Interventions for keeping groups running smoothly

Our previous article outlined the nuts and bolts of 11 group agreements, with commentary intended to enhance the therapeutic value of group work.1 This article offers interventions for addressing challenging behaviors by group members that can dishonor those group agreements. Some amount of overlap exists among the interventions for these nine group-challenging behaviors:

1. Returning from break with food items on the table, beverages other than water placed on the floor underneath the table, cell phone in possession, or holding other items not allowed because of the distractions they create.

The group facilitator might say, “OK, it looks like our break time is up, but before we start everyone go ahead and do a self check-in. Ask yourself, ‘Am I honoring the group agreements?’” This allows group members to assume ownership of knowing what the group agreements are, to take responsibility for being more mindful of the agreements, and to engage in self-correcting behaviors. Members typically will catch themselves dishonoring the group’s agreed-upon protocol; those who don’t are usually caught and corrected by other members honoring the group norms.

A sign at the entrance of the room where we meet states, “Please leave food or beverages other than water outside group room.” Under the sign is a trash can and table to accommodate a holding place for such items until the end of the session. If this is unnoticed or not honored, the facilitator makes a verbal request to honor the message if other members of the group have not already brought it forward.

2. Cross-talking.

When necessary, the facilitator simply stops all activity to bring awareness to cross-talking. Once the session is paused, the group facilitator could directly ask one of the cross-talkers to explain to the group the message they are sending by speaking over others or speaking out of turn. This provokes reflection and prompts those engaging in cross-talking to comment on its impact.

Those who are speaking over others might say something along the lines of, “I wasn’t listening,” or “I felt that what I had to say directly addressed something someone else was saying and had to say it when I did.” The facilitator should take this input and help guide it to a productive place for the group.

It also is important to ask group members to offer their interpretations of cross-talking to help them understand the varied meanings that inform the behavior, regardless of the cross-talker's intent. This powerful intervention holds group members accountable for their behavior. Group members might construe cross-talking as indicating that the cross-talker does not care, believes what he/she has to say is more important, or lacks empathy.

This is probably one of the most effective ways to eliminate this distraction long-term, as members provide feedback and offer comments on how they are affected by cross-talking; as cross-talkers learn how their behavior shapes the group’s opinion of them; and as cross-talkers become increasingly aware of their behavior by reflecting on the group’s reactions, ultimately taking a deeper look at their behavior.2 The session is then less likely to return to cross-talking.

3. Getting up and leaving the group session.

We have not yet encountered a client leaving without first asking the facilitator or the group to understand their desire to leave. But what we might suggest is that anyone who leaves be allowed to experience whatever outcomes a missed session generates. The group facilitator also might say, “All behavior carries with it pleasure, cost and benefits.” Asking the member what those are and leaving it at that usually suffices to get the member to reconsider whether leaving is worth it.

4. Packing up before the session ends (sometimes as much as 15 minutes early).

The group facilitator can engage the entire group in a mindfulness activity that is fruitful for delivering the message that leaving early dishonors the group.

The facilitator begins the exercise by inviting the group to play a game. This usually will grab the group’s attention. Tell members to sit silently with their eyes closed for the next minute and instruct each person to raise his/her hand at the point when 60 seconds have passed on the clock. The aim of the game is to see who can produce the most accurate prediction. The group facilitator times the exercise, recording the time at which each member raises his/her hand to guess.3 When time is up, check in with members to see what they learned and felt. This brief group intervention usually expands group members’ capacity for patience.

The group facilitator also could encourage members to create time mantras, such as “I am not the Wicked Witch of the West and time is not water. So I won’t melt if I have to wait another minute.” Members can make up their own “thought stoppers” to help forestall impatience. The facilitator also may explain to the group that members might avoid feeding their “problem of immediate gratification” (or PIG), or relay what Marlatt explained using this memorable abbreviation:

“The pig is an animal with a huge appetite; it stands for the “problem of immediate gratification.” The pig shows up, grunting, 'I’m hungry. I’m really having a craving. Come on, feed me.' If you respond, 'Okay, if that’s what you need, I can give it to you,' then what happens? The pig gets bigger and gains more control. When your pig is saying, 'Give me, give me, give me,' we suggest you talk to the pig. Have a moment of contact.”4

Members can be instructed to envision their emotions regarding rushing to the end of the session—anxiety, excitation, impatience, etc.—as reflecting the PIG, and be prompted to talk about it. Members have made statements such as: “I don’t want to feed my time PIG another minute”; “I don’t want my PIG to get any bigger”; and “I can’t give in to these feelings ‘cause my PIG is going to grow and get stronger and I really won’t have any control over it then.”

