • We all have to learn when, how much, and how long to depend upon others • Some people find it very difficult to end a relationship with another person because although they wish to dissociate from them, they also do not want to hurt them • Some people find it very difficult to reject others’ demands and requests for their company • Some people fear that if they depend upon others they will be less free to do what they want, when they want • Some people fear that they will become too dependent upon others • Some people fear that they will not be able to tolerate the loss of the people they have become dependent upon • Some people fear that the people they may become dependent upon may in the future misuse them • Some people have had the misfortune of becoming chemically dependent very early in their human development (early adolescence) and of not having had positive experiences with depending upon caring others • Some people who are chemically dependent believe that it is better to depend upon drugs than people because then they can avoid dealing with the complications of relating to others • One advantage of depending upon professionals is that you are not expected or required to let the professional depend upon you • When you rely upon others, it is socially acceptable that some day they may ask to depend upon you • Depending on others can be a helpful or harmful experience • If people want to stop depending upon alcohol and other drugs, they need to decide how much they may need to increase their dependency upon others • One way to decrease dependency on others is to increase one’s dependency upon independent constructive activities: any personally satis-

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fying activity that can be accomplished independently, e.g., walking, bodybuilding, reading, drawing, repairing mechanical and electrical objects, playing music, etc.

Part II: Psychological Exercises 1. Word Association • Dependency • Dependent 2. Psychological Question • Other Directed Why do you think other people would not depend upon others? Why do you think other people would depend upon others? • Inner Directed Why should you not depend upon others? Why should you depend upon others?

Topic #3: Accepting Help From Others Goal: to encourage all patients to accept all the professional treatment and self-help/religious experiences that they may require to free themselves of chemical dependency problems. People with chemical dependency and psychiatric problems may require a wide variety of professional services. Knowing what professional treatments are required and how long they need to be applied is part of an ongoing assessment process. Helping patients to identify what behaviors need to now change and which behaviors would be advantageous but not essential to change is one of the services professionals can contribute. For professionals to be useful, patients need to be willing to permit professionals to help them define the patients’ problems more appropriately, that is, from the professionals’ perspective. Ignorance and fear can lead to people not accepting the needed treatment that is available and effective. The more information and understanding people have of what the treatments expect and demand of them, the more responsible choices they can make regarding the acceptance of and compliance with professional treatments.

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Part I: Mini-Lecture The following are suggested psychological concepts and terms: • • • • • • • • • • •

• • • • • •

Accepting help from others is an interpersonal* experience Family, friends, significant others, and professionals can provide help Help can be asked for Help can be accepted or rejected Help can be requested for short or long periods of time Some people offer help with the expectation that you will help them in the future Some people offer help with no expectation that you will help them in the future Asking and accepting help is an adaptive behavior when the help needed will aid our survival Not asking for and accepting help when needed is maladaptive, selfdefeating, and can be very harmful to the person Asking for and accepting the appropriate help is a responsible act Asking for and accepting the appropriate help demonstrates a greater level of social and psychological development because at times it is unrealistic to expect or attempt to cope with all of life’s challenges without the assistance of others Gratitude is one feeling that some people have when others help them Some people feel that once they ask for help they are more vulnerable to others’ influence Some people feel that others will think less of them for needing and asking for help One possible explanation for why women live longer in our society is because they are more willing to ask for and accept medical treatment sooner than men Accepting help may require accepting the “patient” role* Many people in our society find it easier to ask for and accept prescribed medication to treat their physical symptoms, rather than accept psychological help to treat their physical symptoms. Example: rather than dealing with an anxiety reaction* by exploring and becoming aware of psychological causes, many people will prefer and be satisfied with psychotropic* medication which has the advantage of quickly reducing physical symptoms of an anxiety reaction, but which does not address the psychological causes. Thus many people will open their mouths to swallow prescribed drugs, but find it very difficult to open their

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mouths to describe the possible thoughts and feelings that are causing the anxiety reaction

Part II: Psychological Exercises 1. Word Association • Help 2. Psychological Question • Other Directed Why do you think other people do not accept professional help? When do you think other people should accept professional help? • Inner Directed Why should you not accept professional help? Why should you accept professional help? When should you accept professional help?

Topic #4: Listening Goal: to increase patients’ awareness and appreciation of the complexity of human communication and to further develop accurate listening skills. Learning how to listen to others in a respectful, accepting, nonjudgmental, and empathetic manner can improve social acceptance and interpersonal effectiveness. Listening and being listened to is a fundamental interpersonal behavior in group treatments. Exploring how group members think and feel about these communications may help to facilitate their acceptance of group treatment norms. The PGC leader is very attentive to a patient’s ability and capacity to listen to other group members. Leaders actively praise and reinforce all patients’ attempts to listen to other group members, including the leader. This plan helps to remind patients that the more they are able to listen to others, the more they can benefit from the group experience by decreasing the harmful effects of their excessive self-absorption, and by helping others gain from the group treatment process.

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Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Listening to others requires focused attention, concentration, and effort • When people are emotionally confused, conflicted, and preoccupied with their mental problems, they are not able or ready to listen to others. Listening to others becomes more difficult when we are preoccupied by our own mental/physical concerns • Listening is an important social behavior. Not listening can be interpreted as being disrespectful, uncaring, and selfish • When some people are emotionally upset, they might choose to avoid other people, because they know they are unable to listen to them, and they do not wish to be seen as offensive, disrespectful, or uncaring • Listening to others describing their thoughts and feelings helps us to better appreciate how we are similar and different from others • Miscommunications, which can often lead to conflicts, are frequently caused by inattentive listening • Some people find it difficult to listen to people who often repeat themselves, who speak very slowly or very fast, and who speak with accents • Some people are easier to listen to than others • Listening to others describe how they experience our behavior can help us to better understand why they react to us the way they do. • Listening to yourself, that is, reflecting upon what you said and how you said it to others, also can help you to better understand people’s reactions to you. Example: some people raise their voices when they feel strongly about what they are communicating and some people who are listening may interpret the loud voice as representing anger, to which they then react in a negative manner • Being listened to by a respectful, caring, accepting,* nonjudgmental,* empathetic* person can help us to cope with our emotional problems better and to change our maladaptive behaviors • When some people are upset and become mentally preoccupied, they don’t listen to others. Listening to others can help reduce people’s excessive self-absorption and preoccupations. Having the opportunity and being encouraged to listen to other group members permits patients to have a brief “vacation” from their troubles. This is one of the unique advantages of listening and group treatment

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• Listening to others can be helpful and harmful; knowing who to listen to requires judgment and trust • Being listened to can increase a person’s self-worth and hopefulness, and decrease alienation and social isolation

Part II: Psychological Exercises 1. Word Association • Listen 2. Psychological Question • Other Directed Why do you think people do not listen to others? When do you think people do not listen to others? • Inner Directed Why do you not listen to others? When do you not listen to others? Why should you not listen to the people in this group? When would you not listen to others? When others do not listen to you, how do you feel? Please describe one or more feelings

Topic #5: Accepting Criticism Goal: to help patients be more accepting, receptive, and tolerant of receiving criticism, and to increase their appreciation of how the acceptance of criticism is an important aspect of the psychological treatment process. Early in our human development we first receive criticism from others and then we learn to criticize others. As children we may initially confuse receiving criticism with personal disapproval. In reality, it is a child’s actions which are disapproved/criticized, and not the child. As we develop, we learn that our actions can be viewed separately from ourselves and that we can receive criticism without feeling disapproved of as a person. However, some people have not learned to separate criticism from disapproval, and these people have a disadvantage with intimate relationships, and in learning new material and behavioral skills from others. Accepting criticism is an essential factor in gaining maximum benefit from psychological treatment where patients receive feedback regarding their

