Lecture Notes on Time-Limited Group Therapy

Time-Limited Group Therapy

• Group psychotherapy is a common treatment for substance abuse disorders.
• Group therapy involves meetings of two or more people for a therapeutic purpose or common goal.
• Differs from family therapy by creating open- and closed-ended groups of previously unknown individuals.
• Lessons are applied in the normal social network.
• Limited research on group therapy for substance abuse, but clinical evidence suggests a significant impact.
• Manual 8 (CSAT, 1994a) cites group therapy as the preferred modality.
• Offers individuals the chance to observe abuse progression in themselves and others.
• Provides opportunities to experience individual and collective success in a supportive environment.
• Curative factors (Yalom) include:
  • Instillation of hope.
  • Universality.
  • Insight development through relationships.
  • Support for substance-abusing clients and their recovery (Yalom, 1995).
• AA and NA recognize the importance of breaking isolation and connecting individuals with a shared goal.
• Time-limited group psychotherapy maximizes therapist and client treatment energies.
• Most client improvement occurs within 2-3 months (Garvin et al., 1976).
• Short-term therapy can be as effective as long-term therapy.
• Short-term group therapy is more goal-oriented, structured, and directive.
• Intensified through high-impact techniques like psychodrama.

Appropriateness of Group Therapy

• Groups can be beneficial for individuals with substance abuse problems.
• Groups for alcohol-dependent clients (Levine and Gallogly, 1985):
  • Reduce denial, process ambivalence, and facilitate acceptance of alcohol abuse.
  • Increase motivation for sobriety and other changes.
  • Treat emotional conditions (e.g., anxiety, depression, hostility).
  • Increase capacity to cope with situations that may precipitate drinking behavior.
  • Meet needs for social acceptance and support.
• Beneficial effects happen more easily in groups than in one-on-one therapy.
• Group members confront each other, do "reality checks," practice reflective listening, mirror each other, and help each other reframe issues.
• Individuals in earlier stages can witness later stage experiences, understanding where they could progress if they do not reduce their use.
• Group members can be more effective than therapists in confronting a participant who is not facing an important issue.
• Example: An angry member's ex-wife sent a bottle of whiskey with a note, "Dying to get together again."
• The supportive group listening that followed occurred largely without therapist involvement.

