What was the situation in which the lapse occurred? Had the client identified it in the past as a “risky situation”? Was it a “blind spot?” Are there other blind spots? What is the “risk/value” ratio of this type of situation? If it’s high risk/low value, what might be done in the future to avoid such situations? If it’s high value, what might be done to prepare and better cope with it? What possible decisions may have led to the person encountering the risky situation?

 

Viktor Frankl
Use of curricula in group treatment provides structure for the therapeutic process. It helps assure that individuals in addiction recovery are exposed to important principles and skill development, it prompts clinicians to address key topics, it provides a common language for clinical communication, and it contributes toward seamless coverage in the event of a group facilitator’s absence. Additionally, training on curricula provides clinicians with knowledge and skills in specific concepts and strategies.

Open-Group Curricula
More often than not, treatment curricula are designed to be implemented sequentially—that is, beginning with session 1 and then proceeding in order such that the individual’s knowledge base and skills develop progressively. Knowledge and skills acquired in earlier sessions make the plat– form for knowledge and skills addressed in later ones. Typically, there is a defined number of sessions, concluding with a termination session. Sequential approaches lend themselves to individual counseling. They are also used in “closed-group” formats, where all clients begin at the same time
with session 1 and progress as a group through a series of sessions, each building on the ones that came before. There are well-designed, evidence-based sequential models available, and there is certainly value in sequential approaches when and where they can be implemented. Unfortunately, economic and other practical realities make those opportunities rare. Treatment programs commonly adapt evidence-based curricula from closed-group formats for use in open groups. There are seldom any guidelines in sequential curricula to inform such adaptation. Consequently, evidence- based curricula are sometimes modified and implemented in ways that are inconsistent with the manner that gave evidence of their effectiveness. While adapting closed-group models to open-group formats may sacrifice design advantages of the particular sequential curriculum, it also risks failing to recognize and use strengths inherent in open-group approaches. Mindfulness-based sobriety is a collaborative approach to open-group therapy that is intended to help individuals with substance-use problems achieve and maintain sobriety by enhancing awareness, accepting experience, and committing to value-based living.

Strengths of Open-Group Approaches
Group therapy in either open or closed design offers opportunities to improve peer relations and supports, enhance social skills, obtain feedback from others, provide feedback, observe others in change processes, and practice new skills in role-play scenarios. MBS was designed as an open-group curricula. Use of open-group formats may offer both operational and clinical advantages. Operationally, open groups offer scheduling efficiency and economic benefits. New clients can join groups at any juncture. Vacancies in group membership do not have to continue until the next cycle begins for the closed group. The prospective client can more easily access treatment without having to approach a different treatment provider. Clinically, open groups may better lend themselves to treatment engagement by allowing the person to begin treatment when he or she is motivated to do so. With a closed-group model, what can you tell the person who has to wait for the next group cycle to begin? What are the person’s options? Continue the status quo, attempt sobriety on your own, or seek help elsewhere. By the time a new closed group begins, the person’s motivation for treatment may have waned. Open groups may better lend themselves to individualized therapy. There is a range within the client pool in terms of readiness and preparedness for treatment (“starting points”) and in regard to treatment needs. Some clients are entering treatment for the first time, while others have prior treatment experience (sometimes with periods of sobriety success). Clients also vary in terms of severity of addiction, co-occurring issues (mental health and medical), quality of life, coping skill sets, and social supports. Consequently, a closed group of individuals starting at the same time, undergoing the same curriculum at the same pace, and then concluding at the same time may lack flexibility in accounting for participants’ individual strengths, problems, and needs. In open groups, clients’ lengths of stay vary. Some will need repeated, reinforced exposure to therapy content and skill practice, and additional in-treatment life experience accompanied by refined sobriety planning. Others will need less time in treatment.

