Group Therapy for Adult Survivors of Childhood Abuse

A Practical Guide for Mental Health Professionals

Lorraine McColgan

• Publisher: Routledge
• Year: 2022
• Print ISBN: 9780367862565
• eBook ISBN: 9781000551709
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book presents the therapist with a reflective and robust framework for group treatment that promotes an end to the shame and secrecy so frequently experienced by survivors.

Through a series of tools such as visualisations and art exercises, the practitioner is guided through the process of establishing and running a group in this modality. The synthesis of both an educational and a process-based model is imbued with a sense of warmth and a deep understanding of this client group. Themes such as self-soothing, strengthening boundaries, inner-child work, making meaning of endings, and ways forward drive this therapeutic approach. Taking group work as the optimum matrix for change for this client population, this model provides a convincing rationale for the establishment of said work as best practice in the institutions that provide for their care.

Practicing therapists and mental health nurses will find this new model of therapy an instrumental resource in their approach to treatment for survivors of trauma and abuse.

Part 1 Forming a Group

Chapter 1 Assessment

DOI: 10.4324/9781003268888-3

Choosing the members of a therapeutic group is perhaps the most important and crucial aspect to get right. When a group gels and acts as a supportive and reflective and safely challenging space, there is nothing as effective for the promotion of profound and positive change. If there is a misstep at this point and an unsuitable person or persons are admitted to the group, you will have considerably reduced the efficacy of tire work, if not effectively sabotaged it.

A client population that has survived the experience of trauma and abuse has often done so within a family or pseudo-familial context. The experience of participating in the therapeutic group should in no way echo those early group memberships and rather should be wholly supportive, clean, honest, boundaried and clear. The desire is to create a healthily functioning community where the traumatised client can recast their mental and emotional template of this intimate environment. Assagioli speaks of the group as a place where people can begin to practice “right relations” and to form a clearer understanding of the practice and function of this way of relating (Assagioli, 1983, p.27). As a consequence of this internalised new framework they should be endowed with greater clarity, trust and robustness within their own families and communities. Admitting a member who is unable to adhere to the principles, boundaries and spirit of the group, for reasons of motivation, personal development or location in their personal journey, is at best ill-informed and at worst damaging.

Choosing members who are genuinely eligible and able for this type of work is the first act of respect that you demonstrate to the group. It is the foundation for the trust that you are hoping to provide them the experience of. Survivors of trauma and abuse have a near psychic ability to intuit anything or anyone that is potentially tricky or divisive and it reflects poorly on the therapist if they appear to have “missed it”. This is an impossible thing for any group member to speak of or address, as it is damning to both the therapist and the fellow group member and so it cannot be processed safely or at all. As there is little or no therapeutic benefit to working through this issue, the best course is to avoid it.

The appropriate number for a group of this nature is from six to eight people, excluding the therapists. This allows sufficient time for all members to have space, without the room being so Ml that it becomes difficult to hide or to find a way in. There is a mirroring of the family system contained within this size of a gathering that is beneficial to the processing of this dynamic as it will play out in the group. Too many participants and things become unwieldy and more difficult to guide whereas too few participants will create a vacuum of personalities and compromise the push and pull of the interaction; as Yalom notes, “A critical mass is required for an aggregation of individuals to become an interacting group” (Yalom. 1970, p.31).

Criteria for Eligibility

Finding group members who are ready and able for this type of process is central to creating a fertile and healing dynamic. It is a strong and potent matrix to place the individual client within and proper care must be taken that there is sufficient ego strength and resilience to manage it. The client is not expected to be without vulnerabilities or to have achieved clarity on all matters; nonetheless, it is important that the client who will participate in the group process has done a number of things prior to being considered for this therapeutic milieu.

Commonality

Yalom establishes group cohesiveness as one of the founding elements in the formation of any group. He illustrates that “Those with a greater sense of solidarity or we-ness value the group more highly and will defend it against internal and external threats; voluntary attendance, participation, mutual help, defence of group standards are all greater” (Yalom, 1970, p.31). The client must fit the criteria of the group. It must be clear from the outset what this group is and who it is for. Safety is in some sense provided by a sense of commonality of experience. This enables members to know that they will not stick out or be on their own. as was their early experience. This is half of the battle already, as the profound isolation felt by many as being the only one to whom bad and unspeakable things were happening has created a sense of difference or otherness that has remained with them throughout their lives. The very act of sitting in a room with people who shared similar experiences resets the clock. It is evident that the other participants seem and are normal and do not in any way stand out or appear to be marked by their lives in any observable way. The “weirdness” is neutralised in a single stroke.

Attendance and Punctuality

It is crucial that any client being considered for group has demonstrated an ability to attend regularly for their appointments and to do so in a punctual manner. This demonstrates a sufficiently good level of time and life management, good motivation and importantly respect for the therapist and the therapeutic process. Failure to attend regularly and in a timely manner can be read by the group, correctly or otherwise, as disrespectful and can be disruptive to fostering the needed sense of trust and consistency.

