Group treatment agreements: amplifying the therapeutic

As much as anything characterizing group treatment, the constant rehearsal of group agreements before each session can powerfully influence group members. Installing value and purpose into the agreements becomes essential. Yet this emphasis generally means centering the agreements on fortifying structure, creating a sense of safety, setting a particular tone, and articulating expectations that shape social norms as a means to “keep the peace.” To that end, the agreements may fulfill one goal but simultaneously lose their therapeutic luster and durability.

In this case, several things might happen: 1) the group agreements fail to engage members therapeutically as they hear instruction on what is not allowed; 2) mere lip service is given to the group agreements in a round-robin reading exercise before the start of each session; 3) the agreements fail to incorporate lessons on delayed gratification and other features that group members can apply outside of the session. In essence, the group agreements may not offer significant explanation of the value in practicing certain behaviors.

This article aims to enhance the therapeutic value of group agreements by proposing elements that can be added to an existing foundation. We present a set of group agreements and rationales, albeit without a “crowning touch” as the agreements continue to be a work in progress. These agreements apply specifically to a court-mandated subpopulation in an outpatient setting with revolving-door membership.

Before introducing the group agreements, we intend to engage discussion on the question of why these are called “agreements” and not rules, responsibilities, or guidelines. Arguably, what the group agreements are called matters.

Rules

Beneath the surface, for a broad subset of court-mandated individuals the conceptual window is restricted as to what rules mean. Because rules intone punishment or consequence for rule breaking, the word would seem to conjure images of authority, probation officers, authoritarian parents, etc. This generates a set of corresponding thoughts, not the least of which is, “Oh, here we go with the rules…power-trippin’ time!”

For the court-mandated, regardless of how the rules are phrased, the word is fused with such negative connotations that it might as well sit as an ingredient in a powder keg. Rules yield a perception that smacks of authority, control and order, which is further reinforced by the way in which the rules might come across in circular reasoning (e.g., “There is no eating in the group room.“ Why? “Because, well, it’s the rule”). Depending on the group member’s personal history with rules, this can also implicitly induce counter-transference. Once that happens, it can trigger the tendency to incite the very “discord” and “sustain talk” (“resistant” behaviors)1 it tries to avert.

Responsibilities

Simply resorting to calling every item on a laundry list “your responsibility” also can be counterproductive. Christening each item as a responsibility offers a weak explanation for why some items should be honored. Hearing this relied on over and over again might become too overwhelming and personally deflating, if every time a group agreement is not followed the person is overtly or covertly called out as irresponsible.

Guidelines

The word “guideline” may invoke the image of a guidepost that a hiker on a trail might commonly see that assists him in staying on the well-trodden path. A more exaggerated image is that of a lifeguard who throws a drowning swimmer a guideline to buoy and reel him/her to safety. Applying that image to group work makes it difficult to see the therapeutic value inherent in guidelines. Guidelines can more loosely come across as “negotiable rules” that apply to any situation, leaving the door wide open to bargaining. Therein lies the problem with guidelines: The term (along with substitute terms such as “expectations”) seems a bit too ambiguous for the group treatment setting.

Group agreements

Although the term “agreement” presupposes that members already have given consent, the group facilitator inevitably cannot go too long before hearing, “I didn’t agree to that group agreement.” When a member objects to honoring any one of the group agreements, the member in effect has cast his/her vote not to participate in the group session as part of the social contract (the group’s agreed-upon structure or protocol) among members.

Here is our set of group agreements and rationales:

1. To practice our “kuleana” (responsibility) to each other, we agree to be on time for all our sessions. We also agree to communicate, by phone, any unexpected delays that might prevent us from being on time. We understand and agree that if the group has started and the group room door is closed, we sit in the waiting area to complete our self-assessment sheets until the door opens at the break.

Rationale: In the real world, timeliness and tardiness each garner different outcomes. This comes to life in group agreement number 1.

2. To practice preparedness, we agree to come to class well-rested, well-nourished with an empty bladder, free from drugs and alcohol, well-supplied with completed assignments, notes from previous sessions, a pen, and ready to share and learn with each other.

Rationale: As in life, preparedness usually improves the experience. Coming to sessions prepared increases the likelihood of an enhanced session experience.

3. In practicing mindfulness and being fully present in the moment, we agree to deposit all our personal items in the space designated by the facilitator. We agree and appreciate the value of eliminating all distractions by keeping our bags, backpacks, purses, etc., in that designated area. We especially agree and understand the value of powering our electronic devices off and placing them in the box designated for such items.

Rationale: While other areas of life might be more challenging to practice mindfulness and being fully present, by practicing and honoring this in the group session room, clients are able to see and experience the absolute possibility of weaving this into real life.

4. In practicing delayed gratification, we agree to leave all food items outside the group room and to limit any beverages to water only (in a clear container).