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interpersonal behavior. Accepting criticism from a psychological perspective does not mean people are going to enjoy the experience or that they will not have to struggle to tolerate it. Accepting criticism is adaptive: it promotes survival and security, and can increase satisfactions in living.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • You can make judgment statements, such as calling someone a “good” or “bad” person. However, from a psychological perspective, when we criticize people we don’t criticize the whole person, we are actually criticizing a person’s specific behavior or part of that person. Example: lying is a specific verbal behavior that can be criticized for many reasons but the whole person is greater and more complex than the sum of a person’s “parts.” Therefore, the whole person is not a liar, the person lies • Learning can occur when our behavior is criticized • When we criticize ourselves, that is a private intrapersonal event • When others criticize us, it is a public interpersonal event • Others can criticize us to help us, e.g., to learn new skills like using the computer • Others can criticize us to hurt us, e.g., using criticism to show us and others that we lack knowledge or skills. In this case, the criticism is offered to lower our self-esteem, and not to help us improve what we are doing. This may be referred to as “destructive” criticism • We can also potentially learn from “destructive criticism” because if the offered criticism is really very helpful to improving a skill we wish to improve, then the fact that is was offered to hurt us psychologically does not diminish the importance of the criticism • Some people are very sensitive to receiving any kind of criticism and will react very defensively to being criticized, especially in front of their peers • We can always choose to learn from any criticisms we may receive • Some people will only accept criticism when offered by someone they know, trust, and who they believe cares for them • Often people who are very self-critical and perfectionistic can have great difficulty in receiving and accepting criticism from others • Criticism is something to give and to receive

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• The better people are at receiving and tolerating criticism, the more they can learn from others • Criticism can be accurate and helpful or inaccurate and harmful • Human beings are not perfect and we make mistakes. Criticisms can be reminders of our shared imperfections, in other words, our common humanity • Accepting criticism may be more difficult for some people when they are physically tired, in pain, hungry, cold, hot, and/or psychologically stressed (anxious, fearful, feeling inadequate, coping with rejection, loss, uncertainty, etc.)

Part II: Psychological Exercises 1. Word Association • Criticism 2. Psychological Question • Other Directed Why do you think you should not criticize others? When do you think is the best time to give criticism to another? When do you think it would be the worst time to give criticism to another? • Inner Directed Would you rather give criticism or receive it from others? Why should others not criticize you? When should you not be criticized? Why should others criticize you? When should others criticize you?

Topic #6: Honest Self-Disclosure Goal: to encourage patients to make open, honest self-disclosures to the PGC group, to the professional treatment staff, and to the significant others in their lives. Early in our human development we learn that unrevealing and dishonest behavior can serve to protect us and increase our satisfaction in certain interpersonal situations. Lying is a learned behavior. Learning that one can

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use words to recreate social reality and change the truth in order to meet one’s egocentric needs is a profound social lesson. For example, when some children first lie and it is undetected by others, children may begin to lie often and indiscriminately because they have not learned that lies are most effective when used selectively and that lies only work when others trust you to tell the truth. If children believe it is in their best interest to continue to lie then they have to learn when to lie and how to lie more convincingly, that is, further develop their lying skills.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Being closed and dishonest can be adaptive at times • Open and honest verbal communication is necessary to establish trust • Expressing honest thoughts and feelings is necessary to begin and sustain an intimate psychological relationship • Certain unexpressed thoughts and emotional reactions can be harmful to self and/or others, e.g., the likelihood of people committing suicide and homicidal acts are less when they are verbalizing these destructive thoughts to professionals and other caring people in their lives • There is a difference between being open (revealing thoughts and feelings) and being honest (telling the truth). You can be open, and be dishonest, by revealing untrue thoughts and feelings • Being “closed” (unrevealing) is not the same as being dishonest • You can choose to be closed (not reveal thoughts and feelings) and still be honest. People who choose not to disclose (are “closed”) rather than lie are behaving honestly, because they are not misrepresenting what they are thinking and feeling by lying, they are just withholding by keeping their thoughts and feelings private • People can choose to be honest and still remain unrevealing or “closed,” e.g., “What are you thinking and feeling right now?” Answer: “I am not ready to reveal my honest thoughts and feelings right now and I do not want to lie to you and the group by telling you the thoughts and feelings that you might like me to have and that you would like to hear. I am tired of lying. I want to be honest so that is why I am choosing not to answer your question” • People choose to be open and honest • When to honestly self-reveal requires judgment

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Part II: Psychological Exercises 1. Word Association • • • •

Honest Closed Open Self-disclosure

2. Psychological Question • Other Directed Why do you think other people do not always speak open and honestly? When do you think others do not speak openly and honestly? • Inner Directed Why should you not speak openly and honestly? When should you not speak openly and honestly? Why should you speak openly and honestly? When should you speak openly and honestly?

Topic #7: Anxiety Goal: to increase patients’ awareness of how to identify anxiety reactions; how feeling anxious influences their behavior; and how to improve the ways they cope with anxiety reactions. Some chemically dependent patients have undeveloped social skills, due to their past exclusive dependence upon alcohol and other drugs to help them function in different social groups. One of the attractions of alcohol and other drugs is that they help many people cope with anxiety, especially social anxiety. Moderate use of alcoholic beverages is socially acceptable in order to cope with the uncomfortable feelings some people experience in new social groups where they are expected to relate to strangers and where they are hoping to be accepted.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Some people believe that the physical signs of having anxiety reactions—increased heart rate, for example—is caused by an underlying

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physical disorder such as a diseased heart. Another example: when some people are having an anxiety reaction whereby they lose their appetite, experience nausea, or have diarrhea, they attribute these physiological reactions to a physical disorder such as a “nervous stomach” Elevated heart rate, loss of appetite, nausea and diarrhea can all be symptoms of physical problems. However, they can also be symptoms of psychological problems such as an anxiety reaction to some perceived or experienced threatening event Anxiety reactions can create physical symptoms but they are caused by psychological behavior or mental processes (frightening thoughts, traumatic memories, unwanted and/or conflicted feelings, etc.) The physical symptoms are real and can be disabling Psychotropic drugs are effective in reducing the symptoms associated with anxiety reactions but they do not address the causes of anxiety reactions Physiologically,* an anxiety reaction is identical to a fear reaction in that they produce the same physical reactions. The big difference is that when we have a fear reaction, we can identify what it is we are afraid of, in other words, we know what is causing our fear, e.g., snakes, disease, etc. But when we are anxious, we do not know what is causing the anxiety reaction, all we know is that we experience intense fear Being afraid is bad enough, but not knowing what we are afraid of is even worse and only increases the intensity of the fear reaction Once people can identify the fear that may be causing their anxiety reaction, they may still experience the fear but now they are in a position to cope with the fearful event. Before, when they didn’t know what they were afraid of, they may have felt helpless. Now they are not helpless Similar to all emotional states, the intensity of the emotional experience is what determines how troublesome and disabling the experience will be Different life events cause people to have anxiety reactions Some people find it very difficult to cope with ambiguity and the unknown Unwanted and disturbing thoughts and intense feelings outside of awareness can cause some people to become anxious Conflicts concerning major life issues (divorce, work, etc.) and decision making can cause some people to become anxious Some people find it difficult to be in the company of very anxious people; it can make them anxious

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• Some prescribed and nonprescribed drugs can reduce the symptoms associated with an anxiety reaction • Psychological treatment can also reduce symptoms and the causes of the anxiety reaction • For some people the combination of carefully monitored, prescribed psychotropic medication and psychological treatment is the most effective treatment for anxiety reactions • For some people sharing their thoughts and feelings with others will help to quickly reduce their anxiety reaction

Part II: Psychological Exercises 1. Word Association • Anxiety 2. Psychological Question • Other Directed How do you know when others are anxious? When do you think others become anxious? Why do you think others become anxious? • Inner Directed How do you know when you are afraid? How do you know when you are anxious? When do you become anxious? Why do you become anxious? Why should you not become anxious?

Topic #8: Conflicts With Others Goal: to help patients better appreciate that how we communicate with others can influence how others respond to us, and that improved communication skills can help to reduce or avoid conflicts with others. Conflicts with others are often the result of miscommunications. Some chemically dependent patients could benefit greatly from changing their communication patterns. They are unaware of and do not appreciate their need to change and better adapt their communication skills to the “nondrug social world” (rehab treatment center, job, training programs, school, etc.).