At any point in time, open groups consist of a set of individuals who have been in the group for varying lengths of time, some more experienced with therapy and some newer to the process. This allows new members to learn from the experiences of others who may have faced similar challenges and who have experienced some success. This can be a source of hope and can help to enhance the newer person’s self-efficacy: “If he succeeded, then I can too.” Conversely, the person who is more experienced with therapy can perceive in the newer member a reflection of how he was in the beginning stages of therapy and therefore gain a sense of accomplishment. Additionally, clients who are experienced at being in therapy can take client-leader roles, which further develop their knowledge, skills, and confidence.

Finally, there may be advantages to the nonlinearity inherent in open-group approaches. The MBS curricula present in each session a holistic perspective of the model. Specific session topics are presented within the larger framework, and topics overlap to reinforce assimilation of knowledge and response fluidity.

Orienting New Members to the MBS Open Group
Since clients may come into the MBS group at any juncture, it is important that they have sufficient orientation to the model. This can be accomplished in two ways, and it is recommended that both take place:
• A brief overview of the MBS model is offered in each group, providing contextual grounding in which each topic can be understood (see appendix B).
• A new client may be oriented through an individual session in which the counselor pro–vides an overview of fundamental aspects of the MBS model.

Addressing Stages-of-Change Issues in an Open-Group Format In 1983, Prochaska and DiClemente introduced the Transtheoretical Model of Change (Prochaska & DiClemente, 1984), which included readiness-to-change levels:

Precontemplation The person is not considering making a change.

Contemplation The person is considering making a change but has not decided to do so.
Preparation The person has decided to make a change and is preparing an approach.
Action The person is actively addressing his problem.
Maintenance The person has achieved and is now in the process of maintaining sobriety.

Since then, the term “stagewise treatment” has been used to refer to attempts to match the treatment approach with the individual’s readiness-to-change level. Accordingly, recovery-skill development (of drug refusal skills, for instance) is sometimes considered appropriate for clients in the “action” stage of change—that is, for clients who are motivated and are taking steps to change. Conversely, these same approaches are often considered inappropriate for clients who are in the precontemplation or contemplation stage of readiness, that is, for clients who have not yet decided to change. The thinking is something like this: “Why teach drug refusal skills to someone who is not motivated to stop using? The focus should be on enhancing motivation.” Some who advocate “stagewise treatment” adopt this premise. While the logic of the above premise is apparent, this curriculum assumes a more nuanced understanding of the issue and adopts a modified approach. MBS takes into account that motivation to change can be influenced by self-efficacy. For instance, a person who lacks confidence in his ability to succeed in making a change may lack motivation for that very reason. After all, why would someone be motivated to attempt something that he didn’t believe he could accomplish? From the person’s perspective, attempting the unachievable would be an exercise in frustration, resulting in failure and feelings of inadequacy. This curriculum holds the perspective that skill development can help to increase one’s confidence and thereby enhance motivation to change. A secondary point here is that skill development may provide resources that can be used at a later time, if and when the person becomes motivated. In regard to individuals who are already motivated to change, would they benefit from motivation enhancement therapies? The answer to this depends on the particular methods used. Attempts to enhance motivation by cost-benefit analyses may run the risk of evoking benefits for not changing along with the benefits of changing. For some, this may help to strengthen motivation to change, while others may be more attracted to the “status quo” side of the decisional balance. Given the diversity within any group and the risk that some may respond by lowering motivation, MBS does not use cost-benefit or decisional balance exercises with the therapy group. In MBS, motivation enhancement is conducted in two general ways: through individual work in the group session and through group exercises. In individual work, motivation may be increased by direct attempts to develop discrepancy between how the person wants his life to become and his current set of behaviors. In group exercises, motivation may increase and commitment may be strengthened through values clarification and enhancement. Please refer back to “MI in MBS” in the “Motivational Interviewing” section of chapter 1 for a description of motivation enhancement in MBS group therapy.

General Facilitation Issues
The purpose of this section is to provide guidance on facilitating processes and addressing issues that are common in intensive outpatient and residential group therapy sessions.