Generally, the contemplation of the PIG concept leads group members to develop visualizations that help with the conceptualization of physiological sensations, unconscious processes, or emotional states that drive impulsive expressions. In this process, it becomes possible to control the behavior.5

Aside from these brief activities, improvement on willingness to wait also can be reinforced by the facilitator sharing what he/she witnesses. An example of a member thoughtfully and carefully practicing mindfulness or delayed gratification can be presented to the group as a self-control success story.

The Stanford marshmallow experiment conducted by a researcher in the late 1960s and early 1970s provides a valuable illustration of the value of delayed gratification as a life skill. In this experiment, an adult leaves a child alone for 15 minutes with a single sweet treat in a boring-looking room, deprived of toys or other entertaining stimuli. He informs the child that if she can resist the temptation to eat the sweet treat, he’ll bring one additional marshmallow that she can have only if she has not eaten the single treat before he returns.

This ability to delay one’s gratification might seem trivial, but it is a powerful predictor of future success with respect to quality-of-life outcomes. Those able to inhibit impulses and hold on without relenting to the urge to obtain immediate, small rewards were found to have better cognitive competence, social skills, and test score performance, with a lower incidence of substance abuse/addiction and habitual patterns of overeating to the point of obesity.6 Interestingly, when children who earlier had failed the test employed the strategy of pretending that the marshmallow was a picture by casting a mental frame around it, they were able to wait the full 15 minutes when tested again. However, reversal of this process led to reversal of progress; the child again was not able to wait more than a few minutes.7,8,9

The lessons here are twofold. Group members can find ways to use their imagination to keep their impulses in check, and group facilitators can teach members ways to check impulses. Here we also should note that self-control doesn’t happen in a social vacuum, since it interacts with the environment. The child’s belief in how reliable the researcher is with follow-through influences self-control. If the researcher had not returned with the promised marshmallow, the children who were able to delay gratification would have been expected on subsequent tasks not to bother with attempting long-term gratification delay.10 The lesson here for group facilitators is that the chances for consistency are increased with increased consistency in the environment: If an agreement is broken, natural consequences will follow. These natural consequences are life’s natural teachers, rather than any program or facilitator’s rules.

To provide one example, imagine that the group facilitator is late for group. The natural consequence and experience might include group members deliberately returning late from break and showing less compunction about arriving late to the next session. If group facilitators want group members to honor the agreements, they must use consistent language and consistently show the attitude of an ally—in other words, demonstrate their own commitment to the group.

5. Nodding off in group/visibly resting one’s head on the table.

One approach here would be to ask the group member to explain to the group what messages are communicated by resting his/her head on the table. If a group member is observed nodding off, the group facilitator could ask the member to brainstorm what he/she could do differently to stay meaningfully engaged in the session. Some possibilities might be standing up in front of one's chair, taking notes, asking questions, or otherwise participating in the session.

The facilitator also could invite the group member to talk after the session about what he/she would like to get out of the session, what he/she thinks the group facilitator could do differently, and what he/she believes is missing from the group.11 If the group member continues to dishonor the group agreement, then the member has chosen not to cooperate, and dismissal from the session accurately reflects the member’s behavior.

Some group facilitators argue that a sort of “three strikes, you’re out” arrangement should apply to the group member. Accordingly, the member would be given at least two warnings, stating in a matter-of-fact way, “Stay with us, Chris. That’s your first warning; after the second one, you’ll be asked to leave the group.”

6. A pen or other material is provided to a group member who wasn’t prepared for group.

In these scenarios, ask the group for a definition of “enabling.” Once a group member offers a definition, ask the enabling pen-giver if he understands the role he is playing in enabling continued unpreparedness of the peer, and how the peer might continue to experience unwanted outcomes in life if unpreparedness continues to be practiced. It’s left alone after that. The point is to provide information to assist someone in making decisions.

7. Returning to the session late from the break period.

Whether late returns to the session from a break are deemed “escape behavior” or something else, the accumulated time absent can simply be subtracted from the next break period or the time at which the member departs from the end of the session after the rest of the group. This logical consequence has proven extremely effective (in fact, more than any other intervention) in reducing escape behavior, as it sets a clear limit and calls for accountability.

8. Members getting out of their seats to retrieve items from bags.

Members can be asked to practice mindfulness, compassion and respect of other members still working or speaking. This also offers an opportunity for practicing delayed gratification, delaying the retrieval of items (including those needed to complete group work) until the designated break time.

9. Only one or two people sign up to clean the room; all other group members dishonor the agreement.

Several approaches can be used for this challenge. First, explain to members that all contribute to tracking dirt and debris (from shoes, bags, clothes) into the group room, and that in theory when one member stays after to clean up, that member in effect has cleaned up after all the others. This explanation generally suffices for some members, who then see the fairness in pitching in.