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Part I: Mini-Lecture The following are suggested psychological concepts and terms: • • • • • • • • • • •

• • • • • • • •

Conflicts with others are often the result of miscommunications Conflicts between people are common and to be expected Conflict with others is an interpersonal event Conflicts can lead to physical violence between people How to resolve conflicts is learned behavior Learning how to resolve conflicts without hurting yourself and/or others is preferred, and requires the development of interpersonal skills One way to avoid conflict is to withdraw from the situation and person who is provoking the conflict Conflicts between people who have an intimate relationship can be very intense Conflicts can occur from intentional and unintentional behavior How we perceive a conflict (intentional vs. unintentional) influences how we respond to the conflict Some people react with anger when they are misunderstood and blame others for not listening to or hearing them, e.g., we say one thing and the other person hears something else, or does not understand our message the way we had intended it to be received Two major issues which stimulate conflicts between people who live together in intimate relationships is how they spend their money and how much sexual activity each desires Another frequent cause of conflicts is when there are significant differences between couples, for example, one person only wants to live in New York, and the other only wants to live in Florida Resolving conflicts between people in ways that do not harm them can lead to a better understanding and improved relationship between them Conflicts between people can last for many years When people do not do what we want or need them to do, this can lead us into conflict with others Some people have difficulty with distinguishing between their “needs” vs. their “wants” Unsatisfied and frustrated “wants” can be easier to tolerate and accept because they are not necessary for survival, thus they are less likely to cause conflicts with others Intense conflicts with others can activate a person’s psychological and physical defense system, creating a “fight or flight response”*

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• Some people have learned to use alcohol and other drugs to cope with conflicts they cannot avoid

Part II: Psychological Exercises 1. Word Association • Conflicts 2. Psychological Question • Other Directed Why do you think other people get into conflicts with others? When do you think other people get into conflicts with others? • Inner Directed When do you get into conflicts with others? Why you should you get into conflicts with others? Why you should you not get into conflicts with others? Why do you get into conflicts with others?

Topic #9: Anger Toward Others Goal: to increase patients’ awareness of when and how they express anger towards others; to increase their abilities to experience and express anger without harming themselves and/or others; and to help patients evaluate whether they would benefit from reducing their anger reactions towards other people’s behavior. An important social and psychological achievement for some chemically dependent patients is learning to express anger toward others verbally rather than physically. Another significant social and psychological accomplishment is to help them learn how to verbally express anger without hurting others. Leaders are advised to review the Intrapersonal Plan: Anger Towards Yourself, since many of the concepts provided in the Mini-Lecture can be selectively used for this topic, Anger Towards Others.

Part I: Mini-Lecture The following are suggested psychological concepts and terms: • People having anger reactions towards others is a very common interpersonal experience

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• Other people do not make us angry; we make ourselves angry. That is, we react angrily towards others’ undesirable behavior • We learn when to become angry and how to express the anger we experience • Much of what we learn regarding when to become angry and how to express our anger experience is by observing and imitating the people who have raised us • Some of us find it more difficult to express our anger towards people we know and care about than toward strangers. However, some of us find it easier to express anger toward people we know and who care about us but more difficult to express anger toward strangers • A common way to express anger toward others is to avoid them altogether • Instead of expressing anger toward others, some people take it out on themselves and/or the environment. Example, when people become angry at their significant others’ behavior, they express the anger by punching their walls so hard that they damage their hands and require medical assistance and then also need to replaster and paint their walls! • Anger can be harmfully expressed toward oneself or others, e.g., by verbally abusing oneself (calling oneself stupid or cursing oneself) and physically abusing oneself (self-mutilation and suicide), or by verbally abusing others (cursing them, calling them stupid) or physically assaulting and even murdering them • Unexpressed anger toward others can influence how a person thinks, feels, and behaves toward these people • Time does not change peoples’ feelings of anger toward others • To stop feeling angry toward another requires changing how you think, feel, and behave • Sometimes when people are “made” angry, they also feel like taking revenge • Revenge is one way to express anger • When anger is expressed toward others, they often become angry in return • Some people become angry to get other people to change their behavior • Unlike happy and sad, there is no opposite emotion to anger • It is important to know when your behavior is stimulating someone to have an anger reaction toward you, because some people have learned that the preferred way to express anger is physically and violently • People in different cultures express anger differently, therefore it becomes easier to have miscommunications when relating to people from other cultures

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• Some people save up their anger toward others and will then suddenly and unexpectedly express their intense angry feelings in dramatic and sometimes destructive ways to the surprise of others • Storing anger is usually not preferred because it intensifies the emotional experience and intense anger may be more difficult for many people to express without harming themselves and/or others • Another reason why storing anger is not preferred is that storing anger increases bodily stress. Internally, the intensity of an emotional anger experience can range from mild to extreme rage, causing blood pressure to rise or even triggering a heart attack • Some people are attracted to the energizing aspect of feeling angry and it helps them to carry out many of life’s activities and makes them feel more powerful and potent when dealing with others

Part II: Psychological Exercises 1. Word Association • Anger 2. Psychological Question • Other Directed Why do you think people become angry at others? When do you think people become angry at others? Why do you think people should not become angry at others? • Inner Directed Why should you become angry at another person? Why should you not become angry at another person? When should you become angry at another person? When should you not become angry at another person? Which do you prefer to have: fewer, more, or the same amount of anger reactions toward others?

Topic #10: Increasing Empathy Toward Others Goal: to increase patients’ empathy toward others; to promote greater awareness of the value of nonjudgmental thinking as a means to increase better understanding of and relating to others; to help patients reduce conflicts with others.

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Part I: Mini-Lecture The following are suggested psychological concepts and terms: • Human beings are more alike than different • Human beings share basic physical and psychological survival and security needs • Although we can never be sure that what we feel is exactly what another person feels, we are able to identify and recognize the feelings of others, otherwise characters in movies and plays wouldn’t influence how we feel • Social injustice can only be understood because we can identify with what it would feel like if we were in the mistreated person’s shoes • Our relationships with others are necessary for our social and emotional development • Increased social experiences potentially lead to new and different emotional experiences, e.g., until other people reject your need and desire to participate with them in some activity, we do not know what it is to experience rejection • When some adults observe people behaving very differently from the ways they are accustomed to seeing people behave, they are confronted with a new social experience which may create anxiety • Judging other peoples’ behavior from a moral position—right vs. wrong, good vs. bad—is a learned behavior • One of the pleasures of relating to young children is that they are very accepting of different behaviors because they do less judgmental thinking than most adults • Judgmental thinking can interfere with our ability to empathize with others • When we get into conflicts with others, one way we explain the conflict is by blaming them for behaving in ways that do not meet our current needs and desires. Sometimes we believe they are behaving this way intentionally or unintentionally and sometimes we are unsure which is the case • It would be an ideal world if all people did what we wanted them to do, when we wanted them to do it, and how we wanted it done. The problem is that this is the way most of us think, at least some of the time • Taking the position and attitude of trying to understand rather than judge another’s behavior can improve communication between two people who are in a conflict

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• When communicating with other people we all have two complex tasks to accomplish: first, to say exactly what we wish to communicate in ways that they can understand, and second, to make sure that they have received the message as we intended • People often believe or assume that the person listening has heard what they have said and understands exactly what they meant to communicate, and often do not make sure that the person has received the message • Not making sure another person has received the message you wish them to receive can lead to miscommunications and conflicts

Part II: Psychological Exercises 1. Word Association • Empathy 2. Psychological Question • Other directed Why do you think people do not want to understand others? When do you think people do not want to understand others? • Inner Directed Why should you not want to understand others? Why should you want to understand others? When would you not want to understand others? When would you want to understand others? Which would you prefer to make: more, less, or the same amount of effort to understand others?

Chapter

Nine Using PGC in Psychiatric Settings

INTRODUCTION Though developed mostly with the needs of chemically dependent patients in mind, PGC has been helpful for a variety of patient populations, especially those with similar misgivings about receiving treatment. The essence of PGC, its values—which are exemplified in the accepting, welcoming, and responsible stance of the leader—do not change. We believe that the methods of PGC are flexible, providing the leader with tools that have multiple uses. The leader uses these tools according to the clinical demands of the situation, just as a builder uses certain tools for certain projects, and not others. This chapter provides case examples illustrating how PGC has been used in psychiatric settings: the acute psychiatric admissions unit, the continuing care (long-term) unit, and the outpatient partial hospitalization setting (day hospital). Naturally, there is considerable overlap between the populations represented in these settings and the chemically dependent population for which PGC was developed. There are also a number of important differences, both in the populations served, and in the nature of the treatment environments. PGC as it is used on the acute psychiatric admissions unit will be discussed in the most detail, since the greater number of modifications needed in that setting best illustrates the flexibility of PGC and the process by which modifications are selected and constructed. 219