Group Therapy Approaches

• Time-limited group therapy has a spectrum of approaches.
• Two fundamental models define group interventions: process-sensitive and directive.
• Process-Sensitive Approach:
  • Direction from analytical theory.
  • Significant range of expression based on facilitator's theoretical base and leadership style.
  • Can examine the unconscious processes of the group as a whole to help individuals see themselves more clearly, offering the opportunity for change.
  • "Group-as-a-whole" approach exemplified by Bion (1961), who sees healing as an extension of the individuals within the group as the group comes to terms with a commonly shared anxiety.
  • Yalom's Interactional Group Process Model (Yalom, 1995):
    • Contrasts group-as-a-whole interventions.
    • Attends to relationships within the group.
    • Helps individuals understand themselves within the relational framework.
    • Provides individuals with significant information about how their behaviour affects others and how they are in turn affected by other members.
    • The leader is careful not to assume a Central role.
    • The group becomes the agent of change, with the leader supporting the process but not initiating it.
    • Attention is focused on the nature and growth of the relationships manifested in the "here and now" as the group takes place.
• Directive Approach:
  • Structured goals and therapist-directed interventions to enable individuals to change in desired ways.
  • Used to address major issues of concern for clients with substance abuse disorders and to facilitate self-discovery and growth through appropriately sequential activities.
  • The therapist is "central" and in charge.
  • Depends less for success on group members and their ability to create a cohesive sense of belonging.
  • Addresses specific agenda items in a logical order, with greater emphasis on content as the primary source of effective change, compared with the process-sensitive group (the cohesive power of the group as a primary curative factor).
  • Perhaps more likely to be effective with those in early recovery.
  • Rational Behavioural Training (RBT) (Maultsby, 1976):
    • A potent example of directive, time-limited group experience.
    • Developed by Maultsby and Ellis.
    • Cognitive-behavioural therapy that takes place over 13 weeks, one session per week.
    • Uses fundamental cognitive-behavioural interventions and the clients' growing awareness of their ability to control their own belief systems and self-talk and thus control their affective states.
    • Clients are asked to share homework assignments and bring real-life situations into the group for exploration and examination.
    • Little effort in this group modality to analyse or direct energy to the relationships within the room.
    • Affords a short-term intervention to develop the client's skill in controlling emotions.
    • The inference is that individuals who experience their emotional world as controllable will no longer need to use substances to exert "external" control.
• Relationships are formed and process issues are experienced in any kind of group therapy.
• Even within the context of a cognitive-behavioural approach such as RBT (more educational than therapeutic), issues of process invariably arise.
• The experienced therapist can use the relationships within the group, even in a psychoeducational framework, to support and enhance the treatment experience.
• The group facilitator should help connect members to members.
• When shared histories are acknowledged, the sense of belonging is increased, and greater cohesion takes place.
• Cohesion is an important motivator for many clients because of the very nature of substance abuse disorders.
• Significant debate within the field regarding the pros and cons of heterogeneous and homogeneous groups.
  • Heterogeneous groups offer greater complexity and more opportunities for a wide range of relationships, which can be extremely helpful to many clients.
  • Homogeneous groups, particularly when composed of clients with substance abuse disorders, tend to lend themselves more quickly to issues of cohesion and safety.
  • Homogeneity has particular utility in the time-limited group.
• Bonding occurs around its history of substance abuse rather than its commitment to recovery in a homogeneous substance abuse disorder group.
• The focus must include issues of living within the context of the group.
• Through modelling and gentle persuasion, the group facilitator can broaden the scope of a substance abuse treatment group to include relationships, concerns about daily living, and newly discovered personal integrity.
• The movement from "what is wrong with us" to "how do we build better lives?" is an important transition in the time-limited group, whether psychoeducational or process sensitive.
• Group therapy can be conducted within the context of almost any theoretical framework familiar to the therapist and appropriate to group goals.
• Often the therapist will work with two or more models at the same time.
• The theoretical bases supporting both process-sensitive groups and a more directive style can be combined effectively to address substance-abusing clients.

Theories of Group Therapy

The group therapy models discussed are:

• Brief cognitive group therapy
• Cognitive-behavioural group therapy
• Strategic/interactional therapy
• Brief group humanistic and existential therapies
• Group psychodynamic therapy
• Modified dynamic group therapy (MDGT)
• Modified interactional group process (MIGP)

The first five models are summarized below and discussed in Chapters 4 through 7 of the manual. MIGP, considered a highly effective type of brief group treatment for substance abusers, is discussed in detail in this section. The 11 therapeutic factors identified by Yalom as the basis of successful group therapy are presented at the end of this section (Yalom, 1995).

Brief Cognitive Group Therapy

• Cognitive techniques work well in group therapy.
• The group is taught the basics of the cognitive approach.
• Individual members take turns presenting an event or situation that tempted them to abuse substances.
• Other members assist the therapist in asking for more information about the client's thoughts on the event and how it did or did not lead to substance abuse (or to negative feelings that might have led to use).
• Finally, the group members provide the client with alternative ways of viewing the situation.
• Chapter 4 discusses brief cognitive therapy in more depth.

Cognitive-Behavioral Group Therapy

• The cognitive-behavioral approach focuses the group's attention on self-defeating beliefs.
• The group members are relied upon to identify such beliefs in each other.
• The therapist encourages group members to apply behavioural techniques such as homework and visualization, to help participants think, feel, and behave differently.
• Chapter 4 discusses brief cognitive-behavioral therapy in more depth.

