Post on 21-Apr-2023
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Integrating a Theoretical Best Practice Into a Group Model
Jon Stentz
Hazelden Graduate School of Addiction Studies
Group Theory and Process
Winter 2015
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Acceptance and Commitment Therapy (ACT) has been proven an
effective form of treatment for a variety of disorders including
chemical dependency. (Ruiz, F. J., 2010). One of the key tenants
of this therapeutic approach is the emphasis it places on the
importance of mindfulness and remaining in the here and now.
According to its founders, part of the ACT approach is
“acceptance (of thought) is not merely tolerance-rather it is the
active nonjudgmental embracing of experience in the here and
now.” (Hayes.2004 2011). This approach lends itself well to the
Process Group model for a variety of reasons that I will discuss
in this paper. I will also discuss how Motivational Interviewing
can be integrated into both ACT as well as the Process Group. My
integration of these theories and approaches will be placed in
the clinical context of chemical dependency treatment and will
include my own personal experiences and observations as a way to
illustrate my integrated theory.
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ACT was developed by Steven C. Hayes, Kelly G. Wilson, and
Kirk Strosahl in 1980 as part of the “Third Wave” of
psychotherapy. ACT emphasizes willingness to accept negative
feelings and then to let them go. The objective is not happiness;
rather, it is to be present with what life brings us and to "move
toward valued behavior". (Hayes, Strosahl, & Wilson, 2011) Noam
Shpancer describes acceptance and commitment therapy as getting
to know unpleasant feelings, then learning not to act upon them,
and to not avoid situations where they are invoked. Its
therapeutic effect is according to him a positive spiral where
feeling better leads to a better understanding of the truth.
(Schaller, 1993)
ACT commonly employs six core principles to help clients
develop psychological flexibility:
1. Cognitive defusion: Learning methods to reduce the tendency to
rectify thoughts, images, emotions, and memories.
2. Acceptance: Allowing thoughts to come and go without
struggling with them.
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3. Contact with the present moment: Awareness of the here and
now, experienced with openness, interest, and receptiveness.
4. Observing the self: Accessing a transcendent sense of self, a
continuity of consciousness which is unchanging.
5. Values: Discovering what is most important to one's true self.
6. Committed action: Setting goals according to values and
carrying them out responsibly. (Hayes.2004 2011).
The style I believe that would best fit my integrated model
in terms of it being either a group centered guided model or a
leader guided model is that of the group centered model. In the
realm of chemical dependency Alcoholics Anonymous and Narcotics
Anonymous have experienced great success by using the group
centered model. The group is most in touch with its needs and
should therefore be the ones to define those needs that they wish
to address within the group. By leaving the autonomy of choice to
the group, the group may develop a sense of control and cohesion
and a sense of mutual purpose.
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The one area I would stray from the group centered model and
use a more leader guided model is in the area of psycoeducation.
It would be my responsibility as a facilitator to provide the
necessary education in terms of ACT. However, even within the
psychoeducational aspect of the group process, clients would be
encouraged to provide input and feedback as to be benefits and
possible failings of ACT.
As a facilitator of this integrated group model, I would
seek to foster an air of permissiveness and acceptance in keeping
with the ACT’s similar approach to the client’s individual
thoughts. The group should function as an experimental lab for
the group’s interactions in the world outside of group. The
outside world while controlled to a certain degree by laws and
societal norms is a wide open in terms of day to day
interactions. Clients through this integrated model can become
more prepared for these interactions by quieting their internal
negative monologues via the utilization of the ACT skills and by
value testing with in the group’s social microcosm.
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In order to adequately describe how an integrated theory
operates within a group setting, it is useful to place it within
an established structural model. The group development process
as described by Irvin Yalom generally follows a three stage
process; the initial stage (orientation, hesitant participation,
search for meaning and dependency), the second stage (conflict
dominance and rebellion), and the third stage (development of
cohesion).
In the initial stage, the group must come together to
determine what goals they want to achieve and how they are going
to achieve them. In the case of a chemical dependency process
group, the main goal is fairly clear, stay sober. The larger goal
is to repair their lives and most importantly their
relationships. Common feelings for those in early stages of
recovery often include internalized feelings of shame and self-
perceptions of inadequacy. Many times these feelings are
projected on those around them; they think they are inadequate
and unworthy of relationships, and they assume, often times
inaccurately, that others must feel that way as well. ACT
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approaches this from the standpoint of non-engagement, and
teaches clients to acknowledge and then dismiss these negative
thoughts. In the context of a process group this ability to
acknowledge and dismiss negative thoughts allows the group to
move forward. Clients who spend time combating negative, often
time’s irrational feelings, can miss out on their feelings and
reactions to others. By using ACT, a client is more mentally and
emotionally flexible to deal with their relationships. This is
not to say that a client should ignore all feelings and simply
dismiss them or “defuse” them. The process group must at times
confront the maladaptive thinking we have towards others in order
to adjust that thinking. However the ability to adjust one’s
thinking in the here and now of a situation and not get trapped
in a maladaptive process makes the value of the process group
that much more valuable because it allows for more free flowing
engagement within the group.
