Client handout 4_6_exercise_on_identifying_triggers

138
Copyright by Linda Carter Sobell and Mark B. Sobell. Reprinted by permission in Group Therapy for Substance Use Disorders:
A Motivational Cognitive-Behavioral Approach. Copyright 2011 by The Guilford Press. Permission to photocopy this handout is
granted to purchasers of this book for personal use only (see copyright page for details).
CLIENT HANDOUT 4.6
Exercise on Identifying Triggers
Individual and Group Session 2
Part of this program involves completing readings and homework exercises prior to your sessions.
These are intended to help you
Prepare for your sessions
Take an active role in changing your behavior
Evaluate your progress
In the first exercise you weighed the costs and benefits of changing. Now we want to help you identify
what is triggering or associated with the behavior you want to change.
THINGS TO CONSIDER WHEN COMPLETING THIS EXERCISE
Because the behavior you want to change has come to play a major or large role in your life, you may
need to make some lifestyle changes. Take a look at the following areas in your life:
Availability: If the things that prompt your behavior are readily available, you may want to
change your environment.
Activities: If you spend a lot of time engaging in the behavior, you may need to find other ways
to spend your time.
Relationships with peers: In some cases, a change in social relationships may be necessary to
change behaviors. If you decide that associating with certain people is too risky, then you might
decide that a change in your circle of friends is necessary.
The following questions and general categories of triggers are intended to help you complete this
exercise.
Questions:
Where and when does your behavior occur?
What other people are present on these occasions and how do they affect your behavior?
What do you accomplish by engaging in the behavior? That is, what purpose does it serve for you?
General Categories of Triggers:
Emotional State (e.g., angry, depressed, happy, sad)
Physical State (e.g., relaxed, tense, tired, aroused)
Presence of Others (e.g., when the behavior occurs are certain people present?)
Availability
Physical Setting (e.g., work, party, ex-spouse’s house)
Social Pressure (e.g., are you forced or coerced into doing things you don’t want to?)
Activities (e.g., work, working at home, playing sports, watching TV, playing cards)
Thoughts (e.g., remember times you engaged in the behavior)
You are now ready to complete this exercise!
(cont.)

139
Exercise on Identifying Triggers (page 2 of 3)
EXERCISE
Describe two general types of situations that have triggered the behavior you want to change.
One thing that can help you to identify triggers and consequences related to changing is to think about
real experiences you have had.
TRIGGER SITUATION 1
Brieﬂy describe ONE of your high-risk trigger situations.
Describe the types of CONSEQUENCES usually associated with this situation.
Consider both NEGATIVE and POSITIVE consequences, and whether they occur
right away or are delayed.
(cont.)

140
Exercise on Identifying Triggers (page 3 of 3)
TRIGGER SITUATION 2
Brieﬂy describe ONE of your high-risk trigger situations.
Describe the types of CONSEQUENCES usually associated with this situation.
Consider both NEGATIVE and POSITIVE consequences, and whether they occur
right away or are delayed.

141
CLIENT HANDOUT 4.7
Sample BSCQ Alcohol or Drug Use Profile from the Assessment
YOUR SELF-CONFIDENCE PROFILE
The following graph shows your confidence that you could resist drinking heavily or resist urges to use
drugs in different situations. Situations in which you have low confidence are more likely to pose a risk
for you. You may find it particularly helpful to think of ways to identify and plan for these situations in
advance. For example, if you have little confidence that you can resist drinking heavily or using drugs
in social pressure situations, you may want to avoid such situations or deal with them differently. You
can also look at your daily alcohol or drug use calendar to see if your heavier drinking days or drug use
occurred when you had trouble resisting urges to drink heavily or resisting urges to use drugs.
How Confident Are You?
The three situations in which you indicated you had the lowest confidence in your ability to resist
drinking heavily or resist using drugs are highlighted in BLACK below.
0 10 20 30 40 50 60 70 80 90 100
Unpleasant Emotions
Physical Discomfort
Pleasant Emotions
Testing Control
Urges and Temptations
Conflict
Social Pressure
Pleasant Times
Confidence to Resist Urges to Drink
Heavily or Resist Urges to Use Drugs
Situation

142
CLIENT HANDOUT 4.8
Exercise on Developing New Options and Plans
In this exercise you will develop new options and action plans for the high-risk trigger situations you
described in the exercise on Identifying Triggers.
TRIGGER SITUATION 1
Describe two options and their likely consequences for your ﬁrst trigger situation in the exercise on
Identifying Triggers.
Be as speciﬁc as possible in describing your options, all of which should be feasible.
For each option, describe what you think would happen if you used that option.
Consider both negative and positive consequences.
Finally, decide which option would be your best and second-best option for dealing with this trigger
situation.
Option 1:
Likely Consequences:
Option 2:
(cont.)

