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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.

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