An example of a client within a group that is wrapped up in
confronting their maladaptive, irrational thoughts rather than
defusing them is often manifested in the form of a quiet client
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that sits back, arms crossed and observes or when they do speak,
keep trying to bring the group back to a certain topic. This
client is obviously struggling with something that they are not
able to resolve on their own. If ACT type methodology has been
introduced and utilized within the group, a counselor can ask
this client if they are struggling with something and if so to
use their ACT skills and determine if this is something that can
and should be discussed within the group or is it something that
can diffuse and then rejoin the group in its defining of goals.
In the second stage of his model of group’s development,
Yalom describes the group’s struggles for hierarchy and
dominance, as Yalom puts it, “It is a time of ‘oughts’ and
‘shoulds’ in the group, a time when the ‘peer court’ is in
session.” (Yalom & Leszcz, 2005) During this period clients are
battling with preconceived notions of how a group should operate
and who should lead it. Many of these group conflicts are based
on internal conflicts with in the clients themselves. Clients in
early recovery are not always able to identify leadership
qualities and are often times unsure as to their own ability to
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lead or even contribute to the group. Many in early recovery are
frozen in their development due to their usage and will either
automatically defer to older, wiser members of the group, or in
contrast, dismiss those members as too far gone. The counselor is
also the focus of rebellion and unreasonable expectations.
Transference is an issue at this stage as the group sometimes
perceives the counselor as having “magical” powers to the point
of “their expectations are so limitless that they are bound to be
disappointed by their therapist, however competent.” .” (Yalom &
Leszcz, 2005) Once again, ACT gives the clients and the
counselor a valuable tool at this stage to keep the group moving
forward in its progress. Clients that become mired in maladaptive
perceptions of others in the group or of the counselor cannot
fully engage. For instance, if a client is continually dismissing
the direction of the counselor because the counselor is in some
way similar to say their indecisive boss, the counselor can first
address the clients behavior, determine the source of the
negative transference, process it, and then instruct the client
to utilize their ACT skills to defuse any future feelings of
negative transference.
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In the third stage of Yalom’s process the group begins to
come together to work toward their goal of building better
relationships. It is at this stage that ACT should be an
established practice for the individual members of the group. By
this time the clients should be able freely let go of negative
and maladaptive thoughts that do not directly affect the group.
They should be able to let go of feelings of inadequacy because
of the negative emotions that arise during the course of a group
therapy session, they should be able to recognize that short term
emotions and feelings are not as important as long term goals.
Clients at this point should be “psychologically flexible”.
Psychological flexibility can be defines as ”the measure of how a
person: (1) adapts to fluctuating situational demands, (2)
reconfigures mental resources, (3) shifts perspective, and (4)
balances competing desires, needs, and life domains. Thus, rather
than focusing on specific content (within a person), definitions
of psychological flexibility have to incorporate repeated
transactions between people and their environmental contexts.”
( Kashdan and Rotterburg 2010) This psychological flexibility
allows group members to fully engage in the here and now process
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rather than being held up by battling with their thoughts. This
is especially important in the process group because it fully
allows the free flow of feelings within the group. Members of the
group that are psychologically flexible do not waste time
debating with themselves if a present feeling is good or bad but
rather they simply express it. This group cohesion mixed with
psychological flexibility is most easily observed within a group
of adolescent males. Often times after a group of this
demographic have been together they freely express issues amongst
themselves without fear of repercussions from the group. Feedback
and criticism is given and received in the spirit of
constructivism. Group members that are encouraged to view the
group in the same way that they are encouraged to view their
thoughts; that is as a non-judgmental place where the negative
exists but does not rule.
Yalom refers to several norms that he feels every process
group should have. Among these are three that I feel would be
important to adopt for my integrated group, they are; the self-
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monitoring group norm, the self-disclosure norm, and the support
and confrontation norm.
Many that enter chemical dependency have lost control of
their lives or at the very least, have lost the sense of control.