143
Exercise on Developing New Options and Plans (page 2 of 4)
CHANGE PLAN
You have selected two options for your Trigger Situation 1. For each option, describe what you need to
do to achieve that option.
Your Change Plan should describe in some detail how you could put your option into practice.
It helps to break your plan into smaller steps.
Option # 1 Change Plan
(cont.)

144
TRIGGER SITUATION 2
Describe two options and their likely consequences for your second trigger situation in the exercise
on Identifying Triggers.
Be as speciﬁc as possible in describing your options, all of which should be feasible.
For each option, describe what you think would happen if you used that option.
Consider both negative and positive consequences.
Finally, decide which option would be your best and second-best option for dealing with this trigger
situation.
Option 1:
Option 2:
(cont.)

145
CHANGE PLAN
You have selected two options for your Trigger Situation 1. For each option, describe what you need to
do to achieve that option.
Your Change Plan should describe in some detail how you could put your option into practice.
It helps to break your plan into smaller steps.

146
CLIENT HANDOUT 4.9
Sample BSCQ Alcohol or Drug Use Profile
from the Assessment and Session 3
YOUR SELF-CONFIDENCE PROFILE
How Confident Are You?
The following graph shows your confidence that you could resist drinking heavily or resist urges to use
drugs in different situations. The GRAY bars show your confidence when you started the program and
the BLACK bars show how confident you are now. Situations in which you have low confidence are
more likely to pose a risk for you. Remember, you may need to avoid situations in which you still have
low confidence that you can resist drinking heavily or resist urges to use drugs, or learn to deal with
them differently.
0 10 20 30 40 50 60 70 80 90 100
Unpleasant Emotions
Physical Discomfort
Pleasant Emotions
Testing Control
Urges and Temptations
Conflict
Social Pressure
Pleasant Times
Confidence to Resist Urges to Drink Heavily
or Resist Urges to Use Drugs
Situation

147
From Group Therapy for Substance Use Disorders: A Motivational Cognitive-Behavioral Approach by Linda Carter Sobell and
Mark B. Sobell. Copyright 2011 by The Guilford Press. Permission to photocopy this handout is granted to purchasers of this book
for personal use only (see copyright page for details).
CLIENT HANDOUT 4.10
Request for Additional Sessions
This treatment program allows you to request additional individual sessions beyond the first four
sessions.
The program is designed to be individualized. Some people will need more sessions than others;
some may need more now, some may need more later.
Consistent with being a program that allows each individual to guide his or her own change, if you
feel you require additional sessions, you need only to ask your therapist.
In addition, your therapist will be contacting you by phone one month after your last session. This
contact allows your therapist to find out how you are doing and also allows you an opportunity to
discuss any issues or problems you are concerned about or request additional sessions.
Please check the option below that reflects what you feel you need at the present time and give this
form to your therapist at the beginning of your next session.
a. I do not feel I need any further sessions beyond the next session, but I understand I can
call and request additional sessions at any time in the future.
b. I feel I need additional sessions at this time, for the following reasons:
c. I would like to discuss the issue of whether I need additional sessions with my therapist
at the next treatment session.

148
CHAPTER 5
Integrating Motivational Interviewing
and Cognitive-Behavioral Techniques
into Group Therapy
Although some CBT [cognitive-behavioral therapy] groups do
currently employ group processes, little attention had been focused
on how a CBT group can systematically use group power to maximize
efficacy or how CBT interventions might impact upon group process.
—SATTERFIELD (1994, p. 185)
A pure motivational interviewing psychotherapy group [original
emphasis] could be developed in which a skillful counselor utilized
motivational interviewing techniques and adhered to motivational
interviewing principles within the group.
—INGERSOLL, WAGNER, AND GHARIB (2002, p. 52)
This chapter discusses issues concerning difficulties that others have encountered when attempt-
ing to extend cognitive-behavioral and motivational interviewing methods to a group therapy
context. It also includes a brief review of the few RCTs that have been conducted comparing
individual and group treatments for SUDs.
Motivational interviewing is designed to develop a collaborative relationship between cli-
ents and therapists in which clients’ resistance is minimized and their commitment to change is
strengthened and sustained. In addition to treating SUDs, studies using motivational interview-
ing have had impressive outcomes across a variety of health and mental health problems (Britt et
al., 2003; Burke et al., 2003; Heather, 2005; Miller, 2005; Resnicow et al., 2002; Wright, 2004).
However, most studies have only involved treatment delivered in an individual setting. The suc-
cessful adaptation of motivational interviewing to group therapy, in contrast, has been difficult
(Walters, Bennett, & Miller, 2000; Walters, Ogle, & Martin, 2002). In their review of moti-
vational interviewing in groups, Walters and colleagues (2002) found that when motivational
interviewing was used in the context of providing psychoeducational feedback to participants
in groups it was not successful. Often this involved a single session done in a non–motivational
interviewing manner to correct deficient knowledge. In many ways, such psychoeducational
efforts are better characterized as lecturing or as conducting individual therapy in a group