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PGC ON THE ACUTE PSYCHIATRIC ADMISSIONS UNIT The Inpatient Environment Although the inpatient admissions unit is a strange and sometimes chaotic environment, the experience of involuntary commitment provides a powerful sense of commonality for patients. Feelings of outrage, betrayal, and desperation are their shared experience. Often, admission to the hospital follows upon the heels of a siege of real-life tragedies: homelessness, divorce, death in the family, sexual assault, and loss of children to protective custody, to name but a few (that occur regularly in combination). Individuals may begin their involuntary commitments from a variety of points of entry. A relative or neighbor calls 911 in fear of, or to be helpful to, the future patient. Or the process may begin with the police after they have stopped the future patient for erratic driving or strange behavior in the community (though perhaps only strange to others). The experience of being handcuffed can be extraordinarily frightening for individuals who are psychologically disorganized, as well as humiliating, especially for those otherwise law-abiding citizens who have rarely come to the attention of authorities. (As one patient put it, “I’m a sixty-five year old lady, and my neighbors saw me taken away in handcuffs!”) Some individuals initiate hospitalization by presenting themselves at local emergency rooms, afraid that they will commit suicide if left to their own devices any longer. Chronically suicidal individuals may mutilate themselves in desperation, thus ensuring that they will not be turned away. A number of psychiatric admissions initiate from medical intensive care units, the result of failed suicide attempts. For some patients, lack of control over whether a life they find intolerable must continue only amplifies their rage and desperation. When patients arrive at the psychiatric hospital, they are interviewed by a psychiatrist (their second or perhaps third meeting with a mental health clinician), searched for items that might compromise their own or others’ safety, given a physical exam to rule out the need for immediate medical attention, and presented with a stack of forms they need to understand in order to sign (such as authorization for treatment, release of information, etc.). Once on the unit, they are interviewed again by nursing staff, and their valuables (keys, identification, etc.) are logged and taken from their possession. Needless to say, for the patient who is disorganized and/or hopeless, this sequence of events is not necessarily experienced as therapeutic. A

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couple of hours may pass before patients can at least relax on the unit, if they can accomplish this while remaining in visual contact of staff (for suicidal patients, deprived even of bathroom privacy as a safety precaution, in the event that they have somehow hidden a razor blade or other lethal implement). While in the hospital, patients’ ability to perform such everyday behaviors as making phone calls or going out for a smoke is controlled by staff, who are mandated to maintain the strictest standard of safety. The vulnerable new patient looks for comfort and validation from a group of often disorganized and/or intimidating companions. The steady arrival of angry new faces freshens the emotional turmoil of patients who have been around for a few days, struggling as they are to imagine how their lots might improve after they are discharged. The group leader on the psychiatric admissions unit who hopes to engage patients in a therapeutic dialogue thus faces a daunting challenge. Bearing the burden of patients’ resentment, acting out, and projections becomes simply too much to handle in a process group format—many clinicians simply consider this population unsuitable for group therapy. The staggering diversity of presenting problems (psychosis, brain injury, drug-induced mania, post partum depression, chronic alcoholism, etc.) leaves one wondering where to begin in addressing the needs of a group drawn from this population. Time is also not on the clinician’s side. The cultivation of a therapeutic alliance is allotted days, not months, and must compete with the clinician’s schedule of treatment planning meetings, administrative meetings, and other obligations. The patient’s time is also spent or given in other directions, such as evaluations, history gathering, meetings with attorneys, and other groups. PGC has much to offer patients and therapists who come together in this challenging environment. The therapist is offered a set of proven, effective tools for engaging “resistant” patients that otherwise might not receive any psychotherapy. The clarity of the PGC format frees the therapist to focus on the quality of interactions with each patient: disruptions that would capsize a process group become manageable, even welcome, opportunities to demonstrate the leader’s curiosity and expertise. By truly accepting patients’ feelings and behaviors (though not necessarily condoning them), the PGC leader is spared the stressful feeling of losing control or not doing therapy “right.” For the patient on the admissions unit, PGC offers a “success experience” that offsets the recent wounds to their self-esteem, as well as pointing the way to a more realistic way to approach the problems that lead to admission. The leader listens to them: they are offered acceptance and a level of respect they may be unable to obtain from others on a regular basis due to their own problem behaviors. The group context provides the opportunity to self-

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confront on important issues (e.g., the pros and cons of having a guardian) that patients would be hard-pressed to discuss in a one-to-one setting without becoming hopelessly defensive. In teaching hospitals, PGC provides an ideal venue for students to learn about their patients by interacting with them authentically, in a safe environment, and with live supervision. PGC’s format and general principles are easy to learn, enabling students to acquire a new set of skills within a relatively short period of time, and its eclecticism appeals to students of widely different educational backgrounds. Though students may initially feel self-conscious coleading a group with their supervisor(s), they quickly come to appreciate that observing other therapists work, and being observed in turn, are unique learning opportunities. This also models respectful collaboration to patients.

PGC Group Setting The logistics of conducting a PGC group on the inpatient admissions ward take into consideration the characteristics of the patient population and the goals of the institution—as would be the case in any context where PGC might be used. Psychiatric inpatient groups can accommodate 10 or more individuals. Most “group rooms” in psychiatric hospitals cannot accommodate more than a few patients comfortably for any length of time—interior design having been dictated by the prevailing group therapy model of a small, intimate process group. Usually, a large day area or TV room is the best choice for an inpatient PGC group. Given that people in the throes of psychosis have often neglected their personal hygiene for some time, a well-ventilated area is essential for the comfort of all (including the psychological comfort of patients with impaired self-care, lest they be subjected to ridicule by other patients). Because some acutely disorganized and paranoid patients will normally attend group, the availability of exits becomes critical. An open area, or a room with open doors, prevents these patients from becoming overly anxious, even though they usually choose to remain seated throughout the session.

Safety Concerns on the Inpatient Psychiatric Unit Overall safety concerns are heightened when working with patients who have recently been aggressive toward others, and it is the PGC leader’s responsibility to anticipate unsafe situations before they arise—all physical

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elements of the group space need to be considered. For instance, standardissue institutional couches and armchairs are the preferred seating, since the sheer weight of these pieces make them virtually fixtures, removing from patients the temptation to play with (or throw) chairs. By carefully exercising the principles of PGC leadership as described throughout this book, the therapist not only protects the safety of the group, but also prevents the occurrence of uncomfortable situations that detract from the therapeutic experience (e.g., the tension experienced when a manic patient with no hurtful intentions picks up a lightweight wooden chair, hoists it over his head, and carries it out of the room).

Use of Cotherapists In psychiatric settings, it is generally desirable to use cotherapists in PGC. For the sake of safety and for logistical reasons, at least two therapists are usually needed, and three therapists are even more ideal, in that they can contribute greater therapeutic variety. When PGC groups are conducted with patients from more than one locked unit, multiple therapists are able to collect patients and meet in the PGC space on time, without there being “dead time” during which waiting patients can become embroiled in arguments with one another, or get anxious and leave, etc. In the surprisingly infrequent event that a patient insists on leaving a session, one therapist is always available to escort the patient to a different unit if needed. As is the case with outpatient groups, the presence of multiple therapists in the room helps reinforce the “external superego” of more acute patients, while enabling anxious or new group members to relax and feel more protected. Though these concerns are normally considered in the conduct of PGC groups, they become amplified in the inpatient context, since there are always acute patients. Likewise, in groups comprising patients from different units, there are always patients who are strangers to each other. Their apprehension will quickly subside as the PGC leaders demonstrate their ability to create a safe and comfortable atmosphere. The use of multidisciplinary therapists becomes a great advantage especially during the Questions and Comments periods. Patients especially seem to appreciate the opportunity to pose questions to medical personnel in the nonthreatening PGC environment. The leaders’ expression of their different disciplinary perspectives models a collaborative alliance, and fosters patients’ trust.

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Group Size The number of patients that seems to work best for PGC groups in inpatient psychiatric settings is between eight and twelve, though there is flexibility in this parameter (as in others), depending on the characteristics of a specific population. (Perhaps a therapist working in another inpatient setting, e.g., an eating disorders unit, would arrive at a different “optimal” range.) Smaller groups are not always more manageable, since patients may become anxious and “shut down” if they feel that they are responsible for a greater proportion of group participation than they would in a larger group. Note that third party payers such as Medicare may specify the maximum group size allowed for reimbursement.