Strategic/Interactional Therapies

• The strategic therapist uses techniques similar to those used in family therapy to challenge each group member to examine ineffective attempted solutions.
• The therapist encourages group members to evaluate and process these attempted solutions and recognize when they are not working, then engages the group in generating alternative solutions.
• The therapist also works, where appropriate, to change group members' perceptions of problems and help them understand what is happening to them.
• Typically, the therapist guides the process, while members offer suggestions and encouragement to each other as they identify and implement effective solutions.
• To address the problem of substance abuse, the group will often be directed to examine problems that might result in substance abuse and reframe their perceptions of these problems.
• The principles of solution-focused therapy are the same for group treatment as for individual therapy.
• These include client goal-setting through the use of the "miracle" question, use of scaling questions to monitor progress, and identification of successful strategies that work for each client. (These techniques are defined in Chapter 5 of this manual.)
• The therapist works to create a group culture and dynamic that encourages and supports group members by affirming their successes.
• At the same time, the therapist works to restrain client digressions ("war stories") and personal attacks.
• The therapist tries to challenge group members--all of whom, unlike in family therapy, are seen as "customers"--to take action to create positive change.
• Chapter 5 discusses brief strategic/interactional therapies in more depth.

Brief Group Humanistic and Existential Therapies

• Several approaches fall within this category.

• The transpersonal approach is useful in meditation, stress reduction, and relaxation therapy groups and can be adapted for clients who have substance abuse disorders.

• In dealing with issues of religion or spirituality, it is helpful to have other people talk about their perspectives.

• In this way, past degrading or punitive experiences related to organized religion can be redefined in a more meaningful and useful context.

• Gestalt therapy in groups allows for more comprehensive integration in that each group member can provide a piece of shared personal experience.

• Each group member plays a role in creating the group, and all of their perceptions must be taken into account in making a change.

• Role-playing and dream analysis in groups are practical and relevant exercises that can help clients come to terms with themselves.

• One of the most influential contemporary experts on group therapy, Irvin D. Yalom, considers himself an existentialist because he is not concerned with past behaviour except as it influences the "here and now."

• A summary of his existential approach is presented in The Yalom Reader (Yalom, 1997) and consists of three sections:

  • (1) therapeutic factors in group therapy,
  • (2) a description of the "here and now" core concept,
  • (3) therapy with specialized groups, including a chapter on group therapy and alcoholism.

• This last chapter details specific techniques to diminish anxiety but still permit the group to maintain an interactional focus--for example, writing a candid summary of the session and mailing it to members before the next meeting.

• Yalom has worked closely with the National Institute on Alcohol Abuse and Alcoholism to apply basic principles of group therapy to alcohol abusers, and his ideas are applicable to those with other substance abuse disorders as well.

• See Chapter 6 for more discussion of humanistic and existential therapies.

Group Psychodynamic Therapy

• Group psychodynamic therapy enables the group itself to become both the context and means of change through which its members stimulate each other to support, strengthen, or change attitudes, feelings, relationships, thinking, and behaviour--with the assistance of the therapist.
• The context sought is one in which the group becomes an influential reference group for the individual.
• Participation of members according to their abilities leads to some degree of involvement of each in pursuing individual and group goals.
• The process of goal-setting and clarification for expectation provides an agreed upon framework for meeting of mutual needs.
• This, in turn, contributes to the building of cohesive forces (Roberts and Northen, 1976, p. 141).
• Chapter 7 discusses psychodynamic therapy in more depth.

Modified Dynamic Group Therapy

• On the basis of psychodynamic theory, a modified dynamic group therapy approach was defined for substance-abusing clients (Khantzian et al., 1990).

• Viewing substance abuse disorders as an expression of ego dysfunction, affect dysregulation, failure of self-care, and dysfunctional interpersonal relationships, MDGT falls in the intermediate length of time-limited group psychotherapy, with its basic structure defined by two meetings per week over a 26-week format.

• Based primarily on interventions to address cocaine addicts, MDGT focuses energy on the individuals within the group and conceptualizes the basic origins of substance abuse disorders as expressions of vulnerabilities within the characterological makeup of the client (Khantzian et al., 1990).

• As a supportive, expressive group experience, MDGT provides substance-abusing clients the opportunity to evaluate and change their vulnerabilities in four primary areas:

  • (1) accessing, tolerating, and regulating feelings;
  • (2) problems with relationships;
  • (3) self-care failures;
  • (4) self-esteem deficits.

• Congruent with this understanding of the origins of substance abuse, MDGP emphasizes safety, comfort, and control within the group context.

• Group facilitation is defined primarily by the therapist's ability to engage and retain substance abusers in treatment by providing structure, continuity, and activity in an empathic atmosphere.

