Chapter 6 - Phase II: Problem-Solving Group

Following completion of Phase I group (weeks 1-12), clients participate in Phase II group during weeks 13 through 24. Phase II of the group treatment program is a semi-structured, problem-solving session that meets for 12 consecutive weekly sessions of 90 minutes duration. By the time they enter Phase II, many clients have established some stability in their abstinence from cocaine and other substances. They have to continue actively working at staying sober and making positive changes in themselves and their lifestyle. Problem-oriented discussions provide group members with a context in which they take responsibility for addressing current problems, figure out coping strategies, receive ideas from other members regarding problems, and receive feedback from the group regarding their attitude or approach to dealing with life problems or ongoing recovery. Giving and receiving help and support also teaches group members the importance of self-disclosure, trust, and reciprocity.

The goals of Phase II group sessions are to help members:

• Identify and prioritize current problems in their daily lives that result from their cocaine addiction or potentially contribute to relapse risk, if not addressed.
• Develop strategies to cope with problems that are identified as increasing their chances of staying drug free and functioning better.
• Identify recovery issues or areas of change and strategies to address these.
• Give and receive support and feedback from each other regarding their recovery and how they cope with current problems.
• Address lapse and relapse crises and strategies to return to abstinence.
• Learn the process of problem-solving and how it can be applied to different problems in recovery or life.

In the problem-solving group, the group counselor’s main role is to facilitate the identification of problems in recovery and the discussion of strategies to address these problems. In the course of the group sessions, the group counselor can educate; stimulate members to talk with each other rather than with the group counselor; help members clarify and explore problems, concerns, and coping strategies; and help members support and confront one another. The group counselor also protects the group process by ensuring that a balance exists among the three components of group treatment: 1) the “I” (individual group member); 2) the “we” (group as a unit or system); and 3) the “it” (problems or issues discussed). To help the group function, the group counselor addresses problems that disrupt the group process, such as a member dominating the discussions, members failing to listen to each other, or members avoiding confronting unhealthy behaviors.

1. Members are encouraged to socialize informally prior to the start of the Phase II group session, while the group counselor collects urine samples and has members take an alcohol Breathalyzer test.

2. The group formally starts with each member stating his name, admitting to the addiction, and providing the last date of cocaine or other substance use. During this “check-in” period, members are also encouraged to provide a brief update on their lives during the past week and discuss strong cravings or close calls regarding cocaine or other substance use.

3. Group members who have lapsed or relapsed since last session will briefly discuss the event in terms of warning signs and contributing factors. They will also be encouraged to develop a plan to return to abstinence and prevent future relapses.

i>4. At times, the focus of the entire group session may evolve from current struggles of group members to stay clean from drugs. Other times, the check-in period takes between 10 to 25 minutes.

5. Following the check-in period, each member states a current problem or concern in his life.

6. Once each group member has identified a problem or concern, the group begins to prioritize and discuss one or more of these issues. Often, problems and concerns discussed will overlap. Even if all group members do not get a chance to discuss their own problems, they can benefit from the process of mutual problem-solving within the group. Learning problem-solving skills that they can apply to recovery or life problems is one of the main goals of Phase II group sessions.

7. During the course of the discussions of a specific problem, group members are encouraged to relate personally to the problem or issue discussed. They are asked to share their ideas on causes and effects of the problem and to give feedback to the member(s) presenting the problem. Feedback may relate to giving ideas on coping strategies or challenging the member’s attitudes or behaviors in relation to the problem presented. The problem-solving component of these group sessions takes about 1 hour.

8. When about 10 to 15 minutes are left in the group session, the group counselor reminds the group of the amount of time left and wraps up the discussion. During the final 10 to 15 minutes, each group member briefly summarizes one thing he or she learned from the group discussion and/or steps he or she plans to take during the upcoming week to aid his or her recovery from cocaine addiction.

9. The group ends with members joining hands and reciting the Serenity Prayer out loud.

Any of the recovery issues discussed in Phase I sessions may be revisited in Phase II problem-solving sessions. The most common issues discussed are those related to staying away from cocaine use, using other substances such as marijuana or alcohol, relapse, relationships, and making positive changes in oneself or one’s lifestyle. Specific problems and issues discussed in groups include:

1. Motivational struggles: These include struggles such as loss of or diminished desire to stay drug free or to make personal and lifestyle changes. Motivational problems are reflected in a denial or minimization of one’s addiction to cocaine, lack of acceptance of the addiction, and failure to accept the need for abstinence as the goal of treatment. Motivational problems often lead to poor attendance at treatment sessions, self-help groups, or lack of compliance with the individualized recovery plan. Poor attendance and compliance, in turn, often contribute to substance use relapse.

2. Strong desires, obsessions, or craving to use cocaine or other substances: These are more common among members who have not established any significant period of continuous abstinence from cocaine or other drugs. For members who have established continuous abstinence, significant increases in cravings or obsessions may occur in response to stress or problems. These strong desires also may indicate a risk of relapsing.