Flexibility of Focus
Session outlines and descriptions for MBS group therapy are presented in chapters 4 (IOP) and 5 (residential). While clinicians will generally follow these session plans, variations may occur when they are clinically warranted. Each session includes an initial check-in where group members discuss recent challenges and successes they have experienced. This check-in may also be used to discuss issues related to group dynamics. Still, significant issues may emerge at times after the check-in period or with needs that extend beyond the time allotted for the check-in. When this happens, clinical judgment should be used. The MBS position is to prioritize current issues and situations in the clients’ lives. Accordingly, the topic of the day might be shortened or suspended to address immediate concerns. It should be acknowledged that a deviation from the plan is an exception, not the rule. Continued deviations from session plans may signify problems with group dynamics or group facilitation. In addition to unexpected significant issues (as mentioned above), the authors recognize that there may be occasions when the topic content, and related group exercises and discussion, requires more time than is indicated in the session outlines and descriptions. When this occurs, the facilitator will again need to make a clinical judgment call. If the apparent value of the topic being presented and discussed is high, the facilitator may need to condense or omit a subsequent topic in the session to allow the necessary time. In some cases, content in a single session may be spread over two sessions. As facilitators become increasingly familiar and adept with the MBS model, clinically indicated modifications will occur naturally.

Processing in Group Therapy
In chapters 4 and 5, where there are descriptions of IOP and residential sessions, references will be made to the facilitator processing various matters with the group. They include analyzing
recent events; troubleshooting challenges; and assessing and improving viability of relapse prevention plans, therapeutic discord in the group, perceptions, comprehension, life strategies, emotions, and responses to life challenges. Processing occurs in a context established by the facilitator: the meeting place and time; session structure and content; and an accepting, growth-oriented therapeutic undertone. The facilitator’s approach should be one that elicits nonjudgmental, therapeutic discussion. Open questions and the use of reflections in a nonjudgmental atmosphere help group members to feel safe in their mutual vulnerability, as they reflect on and disclose personal information. To establish the therapeutic atmosphere, the facilitator functions as a role model in respecting the questions and ideas of group members. There are no “stupid” questions and no “wrong” ideas. In processing a group member’s past actions, the facilitator should seek openings to affirm good- faith efforts and strengths, even in situations in which the person may have fallen short of his values or goals. “Shortcomings” are “grist for the mill”—learning opportunities, not personal failures. The objective is always to promote sobriety through understanding and appreciating the challenges involved, respecting autonomy, providing steadfast support, and recognizing the person’s ability to succeed in value-based living.

Personalizing the Approach
It has been our experience that facilitators who know their clients tend to be more engaging than those who do not. Being able to ask members about the outcomes of significant (or seemingly insignificant) events that happen outside of treatment—for example, being able to ask a client about the outcome of his son’s baseball game or the wedding he attended the previous weekend— demonstrates to clients that the facilitator genuinely cares and is invested in their well-being. Also, knowing the client’s interests, passions, and hobbies can be an important factor in engaging him in treatment and establishing rapport. An example of this would be involving clients in brief conversations about their favorite genres of music or movies or their favorite sports teams before, after, or during group (when relevant). Although we are mindful of the challenges of high caseloads and turnover, attempts to get to know clients may contribute toward engagement, retention, and successful completion.

Another important factor is the ability of the facilitator to be creative and bring the clients’ experiences to the material. The facilitator can do this through summarizing, broadening, and generalizing “real-life” experiences presented by group members so that the whole group can benefit. This can also be accomplished by linking group members’ experiences (with permission) to topics and concepts that were presented in the current or previous sessions. Finally, the facilitator should conduct “temperature checks” on a regular basis. Checking in with the clients in regard to comprehension, pace, and relevancy can be important for engagement and member success. The facilitator can do this by asking questions such as “Does this make sense?” and “Any questions?” The facilitator may also invite the members to ask questions in order to encourage curiosity, honest exploration, and feedback on the members’ behalf.

Some Awareness Areas and Tips
If an individual doesn’t want to talk or disclose something to the group, the facilitator initially can respectfully ask if the group member would like to discuss the reasons for not wanting to talk
(don’t push; respect the person’s decision to remain quiet). If the person appears to be in distress or if the silence continues through multiple sessions, the facilitator or another clinician should meet with the group member individually. When a client lapses, the clinician can help the person process and learn from the experience.