• This supportive approach creates an atmosphere of safety, allowing the client to move away from the safety of the known behaviour associated with substance abuse and into the less known world of recovery.

• As in other group experiences, this group theory encourages issues of universality as a means of overcoming isolation, while at the same time dealing with a common shame so often encountered in the substance-abusing client.

• Unlike interpersonally focused process groups, which look more at relational concerns, MDGT places greater emphasis on the clients' growing understanding of their characterological difficulties and/or deficits, not entirely dissimilar to issues identified in self-help groups such as AA and NA.

Modified Interactional Group Process

• Time-limited MIGP is a synthesis of the work of several theorists (Flores, 1988; Khantzian et al., 1990; MacKenzie, 1990; Yalom, 1995).
• MIGP is distinguished in a variety of ways from the psychoeducational groups so important in substance abuse treatment.
• Referenced in Manual 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT, 1994a).
• Both process-sensitive and psychoeducational group learning experiences are often necessary for the substance-abusing client.
• Even in a short-term, intensive treatment experience, combining a psychoeducational and a process group has significant clinical impact.
• The psychoeducational group is more directive, with the therapist as the central figure.
• It is important to utilize the energy of group process itself, even in a psychoeducational format, to enable clients to make connections and build relationships that will support their recovery.
• The features that distinguish MIGP from a more traditional interactive process are the greater activity of the leader and the sensitivity to the development of a safe atmosphere that allows group members to examine relational issues without excessive emotional contagion.
• The atmosphere of safety is greatly enhanced by the therapist's adherence to group agreements or group norms and by the continued reinforcement of these agreements throughout the group process.
• The importance of confidentiality, the group's accepting responsibility for itself, and self-disclosure are all supported by the facilitator.
• Procedural agreements, including beginning and ending the group session on time and ensuring that each member has a place within the circle, with absences addressed, are part of the development of the safe environment.
• In this process, the therapist helps the clients recognize that they are the primary change agents.
• The group becomes a safe place both to give and to receive support.
• Groups tend to be confrontational, MIGP is far more supportive.
• Denial and other defence mechanisms become more rigid when a person is attacked.
• Group members are encouraged to support one another and look for areas of commonality rather than use more shame-based interactive styles that attempt to "break through denial."

Intellectualisation and MIGP

• Many therapists are told that clients should get in touch with their feelings and experience "what is in their gut."
• Awareness of the affective life is important to everyone.
• Regulation of emotions is essential for many substance-abusing clients in addressing difficulty.
• Emotional exploration is encouraged within the context of MIGP; the facilitator is constantly monitoring the affective energy within the group.
• The therapist is taking steps to break emotional contagion should it begin.
• In a particularly intense group experience, the therapist may ask the group as a whole to take a step back and look at what just took place.
• The group not only learns from its shared life but also experiences its ability to control intense emotional responses.
• This consistent effort to reduce high levels of anxiety or emotional catharsis and to prevent them from dominating the group is another hallmark of MIGP.

General issues in MIGP

• Following the insights of Flores and Mahon, MIGP focuses special attention in four areas of the client's life: gratification and support, vulnerability of self, regulation of affect, and self-care (Flores and Mahon, 1993).
• These four areas receive particular attention because they represent areas of vulnerability within the substance-abusing client that can easily lead to relapse and undermine recovery.

Gratification and support

• Many clients come to treatment with profound issues of guilt and shame.
• They lack the ability to give themselves gratification and support in the face of change.
• The active leadership style of MIGP allows group members to openly support one another and at the same time provides each group member with attention from the leader that leads to higher levels of gratification.
• Affirming group members' willingness to share and support one another is an essential ingredient in time-limited group work.
• It creates a positive atmosphere and increases levels of safety and cohesiveness, which further supports the change process.

Vulnerability of self

• Substance-abusing clients often enter treatment with shattered self-esteem.
• Defending against this internal vulnerability can become damaging, because clients project their fears onto others.
• They may try to hide internal vulnerability by appearing hostile and overly self-confident.
• An atmosphere of safety and empathy enables clients with profound vulnerabilities to enter the process of self-disclosure, through which they become accessible not only to the group but also to themselves.
• The group facilitator actively encourages such self-disclosure but at the same time emphasizes that individual members need not disclose any issue they are not yet ready to discuss.
• Clear boundaries and clear group agreements further support the possibility for self-disclosure.

