I encourage readers of this column to consider joining the American Group Psychotherapy Association. AGPA has been aware of the need to create a bridge to address the split between addiction treatment professionals who come into the field with the benefit of their own recovery and those who come into the field through purely professional training. AGPA now has formed a special interest group within its ranks dedicated to addiction and recovery. The following question from Jonah Schwartz, MSW, was posted on the Internet forum for this group:
I work full time in an outpatient chemical dependency program, running five groups per week. The groups here are pretty much open, and the turnover can be rather high at times. I'd be interested in hearing from others who work in agencies about how issues of group composition are handled. Is a lot of attention given to this matter? How do leaders handle the issue of missing members, given the constraints imposed by confidentiality? (I can't exactly say, “Joe isn't here because he relapsed again and was sent off to residential.” And yet the other members have become attached to Joe and want to know what's happened to him.) Perhaps this board can be a place to discuss these issues, and more.
I want to thank Jonah for his willingness to have his question serve as the basis for this column. First, I want to congratulate him on having five groups per week! Many group therapists identify themselves as such with fewer groups, and many addiction counselors conduct a similar number of groups without identifying themselves as group therapists. The group psychotherapy community's traditional focus on long-term groups may be alienating to group therapists who experience high turnover, as is common in addiction treatment.
Jeffrey D. Roth, MD
I view the matter of group composition from two vantage points: that of the therapist and that of the group. Since my basic stance is to work with the group as a whole, if I am distracted by the group's changing composition, I see my distraction as a consequence of attempting to control something over which I am powerless. When I let go of control, I am in a position to work with the disruption that missing members creates for the group. Frequently, the group will elect (silently or explicitly) one member to voice thoughts, feelings, or fantasies about the missing member(s). These contributions may be powerful starting points for a number of issues central to addiction and recovery.
First and foremost, addiction disrupts most if not all of the important relationships in the addict's life. Therefore, missing members may represent lost family members, friends, and professional peers. The loss of these relationships, as a direct consequence of the addiction, provides an opportunity for work on powerlessness and unmanageability.
In addition, many group members not only have their own addiction but also grew up in families with addiction, in which family members might have been physically or emotionally absent. Examining the group's response to missing members may elicit reactions that lead to useful discussion of addiction in their families of origin.
Contacts outside the group
In terms of confidentiality, I understand member-to-member support as crucial to a group's success. As the authority in the group, I maintain a strict boundary of confidentiality about any information I have about group members from inside or outside of the group. On the other hand, group members are entirely free to share phone numbers or other contact information with one another, with the understanding that any contacts outside of the group will be brought into the group. As group members attach to one another, I may wonder aloud what thoughts they have about supporting one another between group sessions, and I may actively suggest that one group member contact one or more members of the group to address specific needs.
For example, a new member who is fearful, ashamed, or ambivalent about attending a first 12-Step meeting might call a group member with experience in attending meetings. For a member not ready to attend a meeting, but willing to become more honest about the extent of drug and alcohol use, I might suggest communicating on a daily basis to another member about drug and alcohol use.
Such contacts outside of the group may be useful in supporting the creation of a network that connects each group member to the group as a whole. The difficulty that a member has in becoming connected to such a network can also be examined as part of the group's work. Examining what function an isolated member serves for the group is as useful for the group as it is for the isolated member. Because isolation, as a key symptom of addiction, leads to increased suffering and death, a group member becomes a serious scapegoat when the group withholds contact with that member.
Giving members responsibility
This description of the utility of member-to-member contact is a long answer to the question on therapist confidentiality. My wish is that long before “Joe” disappears from the group, we have established enough of a connection between Joe and the group that members can contact him after the disappearance. Giving group members responsibility for maintaining such contact not only protects the therapist's role as keeper of confidentiality, but also blocks members from hiding passively behind their own impulses to isolate.