Another way to address this issue is through a contingency management system. The sign-up sheet for weekly clean-up lists the various chores in one column, with four or five weeks’ worth of sign-up squares across the page. At the end of the four or five weeks, when the sheet is full, every member whose name is in a sign-up square gets to pull a script from a basket. The scripts offer words of praise or appreciation, the privilege to leave five minutes early at break, or a retail gift card. For each day someone participates, he/she receives a chance to pull a script from the basket.

One important thing to note is that this is never explained in advance but rather discovered anew by each individual in the group. Those who participate discover the rewards. Those who do not participate discover what they’ve missed. Based on those discoveries, new behaviors usually evolve. This is also a type of informal commitment contract—while a particular action isn’t put down in writing, the action is promoted by certain elements in the environment.

Conclusion

While these interventions may seem to some to have punitive intent, it should be emphasized that the goal itself is not punitive. Rather, it is to attempt to modify the behavioral patterns that have led to the individuals’ needing the group sessions. Punitive language is never used, since it is restrictive and unsupportive and does not sound like the language of an ally. Rather, offers of help that are aimed at discovering solutions constitute the consistent language and attitude of an ally.

Individual counseling sessions are used to explore the challenges one has in honoring any one of the agreements. Once that difficulty is discovered and identified as part of the “treatment/discovery plan”12, solutions are explored so that the individual can have a better relationship with the group. Cooperation is seen as a benefit, and becomes the choice of the individual.

Honoring of group agreements is part of assessing someone’s awareness and acceptance. Group members understand that treatment progress is measured in stages: awareness, acceptance, willingness, and commitment. Dishonoring the group’s agreements represents either a lack of awareness of the agreements or a lack of acceptance of them.

We believe that patterns of relating to the group agreements offer vital information about the individual, reflecting more broadly what Yalom termed the individual’s “social microcosm.”2 We agree with Yalom’s argument that the manner in which the individual interacts with the group largely represents how one characteristically behaves, relates and thinks in one's social sphere outside the group room, replicating maladaptive behavior to “create the same interpersonal universe one has always inhabited”—a social microcosm that influences the nature of one's drug addiction.2

Therefore, level-of-care transitions are not compartmentalized to a treatment plan, but are viewed symbiotically and holistically by tracking progress via information displayed by the individual about his/her social microcosm in relation to how he/she assimilates the group agreements. In this sense, the benefit of consistently honoring the maintenance of the group agreements becomes a keystone of progression to a less intensive level of care.

Izaak L. Williams, a Hawaii state-certified substance abuse counselor, 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 (CSAT's) Behavioral Health Leadership Development Program. Lorrain Burgess, CSAC, has been working in Hawaii's substance abuse treatment industry since 2006, working mostly with court-referred clients.

References

1. Williams IL, Burgess L. Group treatment agreements: amplifying the therapeutic. Addiction Professional 2014 Apr 22. Retrieved from www.addictionpro.com/article/group-treatment-agreements-amplifying-therapeutic.

2. Yalom ID. The Theory and Practice of Group Psychotherapy. New York City: Basic Books; 1975.

3. McKay M, Wood JC, Brantley J. The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation and Distress Tolerance. Oakland, Calif.: New Harbinger Publications; 2007.

4. Surfing the Urge: G. Alan Marlatt on Mindfulness-Based Relapse Prevention. Retrieved from www.inquiringmind.com/Articles/SurfingTheUrge.html

5. Bowen S, Chawla N, Marlatt GA. Mindfulness-Based Relapse Prevention for Addictive Behaviors: A Clinician’s Guide. New York City: The Guilford Press; 2010.

6. University of Rochester, The marshmallow study revisited, 2012 Oct 12. Retrieved from www.rochester.edu/news/show.php?id=4622.

7. Mischel W. Theory and research on the antecedents of self-imposed delay of reward. In Maher BA (ed.). Progress in Experimental Personality Research. New York City: Academic Press; 1966.

8. Mischel W, Grusec J. Waiting for rewards and punishments: effects of time and probability on choice. J Personality Soc Psychol 1967;5:24–31.

9. Mischel W, Staub E. Effects of expectancy on working and waiting for larger rewards. J Personality Soc Psychol 1965;2:625-33.

10. Kidd C, Palmeri H, Aslin RN. Rational snacking: young children’s decision-making on the marshmallow task is moderated by beliefs about environmental reliability. Cognition 2013;126:109-14.

11. Corey MS, Corey G. Groups Process and Practice (4th ed.). Pacific Grove: Calif.: Brooks/Cole Publishing; 1992.

12. Mee-Lee D. “Doing time” versus “doing treatment”: droughts and storms. The Change Companies: Tips & Topics, 2014 Mar 31. Retrieved from www.tipsntopics.com/2014/03/.