If necessary, the leader may have to stand in front of a group member being physically threatened. Some situations require help, so a lone leader should never conduct a group session without other staff nearby. On occasion, police intervention may be necessary, which could be expected to disrupt the group experience completely. The leader should not suggest touching, holding hands, or group hugs without first discussing this topic in group. This tactic will convey the message that strong feelings should be talked about, not avoided.
In general, though, group members should be encouraged to put their thoughts and feelings into words, not actions. Whenever the therapist invites the group to participate in any form of physical contact for example, in psychodrama or dance therapy , individuals should be allowed to opt out without any negative perceptions within the group.
All members uncomfortable with physical contact should be assured of permission to refrain from touching or having anyone touch them. Leaders also should make sure that suggestions to touch are intended to serve the clients' best interests and not the needs of the therapist.
Under no circumstances should a counselor ask for or initiate physical contact. Like their clients, counselors need to learn that such impulses affect them as well.
Nothing is wrong with feeling attracted to a client. It is wrong, however, for group leaders to allow these feelings to dictate or influence their behavior. Group leaders carefully monitor the level of emotional intensity in the group, recognizing that too much too fast can bring on extremely uncomfortable feelings that will interfere with progress—especially for those in the earlier stages of recovery.
When emotionally loaded topics such as sexual abuse or trauma come up and members begin to share the details of their experiences, the level of emotion may rapidly rise to a degree some group members are unable to tolerate.
At this point, the leader should give the group the opportunity to pause and determine whether or not to proceed. What is happening? How does it feel? Do we want to go further at this time? At times, when a client floods the room with emotional information, the therapist should mute the disturbing line of discussion. The leader should not express discomfort with the level of emotion or indicate a wish to avoid hearing what was being said.
Leaders can say something such as. It's just that for now, I'm concerned that you may come to feel as if you have shared more than you might wish. How are you feeling right now? Let me know when you're ready to move on. A distinction needs to be made whether the strong feelings are related to there-and-then material or to here-and-now conduct.
It is far less unsettling for someone to express anger—even rage—at a father who abused her 20 years ago than it is to have a client raging at and threatening to kill another group member. Also, the amount of appropriate affect will differ according to the group's purpose. Much stronger emotions are appropriate in psychodrama or gestalt groups than in psycho-educational or support groups. For people who have had violence in their lives, strong negative emotions like anger can be terrifying.
When a group member's rage adversely affects the group process, the leader may use an intervention such as. The thrust of such interventions is to modulate the expression of intense rage and encourage the angry person and others affected by the anger to pay attention to what has happened. Vannicelli suggests two other ways to modulate a highly charged situation:. Switch from emotion to cognition. The leader can introduce a cognitive element by asking clients about their thoughts or observations or about what has been taking place.
When intervening to control runaway affect, the leader always should be careful to support the genuine expressions of emotion that are appropriate for the group and the individual's stage of change.
In support and interpersonal process groups, the leader's primary task is stimulating communication among group members, rather than between individual members and the leader.
This function also may be important on some occasions in psychoeducational and skills-building groups. Some of the many appropriate interventions used to help members engage in meaningful dialog with each other are. Noticing a member's body language, and without shaming, asking that person to express the feeling out loud. Do you want to go back and explore those further? Helping members with difficulty verbalizing know that their contributions are valuable and putting them in charge of requesting assistance.
My guess is that you are carrying a truth that's important for the group. Do you have any sense of how they can help you say it?
In support and interpersonal process groups, the leader's primary task is stimulating communication among group members. In general, group leaders should speak often, but briefly, especially in time-limited groups. In group, the best interventions usually are the ones that are short and simple. Effective leadership demands the ability to make short, simple, cogent remarks. Interventions may be directed to an individual or the group as a whole.
They can be used to clarify what is going on or to make it more explicit, redirect energy, stop a process that is not helpful, or help the group make a choice about what should be done. A well-timed, appropriate intervention has the power to. Discover connections between the use of substances and inner thoughts and feelings. Perceive discrepancies between stated goals and what is actually being done. Any verbal intervention may carry important nonverbal elements.
Leaders should therefore be careful to avoid conveying an observation in a tone of voice that could create a barrier to understanding or response in the mind of the listener. Generally a counselor leads several kinds of groups. Leadership duties may include a psychoeducational group, in which a leader usually takes charge and teaches content, and then a process group, in which the leader's role and responsibilities should shift dramatically.