Integrating MI and CB Techniques into Group Therapy 149
setting compared with group psychotherapy that utilizes group processes to facilitate behavior
change.
In their review of failed group motivational interviewing studies, Walters and colleagues
(2000) may have inadvertently provided an explanation for the limited success of motivational
interviewing group studies:
Unlike patient education, motivational interviewing is more a navigation process than a transmis-
sion of information: Behavior change happens when the individual weighs relevant reasons in rela-
tion to the short-term rewards of the behavior. Because of the complexity of interactions in a group,
there is more potential for discrepancy diffusion, non-participation, resistance, and collective argu-
mentation. (p. 381)
Another way of understanding why motivational interviewing does not adapt particularly well
to psychoeducational and many support groups is to realize that although “the group is a vehicle
for delivering a particular package of theoretical material, the nature of the member interaction
is not the prime focus” (MacKenzie, 1994, pp. 47–48). In traditional group psychotherapy, MacK-
enzie (1994) says that the members’ interactional experience is the primary learning vehicle. In
a related regard, Ingersoll and her colleagues (2002), in recognizing that their motivational
group model was psychoeducational in nature, stated that “A pure motivational interviewing
psychotherapy group could be developed in which a skillful counselor utilized motivational
interviewing techniques and adhered to motivational interviewing principles within the group”
(p. 52, original emphasis).
THE POWER OF THE GROUP: CAPITALIZING ON GROUP PROCESSES
Almost all cognitive-behavioral treatments are evidence-based and have been shown to be
effective with a host of clinical disorders in an individual setting (see Bieling, McCabe, & Ant-
ony, 2006; Satterfield, 1994). Although cognitive-behavioral therapies have traditionally been
conducted in an individual format, an increasing number of studies have extended these treat-
ments to a group setting. Despite this expansion, as discussed shortly, RCTs comparing group
and individual treatments, particularly the same treatment, have been few in number (Tucker
& Oei, 2007). Two reviews, published over a decade apart, have compared cognitive-behavioral
therapy in group versus individual settings and both reviews concluded that the results were
mixed or inconsistent (Satterfield, 1994; Tucker & Oei, 2007). Satterfield (1994) suggested that
many group cognitive-behavioral treatment studies have “deemphasized group dynamics”
(p. 187).
Two major problems that have plagued cognitive-behavioral group treatments are (1) their
failure to systematically use group processes, which Satterfield (1994) says “dilutes their power”
(p. 192), and (2) their failure to integrate cognitive-behavioral techniques with group processes.
These concerns, articulated 15 years ago (Satterfield, 1994), were reiterated recently in a book
on this topic (Bieling et al., 2006). In his 1994 review, Satterfield argued that most cognitive-
behavioral therapy groups seemed to view group dynamics as “epiphenomenal or minimize
the importance of group processes to varying degrees” (p. 185), and, “although interpersonal
exchanges do occur in CBT [cognitive-behavioral therapy] groups, interventions usually focus

150 GUIDED SELF-CHANGE
on treating the individual in a group rather than through the group” (Satterfield, 1994, p. 185).
In addition, both Satterfield and Bieling and colleagues have asserted that when cognitive-
behavioral groups target the intervention to individuals in the group, they ignore the power of
the group.
For example, in a behavioral study involving social skills training groups, Monti and col-
leagues (1989) reported that their groups were intended “to educate clients rather than explore
feelings” (p. 126). They further commented, “in the context of behavioral skills training groups,
‘process’ can have a somewhat different meaning than it does when it is used in more traditional
group psychotherapy” (p. 125). Similarly, in describing how to deliver cognitive-behavioral treat-
ment for social phobia in a group setting, Heimberg and Becker (2002) cautioned that in terms
of their group instruction many of the activities “focus on the interaction of the therapist(s)
with a single client” (p. 268). As with Monti and colleagues’ study, Heimberg and Becker’s skills
training groups for social phobia can be viewed as dyadic interactions conducted in a group
context rather than as reflecting true group processes. In summary, cognitive-behavioral stud-
ies typically have been highly structured, and they often have involved a therapist working with
one client at a time while other group members observe the interaction. This, of course, is very
different from using interactions among group members as a force for change.
Satterfield (1994) suggested that attention to group processes and structure could enhance
the outcomes of cognitive-behavioral therapy studies. In looking at some of the key group pro-
cess variables identified by Satterfield (e.g., group cohesion, group norms, isomorphism), it is
easy to understand why successful cognitive-behavioral interventions and motivational inter-
viewing techniques conducted in an individual setting have not readily generalized to a group
setting. For example, group cohesion, discussed in detail in Chapter 6, is defined as the extent to
which a group is reinforcing to its members. Cohesive groups are characterized as having a posi-
tive group atmosphere, a culture in which members take personal responsibility for group work
and for group changes. Cohesive groups also have an absence of interpersonal tension. Thus
groups that fail to use group processes are more likely to have low levels of cohesion, a charac-
teristic that research has found to be associated with poorer treatment outcomes (MacKenzie,
1997; Satterfield, 1994).
A group setting provides a basis for influencing group members’ behavior in terms of social
support and social pressure to change, something not possible in individual therapy. When group
dynamics are operating, interactions are occurring on multiple levels, as well as within the entire
group. One reason that group psychotherapy is viewed as complex and challenging is that a
therapist has to operate on multiple levels (Dies, 1994; Yalom & Leszcz, 2005): (1) as a member
of the group; (2) as a therapist directing the group toward goals and addressing resistive or chal-
lenging members; and (3) as discussed in Chapter 6, as an orchestra conductor getting the group
members to work in harmony to produce a sound not achievable by any single instrument.
ADAPTATION OF THE GSC TREATMENT MODEL
The preceding chapter described how to conduct GSC treatment using an individual therapy
model and contained four individual treatment session outlines for therapists. In contrast, this