Regulation of affect

• Substance abuse disorders can be perceived as the consequences of trying to control one's emotional life with external substances.
• This points to a failure of internal regulation that makes the client uncomfortable when feeling emotions that others might consider commonplace.
• Issues of grief, loss, sadness, and joy can be so affectively charged and linked to the client's past alcohol and drug use that they threaten the client's continued recovery.
• The leader's sensitivity to the levels of affective energy in the group is particularly important.
• Supporting group members to both feel what they are experiencing and at the same time move to a safer and more objective viewpoint regarding those feelings is inherent in MIGP.

Self-care

• Substance-abusing clients often present to treatment unaware of internal stresses and pain, having lost sensitivity to physical cues that lead others to the normal self-care functions of daily living.
• These functions may be as simple as basic hygiene or more complex in terms of boundary setting and relational definitions.
• Setting boundaries within the group and encouraging heightened sensitivity to self-care are ways in which MIGP addresses this issue.
• Clients must hear a consistent message that they are worthy of the group's support and, therefore, worthy of their own attention in regard to self-care.
• All of the above can comfortably be addressed within the context of MIGP, with the leader actively connecting members to members, who support one another on the importance of self-monitoring and care.

Use of Psychodrama Techniques in a Group Setting

• Psychodrama has long been effectively used with the substance-abusing client population in a group setting.
• Wegscheider-Cruse effectively integrated psychodrama as a means to heal family-of-origin issues within the context of addictive behaviours (Wegscheider-Cruse, 1989).
• The utility of such an intervention seems to be clinically well established.
• The techniques can help the group move more quickly in terms of self-understanding and relational awareness.
• The insights gained from the experience of family sculpting (illustrated below) can be worthwhile and potent.
• Psychodrama and other similar expressive therapeutic interventions bring with them a clinical potency that needs to be understood.
• These interventions can raise anxiety and shame to the point where some clients may be pushed toward relapse or even feel the need to leave treatment to escape the internal conflicts encountered.
• As with any therapeutic technique, therapists should not utilize such techniques unless they are thoroughly trained and well supervised.
• Any intervention that has a powerful potential for growth almost always has an equal potential for damage if poorly conducted.
• Training and appropriate supervision are particularly important with expressive techniques because of their clinical potency.
• Psychodrama can be used with different models of group therapy.
• It offers persons with substance abuse disorders an opportunity to better understand past and present experiences--and how past experiences influence their present lives.
• This approach encourages clients to relearn forgotten skills, imaginatively change apparent problems that block progress, rehearse new behaviours, practice empathy, and expand their emotional range by confronting feelings that have never been properly dealt with.
• As clients act, important concepts become real, internalized, and operational that might otherwise be purely theoretical.
• Changes experienced through acting become accessible to the psyche as part of the lived history of the individual.
• Some therapists use psychodrama to help transform internal dynamics that maintain old patterns relevant to substance abuse.
• For example, one therapist invites group members to list "rules" in their family of origin.
• These rules may be related to substance abuse (e.g., "Don't ever say that Mother is drunk. She is taking a nap.").
• After a client describes a situation in which the rule would be invoked, he assigns family roles to other participants, giving them instructions for how they would behave in this situation.
• The client is encouraged to break the rule--in the case of the "napping" mother, by insisting on bringing the truth into the open--with the verbal encouragement of all remaining group members who are not playing assigned roles.
• The client's victory--which can be a transformative, powerful experience--is celebrated as the achievement it is.
• In this example, the individual experiences himself as a powerful truth-speaker rather than the powerless and voiceless participant he perceived himself to be in the past.
• This new experience can enhance his sense of self-efficacy and help foster change in his own pattern of substance abuse.
• In another example of psychodrama, group participants explore "character defects" such as grandiosity or isolation associated with their pattern of substance abuse.
• The defects are dramatized, with half the group engaged in the dramatization and half sitting as an audience.
• For example, persons who experience themselves as isolated sit in the corner or under a table with a "sponsor."
• The therapist gives them sentences to complete, such as, "I like this corner because…" or "The first time I remember isolating is…"
• Finally, they are asked to complete the sentence, "I have to get out of this corner because…"
• The sponsors then gather in a circle and invite the persons they have been supporting to join them, saying, "I want you to join this circle because…"
• This experience of connection often enhances participants' motivation and ability to change.
• A common use of psychodrama in treatment for substance abuse disorders is "sculpting" family members in typical roles and enacting significant situations related to substance abuse patterns.
• In this process, developed by Papp, family members enact a scene to graphically depict the problem (Papp, 1977, 1983).
• The physical arrangement of the family members illustrates emotional relationships and conflicts within the family.
• For example, a family may naturally break up into a triad of the mother, sister, and brother, and a dyad of the father and another sibling.
• In that case, the therapist might highlight the fact that the mother and father communicate through one of their children and never talk to each other directly.
• In yet another form of psychodrama, one person in the group may be asked to give voice to different aspects of her own self that either help maintain dependency or speak for change (sometimes called the "disease" and "recovery" selves).
• The client might speak from a different chair or position for each of these voices.
• The intensity of psychodrama often helps compensate for the shorter time span now commonly funded for treatment.
• Although many participants express concern about acting, the barrier of shyness often drops completely as they enter the process with the assistance of a dynamic and committed facilitator.