A Significant Piece of One-to-One Work Should Have Been Accomplished

Clients should have engaged, in general, in a medium- to long-term therapeutic process. This will have allowed them to form and experience a therapeutic relationship. It should have fostered a level of trust and the ability to reflect on their personal psychological and emotional processes and on their own role in relationship dynamics. Hopefully, this has led to some changes in personal style or behaviour to a greater or lesser degree and if it has not. the therapist should feel that the client is at the tipping point of change and that the group would be an effective catalyst.

This should involve achieving a relatively honest and truthful look at the family of origin as well as the perpetrator(s) of abuse. Tins is important as it would be highly provocative to a group who have acknowledged the inappropriateness of abuse to have a member who is highly ambivalent or affectionate in their feelings towards a perpetrator. It recreates echoes of the original denial and ignorance that survivors are often met with. To encounter it again in this environment would be highly charged and carry a number of negative consequences. It can risk alienating the group member who carried the ambivalence and potentially turn them into a target for hatred or negative feelings. It may also be seen to reflect poorly on the therapeutic process that had been engaged in, as the therapist “hadn't made them see” how any loyalty to the abuser is “bad” or “wrong”

Some ambivalence is tolerable, however, as most survivors who experienced their abuse within a family context are likely to have it. Intolerance for any closeness to a perpetrator, especially a family member, denies shades of grey, and often the client who is most obviously ambivalent is a soft target for the shadow of the ambivalence that lies within most survivors if the perpetrator was a member of the family of origin. Provocation is not negative and provides fuel for this very valuable theme to be drawn out Once there is no significant idealisation of the perpetrator these themes are workable within a group context.

Transference issues should have been experienced and resolved successfully. This is an important piece as many clients of a service working with trauma and abuse will have experience neglect, mistrust and manipulation in their primary relationships. As a result of this, many quite understandably face into other relationships with a foundation of mistrust and suspicion and a personal style of defensiveness that echoes the style that they had to adopt in their early years in order to survive and withstand the blows that came to them. In all therapeutic work of any quality, this style will need to be uncovered, faced and. as a result, modified. It is best if this has been brought into awareness to some degree prior to group entry as an overly defended style will be antagonistic in the group context and has much potential to block safety and trust.

Motivation and Clarity of Purpose

Clients who are volunteering to take the great risk of revealing themselves and their closely guarded secrets and shame, to what, in the beginning, is a group of strangers, should have some sense of why they are doing it. They will of course have been sold the idea by their therapist but it is important that they have identified some tangible potential benefit for themselves. Most frequently, a reduction in isolation is identifiable as a benefit. Other gains are increased self-esteem, selfassertiveness and increases in clarity and direction. It is not of benefit if a client is participating solely on the direction of the therapist and simply being a good client and doing what is suggested. Some nugget of personal price will be instrumental in making the investment in the process.

Unsuitable Clients

As has already been stated, a rogue participant can cause significant distruption to the forming and successful execution of a therapeutic group. Clients with certain characteristics simply do not suit this process and will not benefit personally from it nor bring benefit to others. As therapists we can often like certain clients or possess an empathy for them and their situations that can make us desirous of their inclusion in a group. At times we can have clients who have not moved on and that we might like to wash our hands of. and referral to a group may seem to be a solution.

Group referral, however, is no place for indulging either preferential treatment or burnout. As Benson states, “If members are to achieve personal goals and help accomplish the group task they require a healthy environment which encourages them to have intimate relationships with each other and fosters independence” (Benson, 1987, p. 169). The cost is high for all if an unsuitable candidate enters the group with much of the group's time and resources being hijacked by the individual in question. Tins leads to resentment on the part of the majority of participants who would like to “get on with it” and. quite correctly, do not wish to spend time fire fighting one group member’s negative behaviour and influence. The following list outlines who is unsuitable and why this is the case.

Clients with Active Addiction Issues

Those clients who are actively engaged in issues of addiction, that are obvious to observe and evidently harmful, are not sufficiently stable to engage in group. The use and misuse of any substance to control or modify emotion is indicative of a lack of ability and/or motivation to substantially face or address said emotions.

As this is the very process that underpins the working of therapy, it is crucial that it can be managed by all participants. Groups that work primarily with issues of addiction are far more suitable for this type of client.

I refer principally here to drugs and alcohol and sexual addictions. Other addictions are potentially more workable in the group context. Gambling and eating addictions that are not life or lifestyle threatening may be sufficiently mild that they can be workable and should not be immediate criteria for exclusion. Many clients will engage in self-soothing behaviour that has a negative consequence indeed, this topic is included in the group work. Very fruitful sessions can emerge from sharing experiences of comfort eating and drinking and self-medication with prescription medicines, and to the extent that shame and secrecy can be lifted in these areas, real transformations can be made. It is common also that alcohol and prescription medication can be used as a self-soothing device by many clients. indeed by many individuals who have no need of therapy, and it is a question of degree and level of impact of this behaviour that determines suitability or otherwise.