3. Lapse or relapse to cocaine or other drug use: Group members vary widely in their experiences with lapses or relapses. Some have none, others have one, and still others have multiple relapses during the course of treatment. Clients are not discharged for not achieving or maintaining abstinence. Instead, the focus is on trying to get each group member to develop a desire to initiate and maintain abstinence. It is expected that all positive urinalysis test results members have will be discussed in the Phase II group session. Clients can be referred to higher levels of care to re-establish stability if relapses are severe and the client simply cannot stop on his or her own.

4. Using other substances such as alcohol or marijuana: Some members have a strong desire to give up cocaine, the main drug of abuse, but continue using marijuana or alcohol. Although total abstinence is the main goal of treatment, some members will not accept this and may continue to use these other substances. While use of the substances increases the risk of cocaine relapse, the reality is that some group members will be able to limit their use of the other substances, particularly alcohol. However, the GDC model encourages total abstinence. The group counselor facilitates discussion of the potential risks of using other substances and asks group members who have tried unsuccessfully to do this in the past to share their experiences with the member who wishes to continue using other substances.

5. Problems related to participation in NA, CA, and AA or other self-help groups: Members vary in their use of self-help groups such as NA, CA, or AA. While attendance and active participation are highly encouraged, some clients refuse to attend, attend only occasionally, or participate minimally in the nuts and bolts of the programs, such as getting a sponsor, working the steps, or attending social functions sponsored by NA, CA, or AA. Some members discuss problems such as conflicts with a sponsor or other members.

6. Relationship problems with family members, friends, or colleagues at work: Interpersonal problems run the gamut from mildly distressing ones to severe ones that pose a major threat to recovery or well being. Some specific interpersonal problems or issues discussed include conflicts or disputes with others, anger at or disappointment in others, emotional or physical violence, inappropriate sexual interactions (e.g., unprotected sex, sex with a stranger, sexual promiscuity), involvement in relationships that are nonsupportive or characterized by lack of reciprocity, difficulty saying no or setting limits with others, and difficulty asking others for help or support.

7. Upsetting emotional states such as persistent anxiety, boredom, depression, loneliness, guilt, or shame: The use of cocaine or other substances offers an immediate escape or relief from unpleasant feelings, at least temporarily. Many group members are not used to managing distress or handling feelings while being drug free, so this is often difficult at first. Negative emotional states and the inability to manage them effectively account for the largest percent of relapses to substance use following a period of recovery (Daley and Marlatt 1997). Group members often benefit from learning basic emotional management skills such as being able to identify and recognize feelings, accept them, and learn to live with them without escaping to substance use.

8. Boredom with recovery and the feeling that life isn’t much better despite being off of drugs: Many cocaine dependent individuals like excitement, action, and “living on the edge.” Recovery is a major adjustment for them. It often is much less exciting than the feelings produced by cocaine use, wheeling and dealing on the streets, “getting over” on other people, and partying. Some members also experience boredom with relationships, their job, or other aspects of life.

9. Psychiatric disorders or other types of addictions: Psychiatric disorders are common among clients with cocaine addiction (Weiss and Collins 1992; Beeder and Millman 1997; Sterling et al. 1994). In some instances, group members will have comorbid psychiatric disorders, such as mood or anxiety disorders, that contribute to their difficulty with emotional states, interfere with recovery, cause personal distress, or contribute to suicidal feelings. Some members also have other addictions or excessive behaviors, such as compulsive gambling, sex, spending, or work habits. While the group is not intended as a therapy group for mental health disorders, psychiatric problems may be discussed in the context of recovery from addiction. The group counselor should encourage members with diagnosed psychiatric disorders to talk about their mental health problems or concerns with a mental health professional. However, if members are not in treatment, the group counselor should encourage them to get an appropriate evaluation to determine if psychiatric treatment is needed.

10. Other psychosocial problems related to school, work, housing, finances, the legal system, or how to structure leisure time may also be discussed in group sessions.

In addition to specific problems related to recovery or the lives of the group members, problems are also commonly encountered in the group process. These problems require the group counselor to intervene to make sure the group addresses them. Following is a discussion of some of the more common group process problems and suggested strategies for the group counselor to undertake:

1. A group member dominates the discussion or always brings the discussion back to his own problems or issues. The group counselor can thank the member for the contributions and then elicit opinions and experiences from other group members. If the group member persistently tries to dominate group discussions or always turns the discussion back to his own problems or issues, this behavior pattern can be pointed out by the group counselor to make this member and other group members aware of the behavior. The other members can be asked how they feel about the member’s dominating the discussion, and how they want to deal with this in a way that is satisfying to everyone in the group. Even though this creates a problem on one level, on another level some group members find that it creates a safety net for them because they may believe they don’t have to disclose personal problems or feelings as long as another member is taking up the group time.

2. A member does not disclose any problem or open up in the group session. The group counselor can share his observations about the member’s behavior and generalize the issues by asking group members to talk about difficulties that contribute to problems in self-disclosing (e.g., shame, shyness, social anxiety). Discussion can then focus on ways this member (or other group members who have trouble disclosing) can gradually learn to trust the group to disclose personal thoughts, feelings, problems, or concerns.