Screening Given the acuity and possible dangerousness of patients on the admissions ward, a greater level of screening for PGC groups is needed than would usually be the case in outpatient venues. An initial level of screening is achieved by admitting to group only those patients whose level of supervision permits being “escorted in building” by staff. Mental health workers, who have the most direct contact with patients, provide invaluable information about who may be too agitated to attend group on a given day. Referral of patients from a number of different units makes the need for screening more urgent, since many patients will be unfamiliar to the therapist. However, referrals from different units may help obtain an optimal group size, in addition to facilitating program consistency from unit to unit. “Open” PGC groups on admissions units can in turn become screening instruments for other PGC groups focused on more demanding treatment goals that address targeted problems (e.g., learning cognitive-behavioral self-help skills for depression).

Length and Frequency of Sessions Sessions as short as 30 minutes are more tolerable to psychotic patients in the early stages of treatment, and to other patients whose incentive to attend groups is low to begin with. Given the average three- to ten-day stay on a short-term unit, patients will have a better chance of getting an opportunity to participate in PGC if sessions meet at least twice weekly.

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Recruitment of Patients A first psychiatric hospitalization may mark an individual’s entry into the mental health system, with the result that PGC serves as an introduction to psychotherapy. New patients can be made aware of the existence and purpose of PGC groups in their earliest meeting with the leader (e.g., initial evaluation for services). This gives the leader an opportunity to demystify group therapy and to demonstrate the intention to provide a valuable service: Leader:

I have a group that you might be interested in on Tuesdays and Thursdays. It’s called Planned Group Counseling, and we talk about topics such as coping with being here and deciding whether or not to accept treatment. It’s a little different from some other groups you may be aware of. We use Psychological Exercises, and we go around the room to give each person a turn to speak if they wish. I’ll remind you about it on Tuesday afternoon.

If time permits, the leader may visit different units before the time of group to make the acquaintance of new referrals for group, a courtesy that many appreciate. Directly before group, each cotherapist may canvas a unit, inviting patients who are able to participate to come to group. Often, patients will be napping, playing cards, or watching TV. A little encouragement may be all that is needed to overcome their lack of immediate interest: Leader:

I appreciate that you may be (tired because you’re still getting used to your meds, etc.). But I’d like to see if I could give you some benefit from this group—and I can’t do that unless you come! It’s only a half hour, and it’s OK if you just want to listen and see what you think.

If patients insist they just can’t go to group, the leader still has an opportunity to demonstrate caring and responsibility for the patient: Leader:

I’m sorry you (are too sleepy today, etc.). I will invite you to group again next time.

Patients often express their appreciation for the group leader’s concern, and this initial expression of therapeutic interest appears to enhance their willingness to attend future groups.

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MODIFYING THE PGC PLAN FOR THE INPATIENT PSYCHIATRIC UNIT Leader’s Welcome Introducing group norms. The leader’s welcome, introductory remarks and explanation of group norms need to be concise, clear, and consistent from session to session. On a psychiatric admissions unit one is guaranteed a high proportion of new patients in each session (we have noted around 20%). Despite this, and despite the level of cognitive confusion and psychological turmoil of many patients, the explicit and candid statement of group norms provides an adequate point of reference—most patients are willing to cooperate when they understand what is expected of them, and when they consider the expectations reasonable. The following introductory remarks have been found effective: Leader:

Welcome to PGC. This group is a little different from other groups you might have experienced at the hospital or other places. We have a topic for the day, and a Psychological Exercise that goes with it. After I introduce the topic, I will go around the room and ask each of you the Psychological Question. If you can’t think of something right away, it’s OK to take a “Pass,” and I can come back to you later. We have two requests that we make to people in this group. One is not to interrupt each other, since it’s fair that everyone gets to speak when it’s their turn. The other is that when you raise your hand to ask a question or make a comment, you should dialogue with me one-on-one. The reason for asking you to dialogue one-on-one is that you get the benefit of having a one-on-one with a therapist, even though this is a group. And it helps people who are not sure about speaking up if they know that everyone is not going to jump in and criticize them. We think it makes a better learning environment, and patients have told us that it makes it easier to participate.

In a group with fewer patients than usual (e.g., 5 or 6 instead of 10–12), the leader may forget to request specifically that patients not speak to each other and to please dialogue with the leader one-on-one. Patients seldom pick up on this norm from their observations of repeat attendees, assuming

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that other (experienced) patients dialogue with the leader simply out of preference. If the request to dialogue one-on-one with the leader is not presented initially as one of the “rules of the game,” it is difficult to make once group is underway—patients tend to experience the request as an unfair restriction of their right to “free speech.” Also, patients who have experienced unrestricted member-to-member interaction in a PGC group may object to being asked to dialogue only with the leader in subsequent PGC groups. Mini-Lecture. In the context of a 30-minute inpatient psychiatric PGC group, the Mini-Lecture is best kept short and to the point—actively psychotic patients will have difficulty following even a moderately complicated chain of associations. The leader is also advised to avoid the use of abstract language, since it may confuse psychotic patients. Terminology/vocabulary should be kept very simple, e.g., we have been surprised to be asked to define “pros and cons.” For example, the following would suffice for a Mini-Lecture: Leader:

Today our topic is being discharged from the hospital. We sometimes find that when people are going to be discharged soon, they start doing worse. This doesn’t happen to everyone, fortunately. We realize that some people do worse near the time of discharge because there can be advantages to staying in the hospital, too. So we would like to get you thinking about the advantages and disadvantages of being discharged from the hospital.

Psychological Exercises Word Association. In the inpatient psychiatric unit, as in other settings, the PGC leader is flexible in the choice of Psychological Exercises, letting decisions be guided by the needs of the population and institutional setting. In the context of a 30-minute session, Word Association is usually omitted in order to preserve enough time in the session for using a Psychological Question. Psychological Question. As mentioned above, involuntary patients comprise the vast majority of inpatient psychiatric admissions. This fact heightens the need for the leader to maintain a constructive group process by making explicit to patients that harmful thoughts and feelings about treatment should be expressed and freely discussed. In doing so, the PGC leader hopes to redirect the group away from chronic complaining. Concepts and techniques drawn from motivational interviewing (Miller & Rollnick, 2002) and the

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transtheoretical model (Prochaska & Norcross, 1994) can be helpful. Patients are receptive to the idea of “stages of change,” and are able to apply it to their own situations. Psychological Questions can be framed in terms of a cost-benefit analysis, which makes clear the role of harmful thoughts and feelings in decision-making, e.g., “What are the advantages of taking psychiatric medication? What are the disadvantages?” Clinical judgment is called for in the selection of Psychological Questions for any particular PGC session. On days when patients on the admissions unit are appearing a bit frenzied, less stimulating questions can make for calm, noncontroversial discussion, e.g., “What are some ways to keep yourself from becoming upset when you listen to others’ stories in groups?” Psychological Questions can usefully address recent events in the life of the unit, e.g., “What are some feelings you have when another patient is put into restraints?” Very stimulating questions need not and should not be avoided, however, since they often yield powerful insights for patients, e.g. “What are the pros of being in involuntary treatment? What are the cons?” When introducing such a question, it is necessary to demonstrate one’s awareness of the patients’ point of view: Leader:

We realize that being here as an involuntary patient is not a pleasant experience. Many people find that it greatly disrupts their lives outside as well. However, some patients have told us that talking about their harmful and helpful feelings about being here has helped them. We hope you will keep an open mind, and answer the Psychological Question honestly.

The reader may have noticed that Psychological Questions suitable for PGC groups on the psychiatric admissions unit are more open-ended than the sample Psychological Questions provided in previous chapters for use with a chemically dependent population. Clinical experience seems to suggest that for acute psychiatric inpatients, more open-ended questions are less likely to prompt lengthy responses and off-target digressions than they would usually for chemically dependent patients. Possibly, this observation reflects a lower proportion of patients on the acute psychiatric ward who have the type of neurological damage associated with long-term substance abuse (i.e., frontal lobe impairment) that makes it difficult for them to monitor or “rein in” their own behavior. Perhaps it is the case that chemically dependent individuals (whose group experience typically includes twelve-step meetings) are accustomed to telling detailed and personal stories in groups, whereas typical psychiatric inpatients may not have this expectation. The context of a 30minute session may also serve as an additional cue to patients to provide

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brief answers, regardless of the scope of the question. For any treatment setting, determining how closed- or open-ended the Psychological Question needs to be calls for clinical judgment and flexibility, like other aspects of PGC. In PGC groups on the psychiatric admissions unit, it seems that Psychological Questions that do not directly probe for feelings (especially feelings about oneself) are less likely to lead to “pass” responses—for patients who have never been in therapy before, it can be extremely threatening to reveal their feelings to a group. Therefore, in some cases the leader may choose to pose questions that have little direct connection with feelings, for instance, problem-solving questions (e.g., “What can you do to reduce your symptoms?”). Leaders should be aware, however, that problem-solving questions may have the disadvantage of handicapping patients whose ability to think in reality-based terms is impaired.