chapter describes the adaptation of the GSC treatment model to group therapy. This adap-
tation involves integrating cognitive-behavioral and motivational interviewing strategies and
techniques into a group format. As in Chapter 4, at the end of this chapter there are four ses-
sion handouts for the group leaders (Group Therapist Handouts 5.1–5.4), which describe ses-
sion objectives, session procedures, client handouts, and pregroup planning. In addition, each
group handout presents several round-robin discussions, the format used to conduct the clinical
intervention in a therapy group. This discussion format is designed to get support, feedback, and
advice emanating primarily from group members rather than the group leaders. Within each
round-robin discussion are sample dialogues and clinical examples that allow group leaders to
integrate the cognitive-behavioral and motivational interviewing techniques, strategies, and
homework exercises into a group format. To avoid redundancy, descriptions of the GSC mea-
sures and other session details, explained at length in Chapters 3 and 4, are not repeated here.
Rather, reference is made to their having been described in other chapters.
Composition and Structure of the GSC Groups
As described in Chapter 1 (see Table 1.2), several evidence-based studies have evaluated the
GSC treatment model. Except for the study described in this book (L. C. Sobell et al., 2009), the
other studies were conducted using an individual therapy format. In terms of composition and
structure, the GSC group intervention, like its individual counterpart, is a cognitive-behavioral
intervention that uses a motivational counseling style and strategies throughout treatment.
Because the intervention is time-limited (i.e., assessment and four semistructured sessions), a
closed-group format is used (i.e., no members added after the ﬁrst session).
The client mix can be heterogeneous and include males and females, as well as individuals
with different substance abuse problems. The ideal number of members for such groups is six to
eight (in addition to the leaders). Group sessions are scheduled once a week for 2 hours. Group
members are phoned the day before each meeting to remind them of the upcoming group.
Because the GSC group treatment model uses group processes to avoid conducting one-on-one
therapy in a group setting, the group leaders (cotherapists) need training in how to use group
processes. The same homework exercises, readings, and self-monitoring logs used for conduct-
ing individual GSC therapy are used in the group version of the treatment, with the main dif-
ference being that the group discussions are conducted using a round-robin discussion format,
which is described shortly.
Before starting the group, clients are assessed individually, and the upcoming group is dis-
cussed with them. As part of the assessment, they are given a brochure (Client Handout 5.1) that
describes the beneﬁts of group therapy and the expectations of group members. Before and after
every group, the group leaders meet for 10–15 minutes for pregroup preparation and postgroup
discussions. Although there are only four structured sessions, clients can request additional ses-
sions that would be conducted as individual therapy sessions. In our clinical experience, it has
worked well for one of the group leaders to be the therapist for members who request further
sessions. Finally, all clients are informed that one of the group leaders will call them about 1
month after their last group session to inquire about their progress, to be supportive of changes,
and to schedule additional sessions if needed.