A process group that remains leader-focused limits the potential for learning and growth, yet all too often, interventions place the leader at the center of the group. For example, a common sight in a leader-centered group is a series of one-on-one interactions between the leader and individual group members.
These sequential interventions do not use the full power of the group to support experiential change, and especially to build authentic, supportive interpersonal relationships. Some ways for a leader to move away from center stage:. In addition to using one's own skills, build skills in participants. Avoid doing for the group what it can do for itself. Encourage the group to learn the skills necessary to support and encourage one another because too much or too frequent support from the clinician can lead to approval seeking, which blocks growth and independence.
Supporting each other, of course, is a skill that should develop through group phases. Thus, in earlier phases of treatment, the leader may need to model ways of communicating support. Later, if a client is experiencing loss and grief, for example, the leader does not rush in to assure the client that all will soon be well. What does this bring up for others here?
Refrain from taking on the responsibility to repair anything in the life of the clients. To a certain extent, they should be allowed to struggle with what is facing them. It would be appropriate, however, for the leader to access resources that will help clients resolve problems.
Confrontation is one form of intervention. In the past, therapists have used confrontation aggressively to challenge clients' defenses of their substance abuse and related untoward behaviors.
Trying to force the client to share the clinician's view of a situation accomplishes no therapeutic purpose and can get in the way of the work. William R. Miller explains:. That makes confrontation a goal of counseling rather than a particular style or technique… [T]hen the question becomes, What is the best way to achieve that goal? Evidence is strong that direct, forceful, aggressive approaches are perhaps the least effective way to help people consider new information and change their perceptions CSAT b , p.
Confrontation in this light is a part of the change process, and therefore part of the helping process. Its purpose is to help clients see and accept reality so they can change accordingly Miller and Rollnick Transference means that people project parts of important relationships from the past into relationships in the present.
For example, Heather may find that Juan reminds her of her judgmental father. When Juan voices his suspicion that she has been drinking, Heather feels the same feelings she felt when her father criticized all her supposed failings. Within the microcosm of the group, this type of incident not only relates the here-and-now to the past, but also offers Heather an opportunity to learn a different, more self-respecting way of responding to a remark that she perceives as criticism.
The emotion inherent in groups is not limited to clients. The groups inevitably stir up strong feelings in leaders. The therapist's emotional response to a group member's transference is referred to as countertransference. Vannicelli describes three forms of countertransference:.
Feelings of having been there. Leaders with family or personal histories with substance abuse have a treasure in their extraordinary ability to empathize with clients who abuse substances. If that empathy is not adequately understood and controlled, however, it can become a problem, particularly if the therapist tries to act as a role model or sponsor, or discloses too much personal information. Feelings of helplessness when the therapist is more invested in the treatment than the client is.
Treating highly resistant populations, such as clients referred to treatment by the courts, can cause leaders to feel powerless, demoralized, or even angry. The best way to deal with this type of countertransference may be to use the energy of the resistance to fuel the session.
Feelings of incompetence due to unfamiliarity with culture and jargon. It is helpful for leaders to be familiar with Step programs, cultures, and languages. Can you say a little more about how this relates to your situation? When countertransference occurs, the clinician needs to bring all feelings associated with it to awareness and manage them appropriately. Good supervision can be really helpful. Countertransference is not bad.
It is inevitable, and with the help of supervision, the group leader can use countertransference to support the group process Vannicelli Resistance arises as an often unconscious defense to protect the client from the pain of self-examination. These processes within the client or group impede the open expression of thoughts and feelings, or block the progress of an individual or group. The effective leader will neither ignore resistance nor attempt to override it.
Instead, the leader helps the individual and group understand what is getting in the way, welcoming the resistance as an opportunity to understand something important going on for the client or the group. Further, resistance may be viewed as energy that can be harnessed and used in a variety of ways, once the therapist has helped the client and group understand what is happening and what the resistant person or persons actually want Vannicelli In groups that are mandated to enter treatment, members often have little interest in being present, so strong resistance is to be expected.
Even this resistance, however, can be incorporated into treatment. For example, the leader may invite the group members to talk about the difficulties experienced in coming to the session or to express their outrage at having been required to come. Leaders should recognize that clients are not always aware that their reasons for nonattendance or lateness may be resistance.
The most helpful attitude on the clinician's part is curiosity and an interest in exploring what is happening and what can be learned from it.
Leaders need not battle resistance. It is not the enemy. Indeed, it is usually the necessary precursor to change. It would be a serious mistake, however, to imagine that resistance always melts away once someone calls attention to it.