Questions and Comments Since new patients are never in short supply on the admissions unit, the leader can benefit from using the same PGC plans repeatedly with new patients. During the Questions and Comments period, the leader who has used the same plan over many sessions will have a number of “psychological concepts” for teaching at the ready. The responses of previous patients become part of the leader’s teaching material, and further demonstrate the leader’s knowledge of what patients experience: “When we’ve asked this question before, some patients have said . . . ” There are times in PGC groups with psychiatric admissions patients that few or no questions or comments are spontaneously offered by patients because they might be sedated or experiencing the “negative symptoms” of schizophrenia (e.g., lack of motivation). In this scenario, the leader can pose another psychological question, e.g., “Has anyone here ever had an experience that changed their mind about whether they did need medication?,” and then call for volunteers to make comments. This enables the leader to model the process of therapy with more able patients. Patients who are too disorganized to volunteer, or too defensive, may derive the benefits of other patients’ oneon-one dialogue with the leader (e.g., increased awareness of their discomfort with problem behavior) simply by observing.

Final Questions and Comments In the context of a 30-minute PGC session on the psychiatric admissions ward, the Final Questions and Comments period serves to signal the end of

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group, which can help anxious or acutely paranoid patients remain until the session concludes. The leader’s demonstration of curiosity and interest in each patient’s reactions to the session sets the stage for continued attendance and participation in therapy. Whether the patient’s reaction is positive or negative makes no difference, as long as it is genuine—the leader may need to verbalize this, as patients may be quick to react critically to each other’s statements. A simple response from the leader, such as “Thanks for sharing your thoughts and for keeping an open mind” helps demoralized patients to understand that their participation has been valuable to themselves and others, regardless of their emotional state.

Modifying Plans for Inpatient Psychiatric PGC When tailoring PGC to different settings, it is essential for PGC group leaders to have at least some general experience with the patient population, to enable leaders to look at and understand the common denominators of patients’ experience—which may not be readily apparent to group members, preoccupied with and often feeling quite alone in their individual troubles. In fact, therapists may find that using PGC as a tool can help to deepen their understanding and empathy with a particular population even further. When patients realize that their input is truly valued, they tend to be more responsive and forthcoming in their self-revelations. Addressing Treatment Noncompliance. As noted above, the common denominator of the psychiatric admissions ward is that patients do not for the most part voluntarily seek hospitalization. Once on the ward, routine institutional practices (such as safety checks) reinforce their perception of themselves as detainees—while their cooperative behaviors go by largely without comment. Noncompliance with treatment is expected, and thus subtly encouraged. PGC provides a method for developing patients’ awareness of the expectation that they will resist treatment, using Plans that explicitly address issues involved in accepting treatment. In addressing any problem area, it is essential to develop an accurate definition of the behavior(s) involved. In the context of the psychiatric admissions ward, the multidisciplinary treatment team is an invaluable resource for developing definitions of problem behaviors. (A side benefit of such consultation is increased interest in PGC on the part of treatment team members.) Table 9.1 lists the behaviors that might be considered “noncompliance” on the psychiatric admissions unit. When problems have been operationalized in terms of behavior, it becomes straightforward to frame PGC exercises in terms relevant to behavioral treatment goals. With any behavior of interest, a first approach would be to ask questions such as: What are the pros and cons of the behavior? or What

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TABLE 9.1 Behavioral Definitions of Inpatient Treatment Noncompliance Behavior Domain

Sample Behaviors

Medication noncompliance

Refuses or “cheeks” medication Denies psychiatric illness/need for medication Rejects recommendations for dosage change Misuses psychiatric medications Self-medicates with prescribed and illegal drugs

Obstructs treatment planning

Refuses to sign releases of information Supplies inaccurate/conflicting information to team Misses appointments with team members Refuses assessment (e.g., psychological testing) Refuses to cooperate with guardian Refuses to cooperate with discharge planning

Noncompliant on ward

Does not attend morning meeting Comes late to meals Refuses to shower when requested Physically or verbally abuses staff or other patients Encourages other patients’ noncompliance

Refuses psychotherapy

Refuses to participate in psychotherapy Minimal group participation Disruptive behavior in groups

Other avoidance behaviors

Does not learn names of treatment providers Does not initiate contact with staff when needed Sleeping, pacing, watching TV, in lieu of treatment Attempts to flee from hospital Barricades self in room

feelings does the behavior generate? Table 9.2 lists Psychological Questions used in PGC plans that address treatment noncompliance. Although these sample Psychological Questions might seem to be based on a simple formula, PGC (like most psychotherapy) encompasses broader goals in terms of personal development—these broader goals do not need to be sacrificed to satisfy the requirements of third parties for treatment goals specified in measurable, behavioral terms.

Documenting Progress in PGC In the context of a Psychological Exercise, patients can demonstrate progress on goals by 1) verbalizing answers to the exercise, and 2) showing understand-

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TABLE 9.2 Psychological Questions That Address Inpatient Treatment Noncompliance Target Behavior

Psychological Question and Discussion Concept(s)

Denying mental illness

“Why are some people reluctant to accept professional help?” (denial, rationalization) “How can you tell if a person has a mental illness?” (denial, precontemplation stage of change) “Why is it in your best interests to know a lot about your diagnosis?” (contemplation stage of change)

Medication noncompliance

“What are some of the advantages and disadvantages of taking psychiatric medication?” (decisional balance; contemplation) “What are some the advantages and disadvantages of self-medicating (with illegal drugs or prescription meds)? (decisional balance)

Noncompliance with ward routines

“What are the advantages and disadvantages of following the rules?” (decisional balance)

Refusing treatment planning

“What can a patient do that will help their treatment to work? What can a provider do?” (treatment alliance)

Psychotherapy noncompliance

“What can you do to prevent yourself from getting upset by other people’s stories in group therapy?” (boundaries, empathy) “What are some helpful and harmful feelings that people get from sharing personal stories in groups?” (confidentiality, decisional balance) “What are the risks and benefits of being in therapy?” (decisional balance, ambivalence)

Refusing to cooperate with guardian

“What are some advantages/disadvantages to having a significant outside person (parent, guardian) involved in your treatment?” (therapeutic alliance)

Thwarting discharge planning

“What are some advantages/disadvantages of getting out of the hospital?” (ambivalence)

Avoidance behaviors

“What are the advantages/disadvantages of being with other patients on the unit?” (universality, therapeutic milieu)

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ing of psychological concepts by providing examples or listening. Figure 9.1 is a sample progress note for a PGC session that focuses on taking psychiatric medication. Statements that patients make during a PGC session can be quoted to document participation in a manner that is both useful and compelling. The newly revised Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2002) requires that group members be made to understand the limits of confidentiality (e.g., that their statements in group may be documented in their medical record). Regardless of professional discipline, PGC practitioners are advised to educate patients about confidentiality, e.g., during the introduction to the session, or directly before beginning the Psychological Exercise.

Progress Note (Planned Group Counseling): Jane participated in Planned Group Counseling, a method emphasizing awareness of thoughts and feelings in the “here and now.” Goals are to increase understanding of psychological factors related to inpatient treatment compliance, and to decrease target behaviors associated with noncompliance. Group norms were presented as follows: 1) Honest communication is necessary for therapy and encouraged, therefore one may pass if called on; 2) Group members are asked to speak one at a time; 3) Group members should address comments only to the leader, allowing each person to benefit from the leader’s empathic listening and comments. Target Behavior(s): Noncompliance with medication. Psychological Exercise: Jane participated in answering the Psychological Question, “What are the advantages and disadvantages of taking psych meds?” Questions and Comments followed, re: finding a basis on which to make a decision to take meds. Session Objectives: 1) To verbalize advantages and disadvantages of taking psych meds (Jane achieved this objective); 2) To show understanding of therapeutic concept(s): decision balance (Jane showed progress by giving examples). Participation Level/Quality: Jane was an active participant and observed group norms. Her response to the psychological exercise was “feel better sometimes” (advantage) and “it’s a hassle” (disadvantage). She told the group about how she had gone off her meds because she felt better, but then went back to the hospital. She said she decided it was less of a hassle to take the meds. Jane reported that group was helpful. Observed Mental Status: Affective: Pleasant Cognitive: Alert Thought Content: Organized Speech: Mildly pressured

FIGURE 9.1 Sample progress note.