Preparing to Lead Groups
As is discussed in Chapters 7 and 8, conducting therapy groups (vs. process or psychoeducational
groups) is complex and can present challenges. There are several reasons that group therapy is
seen as more complex than individual therapy. The first is that multiple clients must be handled
simultaneously. Second, as is discussed in Chapter 9, many group therapists have had little to
no formal group training. To meet the challenges of group work and to provide appropriate care
for patients, experts in the field of group psychotherapy feel that specialized training is essential
(Bieling et al., 2006; Dies, 1994; Markus & King, 2003; Thorn, 2004; Yalom & Leszcz, 2005).
Because many of the skills needed to conduct individual therapy do not generalize to group
therapy (Dies, 1994), even the best individual therapists will need training to effectively use and
apply group processes. Finally, a major reason that it has been difficult to integrate cognitive-
behavioral and motivational interventions, especially components such as homework exercises
and personalized feedback, into group therapy has been an insufficient appreciation for group
processes (Bieling et al., 2006).
Concerns When Adapting Motivational Interviewing and Cognitive-
Behavioral Techniques and Strategies into a Group Format
For the reasons just discussed, extending any evidence-based treatment delivered as individual
therapy to a group format requires serious adaptations. As discussed in Chapter 1, when we
decided to extend the GSC treatment model to a group format, it took considerable planning
and work. One of the adaptations involved recognizing the need to understand the dynamics
of running groups using group processes. The primary reason for this is that, unlike individual
therapy, in which there is a dyadic interaction, in groups there are multiple and complex inter-
actions that need to be managed. A sine qua non of successfully running groups is for group
leaders to understand how to use the interactions of the group to guide members toward behav-
ior change (Yalom & Leszcz, 2005) and to “rigorously and responsibly use group processes”
(Satterfield, 1994, p. 192).
We had three major concerns when incorporating cognitive-behavioral and motivational
interviewing techniques into a group format. The first was ensuring that the treatment would
make use of the group format rather than simply being an arena for observing dyadic interac-
tions. In this regard, Satterfield (1994) has asserted that “although interpersonal exchanges do
occur in cognitive-behavioral groups, interventions usually focus on treating the individual in
the group rather than through the group” (p. 185, original emphasis). Our second concern was
to make sure that group processes were utilized to facilitate change. The third major concern
was to integrate motivational and cognitive-behavioral strategies into the group format in a way
that would retain their therapeutic impact and effectiveness.
The first two concerns can be addressed if therapists receive adequate training in group
processes. In terms of the integration of motivational interviewing and cognitive-behavioral
strategies into a group format, which is the main focus of this chapter, we first reviewed the
literature on group therapy to learn how to create an effective integration that would capital-
ize on group processes. We also arranged for experts in group therapy to train the staff. This
experience demonstrated to us that therapists with little group experience could be successfully

trained in group processes (i.e., outcomes for the group and individual treatment conditions in
our study were very similar, and both demonstrated significant pre- to posttreatment changes;
L. C. Sobell et al., 2009).
At the same time that we were determining how to integrate cognitive-behavioral and
motivational interviewing strategies into a group format, we also had to address constraints
inherent in group therapy. The major constraint we faced was including all members in the
group discussions within the time limits of the group. In this regard, we decided to use what we
have termed round-robin discussions. Thus, for many of the GSC procedures (e.g., personalized
feedback, review of homework exercises), the primary way the group sessions differ from the
individual sessions is that the groups use a round-robin discussion format.
ROUND-ROBIN DISCUSSIONS
Round-robin discussions are used throughout the GSC group sessions as a way of including all
group members in the discussion of all major topics and exercises. Table 5.1 contains descrip-
tions of the several round-robin discussions used in the four GSC group sessions (L. C. Sobell et
al., 2009). The four Group Therapist Handouts (5.1–5.4) at the end of this chapter include spe-
cific suggestions for how to focus each round-robin discussion and examples of ways the group
leaders can initiate and maintain the discussions. In addition, the handouts contain notes for
group leaders related to managing the discussions. Table 5.2 provides examples of statements
group leaders can make to bring members and topics into the group discussion (e.g., address
sensitive issues raised by a member, get all members to comment on a particular topic).
Round-Robin Discussions: A Way for Members to Share Time in Groups
Although group members cannot receive as much attention (e.g., homework answers) as in indi-
vidual therapy, the round-robin discussions provide an opportunity for all group members to
discuss some aspect of each topic or assignment and to receive feedback and support from
their peers. At the first session, the following key aspects of group are discussed: expectations
of members, group rules, the need for regular participation, and group members’ need to act
as agents of change (i.e., providing support and reinforcement to one another). Last, for round-
robin discussions to work effectively, group leaders need to manage the time so that all mem-
bers get an opportunity to participate and all topics scheduled for each session are covered (e.g.,
personalized feedback, discussions of homework).
Group leaders also explain to the group that they are looking for balanced participation
and that one way to ensure this is to use round-robin discussions. Although each group member
always gets an opportunity to discuss each assignment and his or her weekly self-monitoring
logs, each is asked to select one example from the homework (e.g., in Client Handout 4.6, one of
the two high-risk trigger situations) rather than discussing everything in each assignment. Over
the years, we have found that if the rationale for round-robin discussions is presented to the
group, they understand and quickly become accustomed to the procedure.
At every group session, members are asked to share their experiences and to comment on
other members’ behaviors and assignments. In this way, commonalities among members can be

