Consultation, Please
October/November 2002

Dear Consultant: 
I work at a mental health center and was directed by my boss to run a time-limited (12 session) alcohol and drug treatment group with patients newly in recovery. There are eight patients in the group, four women and four men. Though I have had experience with this type of group, there is a problem for me and I believe for the group. The eight members include both a sexual abuse survivor and a sexual abuse perpetrator. (I do not believe that they know one another.) When I expressed my concerns about this issue to my boss, he insisted that I run this group, as they needed to focus on their addiction not their abuse issues. I am concerned about the dynamics of the group, the interaction of the members with each other and with me, and the anger that may erupt as the members learn that there is a secret in the group. I would appreciate your help in dealing most effectively with this difficult situation. 

Sincerely,
In Over My Head

Dear In Over My Head:
One of the issues that struck me immediately was the potential for the group therapist to feel abused in relation to the “perpetrator” boss. Being “in over one’s head” is clearly an issue you must deal with, as it will determine how you contain the various dynamics within the group. One of the unexpressed issues in the group may be your anger as the therapist at being asked to run a group in a way that is contrary to your own therapeutic principles. It will be very important for you to find some resolution to your own feelings, especially your anger. It may help to seek continuous consultation while leading the group so that you feel that you have support. 

You are indeed put in a difficult spot when you are told to deal only with addiction issues. You may have to be more directive than usual in order to keep the subject matter contained, or at least direct the topics in the group toward issues related to recovery. You will have to sidestep the issues of anger, abuse, and other complicated dynamics in the group. While it is my experience that revelations about being a survivor or a perpetrator of abuse are unlikely to come up in a group limited to a few months, it may be difficult to contain these issues if a member speaks simultaneously about his or her addiction and the abuse. You may be forced to be even more direct at that point to refocus the group back to the addiction issue. Artificial and not very deep work could result. 

You are indeed in a difficult situation and one that is not unusual in mental health centers where you are not free to work in a way that permits you the freedom many of the rest of us have in private practice.

Scott Conkright, PsyD
Atlanta, Georgia

Dear Over Your Head:
Initially the inclusion of a victim and a perpetrator in the group evoked a strong negative response from me. However, as I thought about your dilemma, I began to see some options. Here are some things to think about.

Carefully frame this group as a structured psycho-educational group with a primary focus on A & D issues, and maintain that focus. Relate any of the substantive issues that are raised, including the sexual abuse issues, to how they will inhibit the participants' ability to remain sober and comply with A & D addiction treatment. Certainly acknowledge the richness of these crucial issues and the necessity of treatment for them, and speculate with the group how they will deal with encounters such as these outside the treatment realm. 

Beware of the potential for the perpetrator or the victim to be cast as a scapegoat if his or her experiences are revealed. Scapegoating could be a way for the group to avoid working on their A & D issues. I would not encourage or facilitate group processing of the details of individual stories (even abuse accounts), but would acknowledge that the group may feel frustrated in not being able to deal directly with such inflammatory or exciting material. If safety becomes an issue for any of the group members, assist the group to define the term and apply that definition to their lives in general and to the challenges they face as they continue to try to maintain sobriety in particular.

Adhere to the institution’s mandate for this group and bracket emerging issues for individual therapy and/or participation in other therapy groups. Here is as an opportunity to discuss boundaries and how to maintain them. If you can help the group bracket and hold boundaries, you will have taught them an invaluable lesson for post-group life.

The victim/perpetrator issue is not the only major unaddressed issue in the group. Another major issue is the impact of your (perceived) helplessness on the group, if you should feel angry and/or helpless as the disempowered leader. There is also the sexual tension of a group evenly divided by gender. Of course, if the group members refuse to go along with your agenda, that’s 12 weeks worth of group material in itself, and you can certainly frame their resistance to the agenda as evidence of the strength they have to overcome their addictions.

As a group leader, allow yourself some private moments of anger and grief because you weren’t allowed to select the group members. This may affect your dynamic work. You might also want to find a trusted colleague to have tea with so you could vent with impunity! 

Carol Lark, PhD, CGP
St. Louis, Missouri

This article was published in the October/November 2002 issue of The Group Circle.