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PGC in Long-Term Psychiatric Settings While the long-term resident of the psychiatric hospital is not in the throes of acute crisis familiar to the admissions unit, for many, chronic anger and despair over ever getting better stand in the way of receiving effective treatment. Although these patients are often lonely and crave interpersonal contact, chronic psychosis presents an obstacle to being able to meet the demands of existing group treatment and take away benefit. Long-term patients may sense that they are “stuck” psychologically, but they lack the interpersonal skills necessary to challenge each other to change in a process group setting. PGC meets the needs of these long-term patients with its welcoming, hopeful, protective, and pragmatic stance. While encouraging honest expression of feelings—accepting but not condoning self-defeating attitudes—the PGC leader is able to maintain a more constructive group process and redirect the group away from chronic complaining. Because the patient population of the long-term unit is less acute (and, hopefully, consists of experienced PGC participants), fewer modifications of the PGC format may be needed and sessions can be longer, leaving time for Word Association. In the partial hospitalization setting (day hospital), PGC may be conducted similarly to PGC in outpatient substance abuse settings. Institutional norms may dictate parameters such as length of the sessions; however, PGC allows this type of flexibility, as we have seen above. PGC Plans in the Long-Term Setting. The development of new PGC plans in long-term psychiatric settings provides an opportunity for ongoing dialogue between PGC leaders and patients who participate in PGC. Comments that patients make in a session may become the kernels from which new topics are developed. That plans truly reflect patients’ needs and concerns is another way for the leader to communicate to patients that their thoughts and feelings are valued. That the PGC leader takes the initiative to develop material from the group (rather than asking for or taking suggestions for plans) reinforces patients’ perception that the leader is involved and responsible. In longterm settings, patients develop leadership roles via their regular attendance, modeling the norms of group for new members, and by their answers and comments. Psychological Questions in the Long-Term Setting. The common experiences of chronically mentally ill people—stigma, poverty, feeling useless, rejection, or overcontrol by family—provide appropriate subject matter for PGC session exercises. Examples of Psychological Questions that have been used in a partial hospitalization setting include: “Who should you tell you’re in treatment? Who should you not tell?” “What advice would you give to a

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new patient in this program?” “What makes you inspired?” “What should most people know about mental illness?”

SUMMARY These modifications to PGC for psychiatric settings are case examples that demonstrate not just a new way to work with mentally ill individuals, but a flexible approach to new settings and populations for whom existing group therapy may not be feasible. The elderly, higher functioning developmentally disabled individuals, and forensic populations could also be considered possible candidates for PGC. We have not yet worked in settings specific to these populations, however mildly demented patients, higher-functioning autistics, and individuals found incompetent to stand trial have attended and obtained benefit from PGC groups in psychiatric settings. The process of tailoring PGC for different settings and populations demands good clinical skills, but the method is accessible to practitioners at various levels and from various disciplines. We have trained mental health counselors, occupational therapists, social workers, and psychologists to use PGC in psychiatric settings. The key to success lies in the values and principles of PGC—not in techniques per se.

Chapter

Ten Using PGC in Educational Settings

CLIENTS Many students who need and could benefit from the services of college counseling centers and high-school counseling departments are reluctant to request treatment because of the stigma attached to being a mental health client. College and high-school students are in the process of developing physically, socially, and psychologically in a competitive and stressful academic and interpersonal environment. Many students struggle with identity issues (sexual and vocational), fear of academic failure, and social rejection, while many also have to cope with unstable and unsupportive social worlds: a function of divorce, remarriage, complicated living arrangements, stepfamily issues, and other family stressors. Becoming a counseling client may likely diminish a student’s self-esteem: receiving counseling requires trust and the acceptance of an increased need of others (counselors), and relating to others in a more dependent way may arouse unwanted feelings (inadequacy, helplessness) that could be associated with increased dependency. Receiving counseling may also threaten a client’s sense of privacy, and the wish to avoid being stigmatized. As a further hindrance, needing and receiving professional counseling services is unfortunately perceived by many students—along with their family and friends—as having a negative effect on students’ future careers, and so they are discouraged from seeking out these services. Most students do not voluntarily request individual or group counseling services, and of the ones who do, the overwhelming majority of them specifi236

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cally request and prefer individual as opposed to group counseling. For some, the reason for this may simply be that they are less knowledgeable or perhaps even ignorant of what group counseling is and what it has to offer compared with individual treatment. For others, the reason might be the confidentiality assurances that individual counseling offers, or the notion that it might reduce their chance of being seen by other students (fellow classmates). Therefore, it is very understandable, and indeed predictable, that many students who may need and could benefit from professional counseling services at different points in their educational careers will deny these needs and avoid treatment, particularly group treatment. Often it is someone else, such as a concerned faculty member/teacher, who refers them to the counseling departments/centers, and even in these cases, many of these students are only referred to counseling when they have been identified as failing academically (academic probation), when they present extreme behavior problems in the classroom, and/or when they are caught misusing legal or illegal chemicals.

ADVANTAGES OF PGC The advantages of using PGC with the above-described client population are as follows: • It is maximally inclusive, and accommodates clients who represent a wide range of intellectual abilities and educational achievements, and who come from different socioeconomic classes and multicultural backgrounds • It is specifically intended to accommodate fearful, distrustful, hostile, highly defensive, and reluctant clients (voluntary or involuntary) • Clients have complete control and responsibility for when and how much they will self-disclose • Clients are not required or expected to maintain confidentiality • Clients are exposed to a noncompetitive, conflict-free interpersonal learning experience • All clients are equally, repeatedly, and systematically invited to participate verbally to create the group process • There are no opportunities for clients “to fail,” because although one of PGC’s basic goals is for clients to learn about themselves and others, it is not required

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• All clients are encouraged to attend on time and to stay for the entire session; however, clients are informed that they determine when they arrive and leave Note: in those high-school settings where attendance is mandatory, the freedom and responsibility to determine clients’ attendance for each session cannot be offered. However, the freedom and responsibility to determine when to make verbal contributions and how much to self-disclose can still be offered. Even though clients do not have the freedom and responsibility to determine their attendance, the leader can use whatever reactions clients may have to these restrictions as “grist for the mill,” by focusing the session on what their clients think and feel regarding this. Freedom and responsibility are excellent issues to explore in these situations.

VOLUNTARY AND INVOLUNTARY CLIENTS Students entering counseling may be voluntary or mandated. Many new counseling clients, particularly those who are mandated, may be angry at themselves and/or others for being identified as requiring mental help, and may enter treatment very reluctantly. Regardless of whether a counseling client is voluntary or mandated, there is no difference in how the PGC method, and its therapeutic goals and techniques, is applied. Paradoxically, it may be easier and quicker for the leader to have a more authentic encounter with involuntary clients, because many of these clients welcome an opportunity to express the anger they may feel toward themselves and/or others.

CONFIDENTIALITY REQUIREMENTS Because newly arrived clients are frequently distrustful, one of the very first things a PGC group leader does is to inform group members that what they reveal is always and solely determined by them. In fact, clients are advised not to self-disclose any personal information that they wouldn’t share with the general public. Some students—and this may be especially true for highschool students who are very concerned about their privacy and individuality—are likely to be more cooperative and receptive to a group treatment method when they learn that what they reveal, and when they reveal, is always determined by them. In educational (as well as medical) settings, there is no confidentiality requirement in PGC for three reasons: 1) it is not necessary to achieve PGC’s

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therapeutic goals; 2) there is no way for the leader to guarantee that group members will or can maintain confidentiality; and 3) PGC is not designed to resolve conflicts. In the event that psychological/physical conflicts result between clients from broken confidentiality outside of the treatment room, professional staff will often not have the advantage of being present to intervene in these conflicts and prevent harm between clients from occurring. The PGC method is committed to providing a harmless to helpful professional group treatment session, and “to do no harm” always takes priority.