Rationale: This increases the value or need of group agreement number 2’s call for preparedness. It also serves group agreement number 3’s call for eliminating distractions, which includes the wrapping and unwrapping of food items during group sessions.

5. In practicing more delayed gratification, we agree to raise our hands and wait to be called on before offering our answers or our feedback.

Rationale: While practicing delayed gratification, this group agreement also offers exercise and practice in patience and tolerance. Depending on the social dynamics, group activity and productivity of group work, the pace of interaction can be facilitated by going “around the horn” taking turns or by using a more loosely structured “popcorn” style interaction. The group facilitator might say, “OK, for this activity we’ll spend the next 15 minutes taking turns as we go around the table sharing our thoughts and personal examples.” Providing opportunities for group members to interact with one another without raising their hand allows members and the facilitator to gauge and examine their practice of delayed gratification, and in turn to gain useful insight.

6. In practicing mindfulness and empathy, we agree to give our full attention to those speaking and allow them to complete their thoughts, their feelings and their statements before raising our hands to offer feedback.

Rationale: Beyond the practice of delaying gratification, practicing the communication skill of listening allows one to learn and increases one’s capacity for a meaningful response.

7. In practicing improved communication skills, we agree to use “I” statements when appropriate and make eye contact with those we are speaking to. We also agree to stay on the topic and offer only positive solutions.

Rationale: With the use of “I” statements, the likelihood of being heard is increased since many clients report feeling defensive when hearing a sentence that starts with the word “you.” The word “you” is usually followed by the word “should.” Many clients report being tired of being told what they should do. Using “I” statements also asks clients to find their part in any situation they are reflecting on. Example: “This relationships sucks” suggests that the relationship needs to change, vs. “I haven’t yet found much pleasure in this relationship” suggesting that I have work to do or decisions to make about remaining in a relationship that I’m not finding pleasure in.

8. In practicing pro-social behaviors, we agree to eliminate the use of aggressive, demeaning or devaluing language or behaviors.

Rationale: This agreement serves to increase the feeling of care and safety among group members. It also serves to practice new ways of communicating that focus on supporting each other rather than judging each other.

9. In building and practicing empathy and healthy boundaries and honoring the confidentiality of our own group, we agree to limit our own discussions about treatment with friends or family to what we have learned about our selves or about positive relapse-preventing solutions.

Rationale: This agreement also serves to increase the feeling of trust and safety among members while still encouraging members to discuss what they’ve learned about themselves with friends and family members. It serves as a practice of honoring boundaries as well.

10. To practice delayed gratification, we agree to remain in group until the group is dismissed by the facilitator, which is at break and at the end of the day’s session. This practice of delayed gratification is supported by our practice of preparedness in emptying our bladder before entering group room.

Rationale: This supports agreement number 3’s call to be fully present while also practicing real life’s demands of completing things we start.

11. In further practicing kuleana and laulima (collective help), we agree always to leave our group room better than we found it, and to ensure that, we agree to work together (by signing up on the kuleana chart) in cleaning our group room at the end of every week.

Rationale: This supports the practice of pro-social attitudes of cooperation and responsibility for self and community.

Conclusion

The group agreements are absorbed into the group identity and are read and explained to newcomers in the group by the existing members who seem to take more ownership with the language as written. This ownership invites new clients to be a part of the group conscience with new practices. For example, it is not atypical to find that the group has elected to postpone its designated break time in favor of remaining in group in order to finish an assignment in the name of “We want to practice delayed gratification.”

In our experience, we have observed that it really doesn't take long for new clients to be practicing the new behaviors and using and enacting the language structured into the group agreements. The group agreements offer:

• A gentle prodding but persistent therapeutic nudging.

• A constructive layer of richness to the conversation of “keeping the peace.”

• An educational tool in group session that encourage practice of new behavior.

• A source of building up a recovery identity.

• Multi-dimensional focus on behavioral change.

Group agreements serve as a crucible for creating a safe, predictable and structured space that facilitates the therapeutic processes of a group session. Amplifying group treatment agreements as a therapeutic factor entails incorporating lessons on mindfulness, delayed gratification, etc., that become an artifact of group work and build a sound rationale for such practices.

Izaak L. Williams, a Hawaii state-certified substance abuse counselor, conducts research in the field of addiction and facilitates group counseling at Ho‘omau Ke Ola on the island of Oahu. He was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment's Behavioral Health Leadership Development Program. His e-mail address is izaakw@hawaii.edu. Lorrain Burgess, CSAC, has been working in Hawaii's substance abuse treatment industry since 2006, working mostly with court-referred clients.

References

Miller WR, Rollnick S. Motivational Interviewing: Helping People Change (3rd edition). New York City: The Guilford Press; 2013.