Clients with Diagnosis of Borderline, Schizophrenic or Other Personality Disorders

Clients who present within the spectrum of the personality disorders, as outlined by DSM, are not eligible candidates for inclusion on this type of group. This client group typically demonstrates symptomology that speaks of a core instability that is too great to be managed in this model of group therapy. Medication is central to the regulation of the symptoms that present with this population and individual therapeutic intervention is more suitable. Clients who have had a diagnosis of bipolar or manic depression in the past but who have been stable for a consistent time period should be able to engage providing they meet the other outlined criteria. It should be noted, however, that participation could trigger a temporary resurfacing of old symptoms and provision and assistance should be made available for this.

Actively Traumatised Clients

Clients who have undergone a recent trauma or significant loss or who experience vivid flashbacks to the extent that they are immobilising to them may find the group setting too provocative and triggering. It is not advantageous to these clients to have “too much too soon” and the experience of having a flashback that has a physical affect in a group setting may be overwhelming for both that client and the group, not to mention the therapist. All clients should have the ability to a large extent to contain strong emotion (which does not mean not to express it) in a manner that does not cause concern for their physical or mental wellbeing. It is preferable if there has been some (it need not be complete) integration of trauma, as wholly unprocessed trauma in a group context can feel dangerous.

Narcissistic Clients

This may be but is not exclusively characterised as a personality disorder. The narcissistic personality is a disorder in which people have an inflated sense of their own importance, a deep need for admiration and a lack of empathy for others. Beneath this presentation lies a fragile self-esteem that’s highly vulnerable and reactive to criticism. Clients who exhibit these traits are most likely poor candidates for therapy as they frequently do not consider themselves to have a problem and instead project any shadow thoughts or feelings outwards. It is very difficult to treat clients with these symptoms individually but their inclusion in a group will only result in sabotage and discord as they are most likely to be hostile to the challenges that will inevitably come to them in this setting.

Perpetrators of Abuse

Clients who actively engage in the perpetrating or perpetuating of any ongoing treatment of abuse should not be included. As stated, clarity on the unacceptability of abuse is a criterion for inclusion and any client who engages in abusive behaviour does not meet the eligibility criteria. There can be subtleties to this however and what is a nrom in one family context may be viewed as an abuse in another. Clients may differ over such issues of parenting style as acceptable curfews, diet, verbal reproofs and sibling rivalry. These again can be useful topics to draw out, however abuse in this context refers to the conscious and deliberate knowledge of or participation in what constitutes a clear abuse of a minor.

Clients Who Are Not Punctual or Good Attendees

Clients who have not demonstrated an ability to make a commitment to regular and timely attendance should not be considered suitable. Central to the smooth and effective running of the group is the consistency of all of the members. This consistency at its most basic refers to being regularly present and being on time.

Referral to Group

It is a good idea to have a clear referral form for all therapists who wish to refer in to a group (see Appendix 4). This guides the thinking of the referral agent as it will indicate the areas of work that should have been addressed prior to considering referral. It is helpful also to furnish referral agents with an information leaflet and eligibility criteria to best guide them in choosing appropriate candidates (see Appendix 7).

The Process of Assessment

Introducing the idea of participation in a therapeutic group is a matter of timing. There is a point where a significant chunk of work has been accomplished and tangible gains have been made, however the client may still lack friendships or a social network of any substance or feel that while they have been seen and understood in the therapeutic relationship, this remains a rarefied experience. It is useful at this stage to begin to explore the widening of this experience into a community setting. This has the advantage of dissolving any myths that it is only possible to be “met” by a mental health professional, due to the indigestible nature of one’s story.

Many clients feel that they are hiding large aspects of themselves and their histories to those close to them and as a consequence, intimacy has been compromised in their lives. The one-to-one therapy should shift this dynamic and shrink the tyranny of shame and secrecy to a good degree. Once this coup has been accomplished it makes sense to capitalise on it. If the therapeutic relationship has been a positive one it is a strong platform for recommending the continuation of the clients’ transformative process in a group setting.

The therapist is a trusted figure who would not make any suggestion that is not in the client’s interest. The process of referral is more straightforward if the same therapist is also going to be the group therapist. This allows for a continuation and further development of the original working alliance and the therapist can function as an anchor or “safety person” enabling the transition to be less anxiety provoking. If the movement is to a different therapist it will be necessary to do a piece of bridging wor...

Table of contents

• Cover
• Half Title
• Endorsements
• Title
• Copyright
• Contents
• Acknowledgements
• Foreword
• Introduction
• PART 1 Forming a Group
• PART 2 Therapeutic Co-Working
• PART 3 Session Structure
• PART 4 Session Themes
• Appendices
• Index