Lapse Management:
• Lapses are commonly accompanied by intense feelings of guilt or shame, and the client may be inclined to move toward a full relapse. One way to address this issue is to describe the lapse as a “slip,” “mistake,” or “learning experience,” rather than as a “failure.”
• What was the situation in which the lapse occurred?
• Had the client identified it in the past as a “risky situation”? Was it a “blind spot?” Are there other blind spots?
• What is the “risk/value” ratio of this type of situation? If it’s high risk/low value, what might be done in the future to avoid such situations? If it’s high value, what might be done to prepare and better cope with it?
• What possible decisions may have led to the person encountering the risky situation?
• Coping strategies may be reviewed and modified.
• If motivation was a significant contributing factor, motivational interviewing may be considered.
• The client’s expectations about substance use can be explored:
• What were the expectations?
• Did the outcome of substance use result in the pleasant experience that the client expected?
• The clinician can review with the client immediate versus delayed effects.

When a client experiences urges, what can a clinician do?
• Normalize cravings: Cravings are normal. They come and they go. They do not indicate signs of weakness or ineffectiveness. It is how we respond to urges and cravings that makes the difference.
• Teach and practice “urge surfing” (see appendix A).

When a client has been in a risky situation and didn’t use:
• The clinician should first affirm the person’s success in not using. Many clinicians fall into the trap of scolding someone for having been in a risky situation. This is counterproductive and may result in a missed opportunity to affirm the use of skills gained in treatment.
• How did it happen that the client was exposed to a risky situation? What possible decisions may have led to the exposure?
• What coping skills worked for the client?

The clinician should seize opportunities to:
• Enhance motivation using a motivational interviewing approach.
• Build the client’s self-efficacy: View the change process as skills building. Help the client reflect on prior and current successes.
• Facilitate client skill development.

Conclusions
This chapter addressed therapeutic principles and general facilitation issues. The MBS curricula are designed for open groups: clients may enter the group at any session, provided that they are
appropriate for the level of care and provided that there is an opening in the group. Consequently, sessions are designed to take this into account, and curricula attempt to best use advantages of the
open group:
• Clients join the group when they are motivated and ready.
• Length of stay in open groups may be individualized.
• There is a seniority range in the open group, from new members to more-experienced members. This provides multiple perspectives on the course of treatment, reflecting progress and inspiring hope.
• There is a nonlinearity inherent in open-group approaches that may be used to help promote a holistic perspective of recovery.

Group session outlines are presented in MBS curricula and should be followed with infrequent exceptions. However, when significant issues emerge, clinical judgment should be used. The “default” position is to prioritize the current issues and situations in the clients’ lives. The group composition may be diverse in regard to readiness to change: some are more sobriety motivated than others. MBS curricula include therapy content that can be applied across a broad readiness continuum. For example, skill-building interventions, traditionally considered appropriate for more-motivated individuals (in the “action” stage of change), are implemented in ways that may improve readiness to change for less-motivated persons. Skill acquisition may serve to improve motivation as a by product of boosting confidence.

For individuals in different stages of the change process, motivation may be enhanced in MBS groups through values clarification exercises. Additionally, the facilitator may engage in brief, individual MI-based interactions within a group session as needed. MBS recommends individual MI counseling sessions (outside of group) where motivational issues are paramount and require more time than can be devoted to a single individual in the group format.

Caution should be taken, however, in regard to using some aspects of motivation enhancement therapy for individuals who are already motivated and committed to change. For instance, developing discrepancy about sobriety should generally be avoided, because this might reintroduce “ambivalence about changing” for a person who had already achieved sufficient motivation and commitment to change.

This chapter provided guidance on facilitating processes and addressing issues that are common in intensive outpatient and residential group therapy sessions, including check-ins, motivational interviewing spirit, knowing one’s clients, and integrating clients’ experiences into session materials. Awareness cues and counseling tips were presented to address lapse management; coping with cravings or urges to use; debriefing after exposure to risky situations; and integrating into treatment sessions motivation enhancement, self-efficacy strengthening, and skill building.