TABLE 5.1. Round Robin Discussion Topics Used in the GSC Group Treatment
SESSION 1
Introductions: Includes normalizing members’ feelings about groups and discussing group rules, what
members expect out of treatment, and why they come to treatment
Self-Monitoring Logs: Discussion of clients’ completed logs for alcohol or drug use since the assessment
interview (Alcohol: Client Handout 3.2; Drug: Client Handout 3.3)
Goal Evaluations: Review of clients’ completed goal evaluations for abstinence or low-risk, limited
drinking, including their goal importance and confidence ratings (Abstinence: Client Handout 3.4; Goal
Choice: Client Handout 3.5)
Personalized Feedback: Discussion of the personalized feedback handouts (i.e., summaries of pretreatment
alcohol and drug use; where their alcohol or drug use fits in with respect to national norms; scores on
the AUDIT or DAST-10 evaluating the seriousness of their pretreatment substance use (Alcohol: Client
Handout 4.1; Drug: Client Handout 4.2).
Decisional Balance: Discussion of good and less good things about changing alcohol or drug use using the
decisional balance exercise (Client Handout 3.1)
End of Session: Wrap-Up and what stood out
SESSION 2
Self-Monitoring Logs: Discussion of clients’ completed logs for alcohol or drug use since Session 1 (Alcohol:
Client Handout 3.2; Drug: Client Handout 3.3)
High-Risk Trigger Situations: Discussion of the reading and exercise on identification of high-risk trigger
situations for alcohol and drug use, including how to take a realistic perspective on change (i.e., Mt.
Recovery) and how to view slips as learning experiences (Reading: Client Handout 4.5; Exercise: Client
Handout 4.6)
BSCQ: Review of the personalized profiles of high-risk situations for alcohol or drug use using the BSCQ
clients completed at assessment; includes a discussion of the relationship of the BSCQ profile to their high-
risk triggers homework exercise (Client Handout 4.7)
Where Are You Now Scale: Review of clients’ completed Where Are You Now scale (Client Handout 3.6)
SESSION 3
Developing New Options and Action Plans: Discussion of the homework exercise on developing new
options and action plans to deal with the high-risk trigger situations identified in Session 2 (Client
Handout 4.8)
SESSION 4
Personalized Comparative Feedback about Alcohol or Drug Changes: Discussion of personalized feedback
about changes in alcohol or drug use from the assessment session through Session 3 (Client Handouts 4.3
and 4.4, respectively)
Comparative Goal Evaluations: Comparative evaluation of clients’ first (assessment) and second (Session 3)
goal evaluations, including their goal importance and confidence ratings (Abstinence: Client Handout 3.4;
Goal Choice: Client Handout 3.5)
Revisiting the Decisional Balance Exercise: Discussion of any additions or changes in clients’ decisional
balance exercise answers from Session 1 through Session 4
BSCQ Changes: Review of the prepared personalized profiles of clients’ high-risk situations for alcohol or
drug use using the BSCQ completed at assessment and at Session 3 (Client Handout 4.9)
Implementation of Options: Discussion of implementation of the exercise relating to new options to deal
with the high-risk trigger situations
Revisiting Mt. Recovery and Relapse Prevention: Review of the high-risk triggers reading
Where Are You Now Scale: Comparative review of the clients’ completed Where Are You Now scale (Client
Handout 3.6) over treatment

identified and group members are given an opportunity to provide support for or critiques of
other members’ behaviors. Except for structured group activities (e.g., homework assignments),
it is not necessary to have all members participate in every round-robin discussion. All mem-
bers should, however, participate in each group session. What builds group cohesion is not the
amount of time that a member participates but, rather, getting everyone actively participating.
Round-robin discussions begin with the group leaders introducing a topic and then open-
ing up the discussion to the group members. If no one initially comments, the group leaders
can ask the entire group who would like to start the discussion, or the leaders can ask a specific
TABLE 5.2. Ways to Bring Different Members and Topics into Group Discussions
Group focus Leaders’ comments
Look for commonalities in the discussion. “Who else has had that kind of experience?”
“Who else has similar feelings?”
“Who else feels the same way as Mary?”
Include more group members in the
discussion.
“What does the group think are some reasons why
someone might decide to drink or use drugs after being
abstinent for several months?”
Invite all members to comment (used with
homework exercises).
“What stood out about the decisional balance exercise
that each of you completed for this session?”
Elicit supportive statements from the group
about other members’ changes.
“It sounds like several members have made big changes
in their substance use since last week. How does the
group feel about these changes?”
Address an issue raised by one member and
invite others to comment.
“It sounds like Bill is ambivalent about not using
cocaine. How have others dealt with similar feelings?”
Get other members to provide additional
suggestions.
“Okay, so Bill has provided one suggestion for how
Mary might handle her difficulties with her daughter.
What other options can the group think of to help
Mary?”
Get all members to comment on a particular
topic.
“How would each of your lives be different six months
from now if you stopped using alcohol and drugs?”
Invite others to provide alternative responses
to one member’s harsh response.
“Mary, that is one way of looking at what has happened
to Bill. What are some other ways of looking at what
happened with Bill?”
Address an uncomfortable interaction and
invite others to comment.
“I am getting the sense that others seem to be
uncomfortable with what has just happened.”
Address tension that has arisen between
group members; group leaders call a time-out
to process what has happened.
“It sounds like a lot is happening, and I want to call a
‘time-out.’ We can come back to the topic later, but let’s
look at what is happening in the group right now.”
Address a sensitive issue raised by a member
and invite others to comment.
“Mary has revealed some very personal things about
herself. That must have been difficult. How do others in
the group feel about what Mary just shared?”
Acknowledge members’ nonverbal responses
and invite them to translate nonverbal
responses into verbal responses.
“I noticed when Mary discussed her difficulties with her
husband, that many of you were nodding in agreement.
What do the head nods mean?”