Therapeutic Factors

• In his classic work, Theory and Practice of Group Psychotherapy, Irvin Yalom identified 11 primary "therapeutic factors" in group therapy (Yalom, 1995).
• Each of these factors has particular importance for clients with substance abuse disorders and can be used to help explain why a group works in a particular way for this client population.
• These curative factors are present in all group interventions and are listed below.

Instillation of Hope

• Many clients come to a treatment setting feeling defeated by life and overwhelmed by their failure to control their use of substances.
• They feel they have nowhere to go and no possibility for a better outcome in life.
• When individuals with this life view join a group of people struggling with similar problems, they have the remarkable opportunity of witnessing change in others, while at the same time having their own small victories acknowledged and celebrated by group members.
• Through this process, hope begins to emerge.
• The energy of hope and the focused attention on this curative factor receive specific attention in the MIGP model.
• A variety of exercises can be utilized to further instil hope within substance-abusing clients.
• Clients can be asked to participate in a visualization exercise where they see themselves in a life without substance use, envisioning particularly how life would be different and better under such circumstances.
• The group energy fuels this experience and adds the intensity of other clients' support.
• As with all "guided imagery exercises," the group leader must move with caution.
• Many substance-abusing clients may not have a picture of life without substances, and consequently such an exercise can be humiliating if not handled sensitively.
• If the client is unable to visualize, he once again perceives failure.
• To guard against such potential shaming, the group facilitator can take an active role in the creation of the image, monitoring it for issues of safety with all members of the group as the exercise develops.

Universality

• Substance abuse disorders tend to impede relationships and force clients into increased isolation.
• In a brief group experience, the clients encounter other individuals who have faced similar problems.
• They become aware that they are not alone in life and can feel tremendous satisfaction in this connection.
• The sense that their pain is not exclusive or unique and that others with similar problems are willing to support them can be profoundly healing.
• It helps clients move beyond their isolation, and it gives further energy to hope, which helps to fuel the change process.

Imparting Information

• The inevitable exchange of information in a group setting helps members get from one day to the next.
• Particularly in conjunction with formal psychoeducational groups, MIGP affords group members the opportunity to reflect on what they have learned and at the same time apply that learning within the group setting.
• The information shared is personal and tends to be experienced as motivational.
• The client struggling with issues of substance abuse can hear from others how they have dealt with difficult concerns and how they have experienced success.
• This mutually shared success gives positive energy to the group and encourages change.

Altruism

• Fundamental to the human condition is the desire to help others when they are in trouble.
• Clients struggling with substance abuse disorders tend to be focused on their own difficulties and have a hard time reaching out to help those in need.
• Group therapy offers the members opportunities to provide assistance and insight to one another.
• Particularly within the model of MIGP, the facilitator pays great attention to altruistic moves on the part of members.
• They are celebrated and acknowledged.
• As individuals recognize that they have something of value to give their fellow group members, their self-esteem rises as change and self-efficacy are supported.