When a group rather than an individual is resistant, the leader may have contributed to the creation of this phenomenon and efforts need to be made to understand the leader's role in the problem. For the group leader, strict adherence to confidentiality regulations builds trust. If the bounds of confidentiality are broken, grave legal and personal consequences may result.
All group leaders should be thoroughly familiar with Federal laws on confidentiality 42 C. Even where a privilege of confidentiality does exist in law, enforcement of the law that protects it is often difficult Parker et al. Clinicians should be aware of this legal problem and should warn clients that what they say in group may not be kept strictly confidential. Some studies indicate that a significant number of therapists do not advise group members that confidentiality has limits Parker et al.
One set of confidentiality issues has to do with the use of personal information in a group session. Group leaders have many sources of information on a client, including the names of the client's employer and spouse, as well as any ties to the court system. A group leader should be clear about how information from these sources may and may not be used in group. Clinicians consider the bounds of confidentiality as existing around the treatment enterprise, not around a particular treatment group.
Clients should know that everyone on the treatment team has access to relevant information. In addition, clinicians should make it clear to clients that confidentiality cannot be used to conceal continued substance abuse, and the therapist will not be drawn into colluding with the client to hide substance use infractions.
Clinicians also should advise clients of the exact circumstances under which therapists are legally required to break confidentiality see Figure A second set of confidentiality issues has to do with the group leader's relationships with clients and clients with one another.
When counseling a client in both individual therapy and a group context, for example, the leader should know exactly how information learned in individual therapy may be used in the group context. In almost every case, it is more beneficial for the client to divulge such information than for the clinician to reveal it.
In an individual session, the therapist and the client can plan how the issue will be brought up in group. This preparation gives clients ample time to decide what to say and what they want from the group. I will not keep important information from the group, if I feel that withholding the information will impede your progress or interfere with your recovery.
Clinicians should warn clients that what they say in group may not be kept strictly confidential. Still other confidentiality issues arise when clients discuss information from the group beyond its bounds.
Violations of confidentiality among members should be managed in the same way as other boundary violations; that is, empathic joining with those involved followed by a factual reiteration of the agreement that has been broken and an invitation to group members to discuss their perceptions and feelings. In some cases, when this boundary is violated, the group may feel a need for additional clarification or addenda to the group agreement.
The leader may ask, both at the beginning of the group or when issues arise, whether the group feels it needs additional agreements in order to work safely. Such amendments, however, should not seek to renegotiate the terms of the original group agreement.
See Figure see p. Because a group facilitator generally is part of the larger substance abuse treatment program, it is recommended that the group facilitator take a practical approach to exceptions. This practical approach is to have the group facilitator discuss the potential application of the exceptions with the program director or member of the program staff who is the lead on the confidentiality regulation.
Substance use disorders include a wide range of symptoms with different levels of associated disability. Clients always bring into treatment vulnerabilities other than their alcohol or illicit drug dependencies. Group interventions may be needed to resolve psychological problems, physical ailments, social stresses, and perhaps, spiritual emptiness or bankruptcy.
In short, successful treatment for substance use disorders should address the whole person, including that person's spiritual growth. While the group experience is a powerful tool in the treatment of substance use disorders, it is not the only tool. Other interventions, such as individual therapy, psychological interventions, pharmacological supports, and intensive case management, may all be necessary to achieve long-term remission from the symptoms of addictive disorders. For example, people who are homeless with a co-occurring mental disorder have three complicated sets of problems that require a continuous and comprehensive care system—one that integrates or coordinates interventions in 1 the mental health system, 2 the addiction system, and 3 the social service system for homeless persons.
In group therapy, each condition should be regarded as a primary interactive problem; that is, one in which each problem develops independently but contributes to both of the others Minkoff and Drake One model offered for treating homeless persons with substance use disorder is a modified training group designed to accommodate a large number of members whenever a traditional small group is not possible.
In this model, participants meet in a large group with the clinician and then break into smaller groups to discuss, practice, or role-play the particular topic. Each group has a client leader, and the clinician circulates among the groups to ensure that the topic is understood and that discussion is proceeding.
The clinician does not participate in the groups. Researchers describing this model note that because the clinicians step back from assuming leadership roles in the groups, the clients become empowered to take group sessions in the necessary direction and demonstrate feelings and insights that might not occur in a group formally led by a clinician Goldberg and Simpson It is well known that Step programs are an important part of many therapeutic programs Page and Berkow While Step programs have a proven record of success in helping people overcome substance use disorders, there is a basic conflict inherent in them that group therapists need to reconcile.