member to start. When members voluntarily comment in the first few sessions, group leaders
should reinforce their comments (e.g., “This is exactly what we are looking to have members do
in group”).
Round-Robin Discussions and Group Cohesion
Round-robin discussions not only ensure that all group members participate regularly, but they
also promote the development of cohesion using group processes (e.g., members identify com-
monalities and provide supportive comments to other members). To use the group time effi-
ciently during pregroup preparation (see Chapter 6), group leaders need to allocate time to
cover the planned session procedures (e.g., Session 1: beginning and ending groups; reviewing
self-monitoring logs; discussing members’ decisional balance exercises; presenting members
with feedback materials; explaining homework exercises for the next session).
A major goal of group therapy is to have the group members, rather than the group lead-
ers, be the main source of reinforcement and support for other members. Besides providing
emotional support to each other, group members can also offer one another consensual valida-
tion and advice on how to handle problems. As is discussed in the next chapter, the goal is to
have the music come from the group. Viewed this way, group members should be doing most
of the talking, while the group leaders orchestrate the discussions and bring members into the
conversations. Early in the formation of the group, the leaders need to encourage participation
by all members. Identifying commonalities among members is a key way to develop group
cohesion.
Starting and Ending Groups Using Round-Robin Discussions
Because some group members report initial anxiety about speaking in groups, a goal in the first
session is to develop a safe climate for sharing and self-disclosure. One way to facilitate this is
to start the first group session by having all members introduce themselves. The first session
contains several nonthreatening round-robin discussion topics (see the Group Therapist Hand-
out 5.1; e.g., introductions of members, normalizing members’ concerns about groups, what
members expect out of treatment). Using nonthreatening group discussions during the first part
of Session 1 can help establish group cohesion, something that is essential for positive group
therapy outcomes (Dies, 1993; Satterfield, 1994; Yalom & Leszcz, 2005).Similarly, in ending
group sessions, it is important to do so in a way that maintains cohesion and positive feelings
about group therapy. The following shows some ways for group leaders to end groups using
round-robin discussions.
USING ROUND-ROBIN DISCUSSIONS TO END GROUPS
“What was it like being in your first group session?” or “What was it like to hear from others
with similar problems?”
To promote skill-based acquisitions from session to session, group leaders can ask, “What
can you take away from today’s group that you could implement between now and the
next group?”

This next question, which is asked during the last 5 minutes of open and closed
groups, in many ways is like a motivational interviewing summary of each member’s
perspective, including the group leaders, about what happened in the group.
“We have talked about a lot of things in group today. Let’s go around and have everyone,
including the group leaders, tell us one thing that stood out about the group.”
INTEGRATING MOTIVATIONAL INTERVIEWING STRATEGIES
AND TECHNIQUES INTO A GROUP FORMAT
USING ROUND-ROBIN DISCUSSIONS
This part of the chapter provides specific suggestions about how to use specific motivational
interviewing strategies and techniques in a group format using round-robin discussions. Because
motivational interviewing strategies were discussed in detail in Chapter 2, only brief descrip-
tions of the techniques as related to their use in round-robin discussions are presented here.
Using Round-Robin Discussions with Homework
Because groups have multiple members, it is not possible to have everyone discuss answers to
their homework exercise, as would occur in an individual therapy session. As discussed in Chap-
ter 3, homework has been a mainstay of cognitive-behavioral interventions for many years and
has several benefits: (1) it strengthens what is discussed in therapy; (2) members are engaged in
treatment outside of sessions; (3) it allows group leaders to point out commonalities during a dis-
cussion, which, in turn, provides a basis for building cohesion; (4) written homework exercises
help to keep all group members on the same page; and (5) importantly, research has shown that
those who comply with homework have better treatment outcomes, perhaps because they are
working outside of sessions (Burns & Spangler, 2000; Kazantzis et al., 2000).
A way to avoid or minimize compliance problems with homework is to explain its rationale
and how fits into the treatment (Addis & Jacobson, 2000; Kazantzis, Deane, Ronan, & L’Abate,
2005). Discussing the need to complete homework exercises is equally important, whether the
treatment format is individual or group. As discussed in Chapter 1, 90% of group clients in
the GRIN study (L. C. Sobell et al., 2009) completed and brought their homework and self-
monitoring logs to sessions. We believe this high compliance rate is directly related to our
therapists’ explaining the rationale and importance of doing homework exercises.
The discussion of homework exercises, which involves all group members, starts with the
group leaders asking members to discuss what they got out of the homework exercise. The lead-
ers can then ask, “Who else has had similar experiences?” Questions like this can be used to
identify commonalities among members.
The Identifying Triggers exercise (Client Handout 4.6) provides a good example of how to
use homework exercises in a round-robin discussion. This homework exercise, which is handed
out and explained to members in Session 1, is discussed with clients in Session 2. This exercise
asks clients to identify and discuss two high-risk trigger situations related to their alcohol or
drug use that occurred in the preceding year (see Session 2 in Chapter 4). In individual therapy,
clients would discuss both trigger situations with their therapists. However, because there is