3. A member consistently rejects the input, advice, or feedback of other group members. The group counselor can point out this pattern and engage the group in a discussion of why this pattern is occurring. Members who offer help and support only to have their attempts rejected can be asked to talk about what this feels like so that the member who rejects their help is aware of the impact this behavior has on others.

4. A member can only pay attention when the discussion focuses on his problems, or he interrupts others when they talk. The group counselor can point out what he observes about the group member and discuss the reasons for this behavior. The group can then discuss the effects of this behavior (e.g., upsets other members, turns them off, makes them feel as if their problems aren’t important). The group can also discuss the importance of “giving and receiving” mutual support by listening to each other’s concerns and problems.

5. A member wants easy answers to problems or is quick to provide easy solutions to others when they discuss personal problems. The group counselor can share his observations of the behavioral patterns of this group member and ask the group to discuss the importance of taking responsibility for finding solutions to their problems and to identify more than one strategy to address a particular problem. The leader can emphasize that while there are many different ways to resolve specific problems, seldom are there easy or simple solutions, and that group members need time, patience, and persistence to adequately resolve problems. When a group member provides an easy solution, the group counselor can acknowledge that this is one strategy that may help some people, but it is also helpful to have other strategies. The group counselor can then engage the group in a discussion of other strategies to address the problem under discussion. Finally, the group counselor can emphasize that learning how to think about problem solving is just as important as dealing with specific problems because everyone in the group will continue to face problems in his or her ongoing recovery.

6. A member tries to engage the group counselor in individual therapy during the group session. The group counselor can ask other group members to comment on the problems or issues this member presents. If the group member asks the group counselor how to handle a specific problem, the counselor first can encourage the member to identify possible coping strategies, then ask other group members for their ideas for dealing with the problem.

7. A member arrives late for the group session or wants to leave during discussions. The leader and group members should develop a rule about arriving late for group sessions. Sometimes, there are legitimate reasons for being late (e.g., the bus a member takes was running 15 minutes late, the member got a flat tire, etc.). Members may be given a break once or twice for being late. However, the group may establish a rule that states that a member cannot join the group after a certain time (e.g., more than 10 minutes after the start of the group session). If time limits are not set, the group counselor can predict that some members will be late often. Members who are persistently late can be asked to discuss this pattern of behavior, how it is repeated in other areas of their lives, and what they think needs to be done to change this pattern. Group members should never leave a counseling session unless there is an emergency (e.g., they have a minor illness and need to use the restroom). Routinely allowing people to walk in and out disrupts the flow of the conversation and gives the message that what members say is not important. Members may want to leave group sessions because they are bored, feel like the discussions don’t relate to them, or want to avoid discussing their own problems or concerns.

8. The group talks in generalities and avoids exploring specific problems in depth. The group counselor can point out this dynamic to the group and ask members to discuss why they aren’t talking about specific problems or concerns in recovery. The counselor can ask members to set the agenda in a concrete way so that specific problems or concerns are identified for discussion. It isn’t uncommon for group members to view counseling groups as no different than free floating discussions held in some CA, NA, or AA meetings. However, Phase II group sessions are designed to explore and address problems and not simply be a repetition of 12-Step recovery meetings.

9. The group avoids confronting a member who behaves inappropriately. The group counselor can point out this dynamic and ask group members what they think about the inappropriate behavior and why they have avoided discussing it.
Other problems may occur during the group time, but those described above are some of the more commonly occurring ones. While the “content” (i.e., problems and issues discussed) of the group is important, if the “process” bogs down, not much will be accomplished. In addition, some group members may miss sessions or drop out as a result of group process problems that aren’t addressed. Unfortunately, group members may avoid bringing up the issues so the group counselor won’t always know the reasons for a member’s poor attendance or early drop out from the group. It is not uncommon for members to be upset over process issues. A “preventive” strategy is to periodically engage the group in a discussion of the group process. The group counselor can ask what members think about the group sessions, what they like and dislike about how the group has been going, and what changes they would like to see occur in the group.

One of the assessments used in the CCTS study was called “Reasons for Early Termination of Treatment.” This assessment aimed to find out specific reasons why clients left outpatient treatment before completing it. While clients gave numerous reasons for dropping out of the individual and group treatment conditions, the most common reasons they gave for dropping out of group treatment were:

• Time problems 42.7%
• Using cocaine again or wanting to use cocaine 30.7%
• Group sessions not helpful 30.7%
• Want a different treatment (individual) 30.7%
• Problems improved 18.7%
• Other unspecified reasons 18.7%
• Unwilling to participate in treatment 16.0%
• Needed hospitalization 13.3%

Clients who participated in group treatment were more likely to find that group sessions alone were not as helpful as group sessions combined with IDC, CT, or Supportive Expressive therapy. This reinforces the point that clients generally do not like to participate in group-only treatment. They both want and need individual sessions, so a combination treatment is preferable when possible.

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