In the Step program, people are urged to cede control to a higher power. Yet, in group, the clinician is prompting clients to take control of their emotions, behavior, and lives. Although the literature currently has few straightforward discussions of spirituality and its role in the dynamics of group therapy, most clinicians would agree that the spiritual well-being of the client is essential to breaking free of substance abuse. When clients join self-help groups, they sometimes hear from individuals who strongly oppose the use of any medication.
Some people in Step programs erroneously believe, for example, that the use of pharmacological adjuncts to therapy is a violation of the program's principles. They consequently oppose methadone maintenance, the use of Antabuse, or the use of medications needed to control co-occurring disorders. Clinicians should be prepared to handle these misapprehensions. It stresses the value of appropriate medication prescribed by a physician who understands addictive disorders and reassures clients that such use of medication is wholly consistent with AA and Narcotics Anonymous' Step programs.
Many clients enrolled in a process group for persons with substance use disorders are likely participating in a Step program or other self-help groups as well. On occasion, apparently conflicting messages can be an issue. For instance, many people with addiction histories try to use AA and its jargon as material for resistance. Such problems can readily be managed, provided the therapist is thoroughly familiar with the self-help group.
Matano and Yalom strongly recommend that group leaders become thoroughly familiar with AA's language, steps, and traditions because misconceptions about the program, whether by the client or therapist, can raise barriers to recovery. Recent research has clearly demonstrated the ability of self-help groups to improve outcomes Tonigan et al. Research also has shown that clients receiving mental health services as well as participating in Step meetings have an even better prognosis Ouimette et al.
Together, the two modalities supply multiple relationship models, potentially of immense value to the client. Some suggestions for maximizing the therapeutic potential of participation in both process and Step groups follow:.
Orientation should prepare new group members who are also members of Step groups for differences in the two groups. A key difference will be the fact that members interact with each other. The group leader should be attuned to this potential and should be prepared to work through these perceptions and the feelings underlying them. Sponsors of Step members may distrust therapy and discourage group member from continuing in treatment.
The leader should be prepared to respond to a variety of potential issues in ways that avoid appearing to compete with the self-help group. As long as I'm not drinking, my life is fine. Group leaders should beware of their possible biases against Step groups that may be based on inaccurate information. For example, it is not true that the Step philosophy opposes therapy and medication, as AA World Service pamphlets clarify.
It also is a misconception that Step programs encourage people to abdicate responsibility for substance use. AA, however, does urge people with addiction problems to attend meetings in the early stages of recovery, even though they may still be using alcohol or illicit drugs.
Finally, some clinicians believe that Step programs discourage strong negative emotions. The following vignette illustrates a typical intervention intended to clarify and harmonize appropriate participation in Step and process groups:. The group leader knew that Henry, who was well along in recovery but new to group, had not expressed his anger at Jenna for having cut him off for the third time.
When asked how he experienced Jenna, he simply replied that according to the program you are not to take another person's inventory. The leader took the opportunity to say that in group therapy it is important to consider one's feelings about what others say and do even if [the feelings] are negative.
Expressing one's own feelings is different from focusing on another's character taking his inventory Freimuth , p. No matter what the modality, however, group therapy is sure to remain an integral part of substance abuse treatment.
Substance abuse affects every aspect of life: home, family, friends, job, health, emotional well-being, and beliefs. As clients move into recovery, the wide range of issues they should face may overwhelm them. Leaders need to help clients rank the importance of the challenges, taking care to make the best possible use of the resources the client and the leader can bring to bear.
Naturally, clients will vary in their ability to address many concerns simultaneously; capacity for change also is variable. For example, some individuals with cognitive impairments will have a much harder time than others engaging in a change process. In the early stage of treatment, such clients need simple ideas, structures, and principles. As the client moves forward, the clinician can keep in mind the issues that a client is not ready or able to manage.
As this process goes on, the leader should remember that the client's priorities matter more than what the leader thinks ought to come next. Unless both client and leader operate in the same motivational framework the leader will not be able to help the client make progress. No matter what is missing—even if it is a roof over the client's head—it is possible to engage the client in treatment. A client never should be told to come back after problems other than substance abuse have been resolved.
On some front, constructive work can always be done. Of course, this assertion does not mean that critical needs can be ignored until treatment for substance abuse is well underway. The therapist should recognize that a client preoccupied with the need to find a place to sleep will not be able to engage fully in treatment until urgent, practical needs are met. Life issues facing the client provide two powerful points of therapeutic leverage that leaders can use to motivate the client to pursue recovery.