The self-monitoring group norm is important for this integrated
group to have because it in many ways will mimic life outside of
the group. The member within the group will have to make
decisions that will not only affect them, but also the other
members of the group. Issues like, animosity towards a member of
the group or concern over how another member is ignoring a member
of the group teaches the members how address these issues in a
constructive way. Outside of group, members will have to make
similar decisions, like “how is my behavior with my spouse and
children going to affect them?” or “how do the actions of
coworkers truly impact this situation or is it my perception of
the situation what I must really address?” According to Yalom,
as a facilitator it is my responsibility to lay down the ground
rules and demonstrate how the group should operate. However,
after that has been established it is vital to let the members
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solve their own problems. ACT emphasizes the importance of a
client realizing their personal values. This aspect, while
personal in nature, also affect the way the group interacts and
guides itself. If a group member is unaware of what is truly
important to them than they will simply ebb and flow with the
other group members. They will most likely get little from the
group and others will gain little from them. Conversely, if a
group member is aware of their values they bring those values to
the group and the other members can either embrace those values
or challenge them, either way the group benefits.
The self-disclosure norm as described by Yalom is
“essential in the group therapeutic process. Participants will
not benefit from group therapy unless they self-disclose.” (Yalom
& Leszcz, 2005) In the context of the chemical dependency group
this would seem to be especially vital. For a group member, the
very admittance that one is an alcoholic or addict is an
essential first step to recovery. Furthermore, the process of
sharing one’s story allows the group to bond with the member by
allowing the members to relate to their story. Self-disclosure
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can also be instrumental in the formation of group cohesion.
Self-disclosure builds trust within the group because it shows
that all members are willing to show vulnerability and brutal
honesty about their addiction and the consequences of it. If
members are not willing or able to show this level of
vulnerability, then the group becomes psychologically hobbled by
individuals concerns of “am I sharing too much?” or “will I
be judges for sharing this information”. ACT skills are once
again useful in the development of this group norm. Group members
that are not held back by negative self-perceptions are better
able to freely share within the group. Group members that sit and
wait until they have sufficiently battled and conquered these
self-deprecating feelings lose valuable time in the group.
Similar in its importance in terms of providing value to the
individual and the group experience, the support and
confrontation norm allows the group to value test in a safe and
supportive social environment. Conflict is a part of life. Those
who perpetually avoid it, risk damaging their own psyche and are
unable to fully engage in life. On the other hand, there are
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those that seek out conflict to satisfy some sort of conflict
within themselves. In either case learning how to confront and be
confronted is a valuable lesson for members of the group. When
members experiment with heated emotional conflict within the
group and walk away with feelings of validation and acceptance,
they learn that confrontation can be a means to a positive end
rather than a necessary evil. ACT skills come into play in this
norm in the form of allowing the member to be fully engaged and
open to the conflict experience. ACT (as does the process group)
emphasizes the importance of the here and now experience.
Conflict is an emotional experience and it is easy to become
wrapped up in feelings of anger and sometimes insecurity about
one’s own deeply held values. It is important in times of
conflict to not hold on to these emotions and to be able to be
open to all possibilities that the situation may present.
MI and ACT on the surface would seem to be rather opposite
given that the focus of MI is the content of language and ACT is
focused on the process of language. To a certain degree this
would be true. However, the two theories are complementary from
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the standpoint that both seek the same goal which is to
internalize the commitment to behavioral change. Furthermore
both require that a patient identify, clarify and then live by
their values. In fact, one of the most commonly used homework
assignments in ACT is for the patient to list life goals and
things that they value in their life. (Corey, 2012) ACT, although
focused on the acceptance of emotions and feelings still seeks
change. ACT seeks to enable change by helping patients to accept,
experience and then move and to not waste time and energy on
changing those feelings and emotions. The main way that ACT and
MI are so complementary is that ACT allows for MI to begin
because it clarifies what can be changed and what cannot, and to
accept what cannot be changed and to move on.
Once group members are adequately freed from past and
present issues that are out of their control, MI techniques can
be utilized by the facilitator to encourage and enable positive
change. Affirmation is an especially useful technique to use in
the early stages of chemical dependency recovery due to the fact
that group members feel beaten down by their addiction and are
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experiencing shame and regret from its consequences. After using
their ACT skills to accept those things that are out of their
control, a group member may be left with a sense of wonder of
“what am I in control of?” As a facilitator it is imperative to
instill a new sense of empowerment by judiciously and genuinely
using affirming language with the client and serving as model to
the rest of the group to do so as well. These affirmations
encourage self-efficacy in the group member which leads to later
advancements like committal to change talk. Just as we affirm
that unpleasant emotions within ourselves we offer external
affirmation to other members of the group the difficult nature of
the work they are doing within the group and the positive
outcomes that are possible for themselves and the group.