Corrective Recapitulation of the Primary Family Group

• This therapeutic factor pertains to the importance of relationships within the client's family of origin, which invariably finds expression within the group experience.
• "Recapitulation of the family group" happens when a client--both consciously and unconsciously--relates to another group member as if that person is a member of his family of origin with whom he has struggled in the past.
• This occurrence is clearly a projection, but it can be identified by the leader, and both group members involved can benefit as they investigate new ways of relating that break the old dysfunctional patterns of the family of origin.
• In a way, the group begins to serve as a substitute family.
• The group members are the siblings, and the group facilitator is in a parental role.
• Even in a time-limited group, issues of transference and countertransference may require attention.
• However, MIGP tends to dilute the transference by "spreading it throughout the group" rather than concentrating it within the dyadic counselling relationship.

Development of Socialising Techniques

• Many substance abusers are "field-sensitive" or "field-dependent" individuals who are keenly conscious of the network of specific relationships as opposed to principles or generalizations that apply regardless of context.
• Group therapy can take advantage of this trait and use the energy of the relationships to facilitate change.
• As participants engage in relationships, they learn new social skills that can help them break through their isolation and connect with others in more meaningful ways.
• They also learn how to disconnect, which is equally important given the anxieties often associated with relational loss and grief.
• The group facilitator may at times deliberately focus on these social skills through role-playing or modelling exercises within the context of the group itself.
• The healing takes place as the clients take what they have learned and experienced in group and actively generalize it in their lives outside of the group.

Imitative Behaviours

• Imitative behaviours are an important source of learning in group therapy.
• The process of modelling can be particularly important as clients learn new ways to handle difficult emotions without resorting to violence or drug use.
• Therapists must be acutely sensitive to the important role they play within this context; clients often look to the therapist to model new behaviours as they encounter new situations within the group context.
• Group members can also learn by imitating other members who are successfully dealing with difficult relational issues.
• It is helpful for a new group member to witness an ongoing group where people are confronting their problems appropriately, moving beyond old dysfunctional patterns, and forming new relationships that support change.
• The group becomes a living demonstration of these new behaviours, which facilitates and supports insight and change.

Interpersonal Learning

• Groups provide an opportunity for members to learn about relationships and intimacy.
• The group itself is a laboratory where group members can, perhaps for the first time, honestly communicate with individuals who will support them and provide them with respectful feedback.
• This interpersonal learning is facilitated by the MIGP model, in that special attention is given to relational issues within the context of the group.

Group Cohesiveness

• Often misunderstood, group cohesion is a sense of belonging that defines the individual not only in relation to herself but also to the group.
• It is a powerful feeling that one has meaning in relationships and that one is valued.
• Development of group cohesion is particularly important in the MIGP model, so that group members feel safe enough to take the risks of self-disclosure and change.
• The experience of belonging is both nurturing and empowering.

Catharsis

• Sometimes group participants will gain a sudden insight through interaction with others, which can cause a significant internal shift in the way they respond to life.
• Such insights may be accompanied by bursts of emotion that release pain or anger associated with old psychological wounds.
• This process happens more easily in a group where cohesion has been developed and where the therapist can facilitate a safe environment in which emotions can be freely shared.
• It is important to recognize, however, that although catharsis is a genuine expression, it is not seen as curative in and of itself.
• High levels of emotional exchange not addressed in the group can become potential relapse triggers, which endanger the success of individual members.
• The therapist acknowledges the powerful emotions after the member has shared them but asks the group as well as the member to give those emotions meaning and context within the group.
• Thus, both the experience of the emotion and the understanding of how that emotion either interferes or supports relationships are healing.

Existential Factors

• Existential factors of loss and death are often issues of great discomfort in the substance-abusing population.
• The brevity of a time-limited group experience forces these issues to the surface and allows members to discuss them openly in a safe environment.
• Time itself represents loss and also serves as a motivator, as the members face the ending of each group session and of the group treatment experience.
• As they become more aware of the frustrations of reality and the limits they face, clients can receive support from the group in accepting "life on life's terms" instead of their past patterns of escape.

Using Time-Limited Group Therapy

• The focus of time-limited therapeutic groups varies a great deal according to the model chosen by the therapist.
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