VARIOUS USES OF PGC PGC leaders in educational settings can integrate PGC into their counseling programs in a number of different ways. Orientation Groups. PGC is ideally suited as an orientation group for new clients, because of its adaptability and its ability to accommodate lateness, irregular attendance, early departures, and unpredictable group size. College Freshman Orientation Classes. The PGC method can be used as one of the components of freshman orientation classes in which the content would focus on the services provided by the counseling department/center, while at the same time promote a more positive attitude toward receiving the benefits of counseling services. Ideally, the session or sessions would be conducted at the counseling center, providing all incoming freshman students with an opportunity to become acquainted with the physical environment, and some of the administrative and treatment staff. This could help desensitize freshman students from the negative associations attached to receiving mental health services and to help better integrate the counseling services into the larger academic community. As part of the orientation, students could be invited to attend ongoing, regularly scheduled PGC sessions for the benefit of obtaining further psychological knowledge and personal development. Alternative Group. As an alternative group, PGC is intended to complement and support other kinds of group treatments being provided by the counseling center/department, and as such, can readily be offered as an open-ended, ongoing, regularly scheduled (weekly) group session. The method’s flexibility makes it easy to accommodate and accept an assortment of clients. It is especially well-suited for those who—because they are very reluctant and at high-risk (potentially suicidal, binge drinkers, illegal drug users)—would benefit from being professionally monitored. The method is also ideal for those who have been mandated to receive counseling and are uncommitted to attending their regularly scheduled group treatments.

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Assessment/Transition Group. As an assessment group, PGC can focus on assessing patients’ abilities to comply with the attendance expectations and demands of other group treatments for which they are being considered. As a transition group treatment, PGC can inform and prepare clients who are awaiting assignment to enter a closed, time-limited, traditional counseling group.

SUGGESTED CONTENT AREAS The following is a list of commonly encountered problems and issues that students struggle with, and which the PGC method could be used to help address: • Learning problems—caused by any one or combination of the following: emotional problems, concentration, time management difficulties, and inadequate learning skills—all of which can be aggravated by a lack of emotional support from significant others • Communication skills—helping students to practice expressing their thoughts and emotions to better achieve their vocational and personal goals • Making choices—regarding vocational future, sexual behavior, and consumption of alcohol or other drug usage • Underachievement—caused by any of the following: inappropriate vocational choice, social anxiety, shyness, lack of confidence, low selfesteem, and unsupportive, critical, punitive, significant others • Relationship issues—helping students learn how to begin, sustain, and end a variety of intimate relationships without harming themselves and/or others • Chemical dependency problems—helping students accept professional help

Epilogue

This book was written to give group therapists a detailed, replicable guide to a new, safe group method that they can easily learn, and which can help more reluctant chemically dependent and psychiatric patients accept and benefit from professional group treatment. As an alternative group method, Planned Group Counseling also offers group leaders from other professional disciplines a different model for meeting the needs of their specific reluctant patient and client populations in a variety of medical and educational settings. PGC was created to meet a pervasive clinical challenge: how to better engage, encourage, and retain reluctant chemically dependent and psychiatric patients, who need all the psychological help they can get, and get them committed to accepting and benefiting from professional group treatments. Existing professional group treatments do not fully or adequately meet the particular treatment needs of many reluctant patients; therefore, those patients who most need what group therapy has to offer are not able to gain from the unique benefits provided by these group treatments. When reluctant patients avoid or terminate their treatments prematurely, everyone loses; the patients do not get the necessary treatment they require, and the professional loses the opportunity to be helpful. PGC addresses this clinical problem by offering very reluctant patients a safe, interpersonal learning environment that is always welcoming and protective, and a group method that is realistic, simple to understand and follow, and which can be tolerated and accepted by most patients. Often chemically dependent patients needing professional treatments are labeled noncompliant and unmotivated because they come late to scheduled sessions, miss sessions, and/or prematurely terminate their treatment pro241

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grams. However, many patients who do not comply with the demands of professional group treatment can and do comply with the behavioral expectations and demands of self-help group experiences, which are often not only free and readily available, but where people are also responsible for determining their attendance patterns. For example, in highly populated urban areas such as New York City, self-help groups are offered every day and night, with additional groups being scheduled during the most stressful times of the year, e.g., the holiday season. People attending are free to come and go as they please and attend as regularly as they wish for as long as they wish—some even choosing to attend multiple groups daily over the course of many years. Many chemically dependent people praise and describe these group experiences as helpful. This suggests that many patients who reject professional group treatments and accept self-help group experiences demonstrate some capacity for involvement in group experiences designed to help group members learn how to live their lives without depending upon chemicals. Because patients are “not motivated” to attend professional group treatments does not necessarily mean they are unmotivated to free themselves of their harmful chemical dependencies. And although some patients complain that self-help group experiences are not psychological enough and rely too greatly on faith, these limitations do not stop many chemically dependent people from attending and benefiting from what self-help group experiences always have to offer: hope and acceptance. The PGC method is also based on offering hope and acceptance, while at the same time offering psychological learning opportunities. This group method incorporates the same flexible and accepting approach which characterizes the self-help group model. Patients are welcomed at any time, they always determine their level of participation, and they have maximum responsibility for how frequently they attend. Often, for a variety of complex reasons, administrative needs conflict with and ultimately supersede treatment needs, thus limiting how flexible and accepting professional group treatments can be toward patients’ attendance. In some instances, treatment programs may not be able to obtain government and/or private enterprise reimbursements unless patients strictly adhere to scheduled appointment times. Therefore, treatment programs which rely on these revenues need to enforce strict attendance requirements. This needs to change if, as a society, we want to treat more chemically dependent and psychiatric patients, rather than imprison them. Similarly, change is necessary to permit new alternative group treatments to be developed and to encourage more professionals to apply these new methods.

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Prior to this book being written, the PGC method was taught for many years to psychology interns during their clinical internship year. For most of these interns, the PGC method was often very different from their past group leadership experiences, and therefore required them to change their unhelpful thoughts and feelings related to learning this new group method. To help newly assigned interns become more aware of any potential thoughts and feelings which might interfere with their learning, the following questions were posed to them: 1) Why should you not learn this group method? and/ or 2) Why would other professionals and interns not want to learn this group method? These questions were often helpful to interns in two ways. First, they provided an empathetic learning experience, since these questions required them to do exactly what they would be inviting their patients to do, namely, to give an honest response to a specific psychological question which has been previously chosen by the leader and which has been designed to encourage patients to self-disclose what they honestly think and feel in the now while others listen. Second, these questions gave them the opportunity and the permission to express their reluctance, reservations, and concerns about leading a group of patients using a group method based upon a single-session workshop model that relies on very active and directive leadership skills, and where the group leader was responsible for the content of the session and for limiting the group process to leader-to-member and member-toleader interactions. As one would expect, their answers to these psychological questions were strongly influenced by past educational, training, and clinical experiences, which usually defined the most potent form of group therapy as requiring and relying upon group members freely interacting, thus implying that the fewer the number of member-to-member interactions, the less potent and helpful the group experience. Some also found it initially difficult to conceptualize and believe in some of PGC’s paradoxical features: that while memberto-leader interactions are encouraged and interaction among group members is actively discouraged and considered not central to the group process, this does not stop the PGC leader from accepting, accommodating, and assimilating these unwanted interactions between group members in order to provide additional here and now “grist for the mill.” It was difficult for some of them to imagine that a group method that was so highly structured would permit them to achieve even limited traditional group therapy goals. Some readers of this book may be equally skeptical and reluctant to learn and use this group method because of the leader’s need to be so active and directive, as well as the leader’s responsibility for developing the session’s

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content and limiting the group process. For all the same reasons, I, too—as the first author—found myself initially reluctant to rely upon the specific techniques that define this group method: it was not my desire to be that active and directive, and it was not my desire to limit the group process, which I was taught to believe was essential to effective group therapy. Most important, as an inexperienced group therapist, I had a limited appreciation of how important it was to match treatment procedures to unique needs of specific patient populations. It was only through a combination of necessity, clinical observation, and my determination to be an effective group therapist, that I was motivated to overcome my own reluctance to rely upon the PGC group method. The incentive and reward for my continuing to refine and rely upon the method was observing patients’ acceptance of the PGC group norms, and regularly receiving their unsolicited positive comments, specifically that they found this group method to be meaningful and helpful. Reluctant chemically dependent and psychiatric patients should have access to the full range of professional services in order to help free them of their harmful chemical dependencies and to improve their physical and psychological health. This book was written with the hope that other professionals struggling with meeting the clinical challenges posed by these reluctant patients would be able to benefit from our extensive clinical experience in using the PGC method, and would also share in the professional satisfaction and pleasure of using an alternative group method that an overwhelming majority of patients can tolerate and accept.

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