Reflective listening is another technique that can be used
as an integrated ACT/MI technique. Reflective listening allows
the facilitator and the group as a whole to provide a group
member with a sense that they are being heard and understood,
while at the same time pointing out both positive and negative
thought processes that the group member may be engaging in. For
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instance if a group member continually engages in self-
deprecating humor, the facilitator can point out that the group
member is continuing to engage negative self-talk and that they
are continuing hold on past items that do not hold relevance for
the here and now. Reflective listening provides the opportunity
for the facilitator to hold up a mirror to a client’s thought
processes and their behaviors and allow the group member to
either recognize or clarify these reflections, or to contradict
and confront them. Either way it opens a dialogue for the group
to engage in which in turn enables others to recognize patterns
within themselves.
As I have stated earlier, AA and NA have had great success
using the group model to treat addiction. The intent of the AA/NA
group is to enrich each other’s lives by encouraging positive
change and the pursuit of holistic recovery as opposed to simply
staying sober. This is done so through the careful and thoughtful
journey through the twelve-steps. The twelve steps are useful to
my integrated theory because they mirror the process of self-
evaluation followed by actions based on those evaluations. The
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spirit of the twelve steps is contained within the very title of
ACT, acceptance and committal.
The first step states that an addict or alcoholic must
accept that they are powerless over drugs and alcohol. This
acceptance stops the battle that they have within themselves that
they can control their addiction and in fact to the contrary,
their addiction will and has indeed controlled every aspect of
their lives.
ACT makes a similar claim. One of the most famous and useful
analogies used within ACT is that of the bus driver. In this
analogy the client’s progress in life is symbolized as a bus and
the individual is the bus driver. The bus driver must let on
passengers, but has little control over which passengers leave.
These passengers represent a whole host of both positive and
negative perceptions and emotions that the bus driver is
essentially stuck with. Regardless of who is on the bus, the bus
driver must still drive the bus. Similarly, the first of the
twelve steps essentially says that an addict or alcoholic is
powerless to control who has gotten on their bus and to accept
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the passengers for what they are, to accept life on life’s terms.
This overall attitude of acceptance leading to change is the
essential thread that runs through my integrated theory. It is
impossible to make positive change in a group member’s life if
that group member is mires in a constant battle to change what
they cannot change. The first step is step that makes all other
steps possible. The same can be said of the acceptance contained
within ACT allows the change contained within MI as well as the
process group.
One of the most influential experiences I have had within
the experiential groups this semester is the dynamic of the
group’s reaction, resistance, and inability to overcome the power
of the monopolist member of the group. The phrase “the squeaky
wheel gets the oil” does not even begin to describe the effect of
the monopolist because it appears that no amount of oil can stop
the squeak. From the very beginning the monopolist within the
group through the use of passive aggressive techniques has
dominated the attention of the group to the point that little
else can be accomplished for anyone else.
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This is an important experience to have because I have
already faced this with groups I have encountered on the units I
have interned on. What I have learned from this is that a
monopolist will continue their behavior until confronted with the
impact it has on themselves and others. The monopolists I have
encountered seemed oblivious to the effect they were having on
the group. They seemed to think that their constant interjections
and outbursts were merely “good fun” and were perplexed when
others did not see it as so. However, when it was explained to
them that their behavior was inappropriate and actually damaging
the progress for others in the group and themselves, they altered
their behavior.
This brings me to the other important lesson I have learned
from the experiential group and that is the need for facilitator
leadership through observation. It is ideal for the group to
function in a Rogerian Utopia where the group is able to
facilitate itself and lead itself to the promised land of reduced
pain and better relationships. The reality however is that a
group needs a leader. The experiential group I am engaged in has
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been unable to make much progress beyond recognition of the
obvious. We have spent a great deal of time noticing and pointing
out the effects that each other have on the group, but precious
little time examining how that it is going to move the group
forward. We seemed to be locked in a place where we all admit
that we like each other on a rather superficial level and that
there are aspects of each other’s personality that rub us the
wrong way. We as facilitators have not stepped up and to really
move the group forward very well. I believe it is important for a
facilitator to calculated risks in the pursuit of progress. This
requires us as facilitators to make interpretations that may be
off the mark and may even hurt the feelings of a group member. In
short I believe it is vital to risk the “short term pain for the
long term gain” and I believe it is the responsibility of the
facilitator to model the risk-taking behavior.
In conclusion, my integrated theory combining ACT with
process group and MI is a way for a patient to start from the
inside out. By using ACT they can analyze their thought processes
and let go of negative self-talk. After this has been
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accomplished a client is better able to seek to commit to and
pursue positive change through MI as well as group therapy.