First, group leaders should be aware that people with alcoholism and other addictions will not give up their substance use until the pain it brings outweighs the pleasure it produces. Consequently, they should be helped to see the way alcohol and drugs affect important areas of their lives. Second, early in treatment, group leaders should learn what is important to each client that continued substance abuse might jeopardize.
For some individuals, it is their job. For others, it is their spouse, health, family, or self-respect. In some cases, it might be the threat of incarceration.
Such knowledge can be used to encourage, and even coerce, individuals to utilize the tools of treatment, group, or AA Flores While spirituality and faith may offer to some the hope, nurturing, sense of purpose and meaning, and support needed to move toward recovery, people obviously interpret spiritual matters in diverse ways.
It is important not to confuse spirituality with religion. Even if clients are not religious, their spiritual life is important. Some clinicians mistakenly conclude that their own understanding of spirituality will help the client. Other clinicians err in the opposite direction and are overly reluctant to address spiritual beliefs.
Actually, a middle ground is preferable. The leader should explore the importance of spiritual life with the group, and if the search for spiritual meaning is important, the clinician can incorporate it into group discussions.
For clients who lack meaningful connection to anything beyond themselves, the group may be the first step toward a search for meaning or a feeling of belonging to something greater than the self. The clinician's role in group therapy simply is to create an environment within which such ego-transcending connections can be experienced. Professionals within the entire healthcare network need to become more aware of the role of group therapy for people abusing substances.
To build the understanding needed to support people in recovery, group leaders should educate others serving this population as often as opportunities arise, such as when clinicians from different sectors of the healthcare system work together on a case.
Related Content. Live Webinar Finance and Business Strategy. Live Webinar Denials Management. Live Webinar Benchmarking and Forecasting. News Value-Based Payment. Medicare readmissions reduction program penalizes hospitals inaccurately, study finds. Oct 22, Lower-revenue hospitals were more likely to be wrongly assessed penalties. Within each condition, the share of hospitals that incorrectly went unpenalized was: When asked about for its views on the study's results, CMS emailed the following written statement: CMS "is committed to ensuring that quality and safety are high priorities for patients and people with Medicare.
But a growing body of research has been critical of the program. Follow Rich on Twitter: rdalyhealthcare. Sign up for a free guest account and get access to five free articles every month. When people can take home more of their paychecks, consumer spending increases. This personal consumption is one of the four components of gross domestic product GDP.
Capital gains tax cuts reduce taxes on sales of assets. That gives more money to investors. By putting more money in investors' pockets, they are more likely to buy more stock in companies, helping the companies grow.
It also drives up the prices of real estate, oil, gold, and other assets. Inheritance or estate tax cuts reduce the amount paid by heirs on their parents' assets. Business tax cuts reduce taxes on a company's profits. The goal of these cuts is to give firms more money to invest in growth, wages, and hiring. Another way to look at the impact of federal tax cuts is to review how past presidents used them. While presidents may propose tax cuts, they cannot change the tax code on their own, and they must ultimately convince Congress to change the tax law.
It's difficult to analyze the effects of tax cuts since many other policies could have been implemented at the same time. For example, an increase in debt could be the result of tax cuts or increased spending. The Federal Reserve could have lowered interest rates, a tool of expansionary monetary policy.
Any actions like these affect the economy, and it's challenging to assign specific economic trends to a specific economic policy. It's especially tough to determine the impacts of tax cuts during a recession. Governments typically use any tools at their disposal during recessions, and the more tools that are used, the more difficult it becomes to figure out the specific impact of each policy.
Here's a quick analysis of well-known past tax cuts and their impacts:. John F. Kennedy advocated a cut in income taxes. However, he was assassinated before he could implement the cuts. The George W. Bush tax cuts were implemented to stop the recession. The government cut the top income tax rate from The Bush tax cuts may have boosted the economy in the short-term:.
However, the tax cuts might not have been the only reason for increased growth. The tax cuts benefited high-income individuals the most. Tax rates fell by 4. These cuts also increased the U.
Barack Obama pushed through several tax cuts to end the Great Recession. These tax cuts included:. The Great Recession ended in July The economy grew:. In this case, the ARRA tax cuts were probably more effective than monetary policy in boosting growth. The American Taxpayer Relief Act of taxed incomes at and above the top income threshold at the Clinton-era It cut income tax rates, doubled the standard deduction, and eliminated personal exemptions.
It also repealed the Obamacare tax on those who don't get health insurance. The GDP growth rate increased by about 0. In , the GDP sharply declined.
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