not enough time to have all group members discuss both trigger situations in the group, each
member is asked to select and discuss one of their two trigger situations. The trade-off is that
although group members have less time to discuss their personal situations, they benefit by
sharing their experiences with other group members who can be supportive and who can offer
advice about how they have handled similar situations. The Group Therapist Handouts contain
discussions of how to present the homework exercises using a round-robin format.
Incomplete Homework
If clients come to group without their homework or self-monitoring logs, we recommend that
the group leaders ask them to complete them before or at the start of the group. This, of course,
requires that the group leaders check that the various assignments have been completed before
starting the group. Although this might seem disruptive, the alternatives (i.e., not having the
assignments completed, leaders not knowing whether members have completed their home-
work) can diminish members’ participation.
It is important for group leaders to address noncompliance with homework early because if
one or more clients repeatedly do not complete their homework, other members might get the
impression that it is not important to do so. However, as discussed earlier, if the group leaders
explain the rationale and importance of doing homework at the first session, compliance is usually
not a problem. If a group member repeatedly fails to complete the assignments, the group leaders
should address this in a nonjudgmental, motivationally enhancing manner (e.g., “It looks like some
folks are struggling to complete their homework before group. I know we are all busy, but I’m
wondering what advice others have for how to fit these assignments into one’s schedule?”).
Using Round-Robin Discussions with Personalized Feedback Materials
Groups provide a rich forum for discussing feedback materials. Using round-robin discussions,
we have group members comment on the personalized feedback materials we provide them in
group. Members are also encouraged to discuss their reactions to the materials. As shown in
Table 4.1, several types of motivational feedback handouts are part of the GSC group interven-
tion. The four Group Therapist Handouts contain examples of ways group leaders can present
feedback throughout the group sessions. The following example is a generic way of presenting
feedback.
“We will be giving everyone a lot of information today. The first type of feedback is based on
the information you provided in your assessment session and relates to your past alcohol
or drug use. The reason we give you feedback about your [insert risky problem behavior
here] is to provide you with information that you can use to make more informed choices
about changing. Let’s have everyone look at the personalized graphs we prepared of your
[insert risky problem behavior here] and tell the group what stands out for you about
these summaries.”
Motivation for change often occurs when people recognize a discrepancy in their risky
problem behavior (i.e., a difference between how they are acting and how they think they should
act). Personalized feedback is one way to address such discrepancies. As discussed in Chapter

2, the way feedback is presented is important. Feedback or information presented in a neutral,
nonjudgmental manner is more likely to be positively received by clients than is being lectured
to about the negatives of their behavior or told that they have to change. The ultimate objec-
tive of providing feedback is for clients to recognize that their risky problem behaviors are not
within the norms and, if continued, can result in more serious consequences.
Using Round-Robin Discussions with a Decisional Balance Exercise
The decisional balance exercise (Client Handout 3.1), designed to address ambivalence about
changing, asks clients to consider both the good and less good things about changing and not
changing their alcohol or drug use (or other risky problem behaviors). This exercise is used
to help clients recognize that there are rewards associated with their substance use, although
those rewards are short term and could result in long-term negative consequences. The discus-
sion of both the good and less good things about engaging in a behavior also helps clients make
sense of their actions, and it makes salient that a continuation of the behavior risks highly unde-
sirable outcomes.
As discussed in the ﬁrst handout for group therapists (5.1), the decisional balance round-
robin discussion invites all group members to talk about their responses and what they have
learned from this exercise. This discussion provides an excellent opportunity for the group lead-
ers to identify similarities among members and to prompt group discussion about the need to
make decisions based on long-term goals. The ultimate objective of a decisional balance exercise
is to help clients recognize their ambivalence about changing and to get them thinking about
what it would take to change. Although several discussion topics are listed here, all topics do not
have to be addressed, only those relevant to the ongoing group discussion.
POSSIBLE DISCUSSION TOPICS FOR USE
WITH THE DECISIONAL BALANCE EXERCISE
“What did each of you get out of this exercise?”
“How did the use of the decisional balance exercise affect your thinking about your [insert
risky problem behavior here]?”
“What are the good and less good things about doing this exercise?”
“What strikes you most about this exercise?”
“What surprised you most about doing this exercise?”
Using Round-Robin Discussions to Support Self-Efﬁcacy
Group leaders need to recognize small gains that clients make from session to session. Reinforc-
ing gains is best done by getting group members to comment about the positive changes other
group members have made. If a group member discusses changes but other members fail to
comment, the group leaders need to elicit comments from them by saying something like, “Bill
was drinking thirty drinks per week before he came to group, and now he is down to one or two
per day. How does the group feel about what he has done?” Getting group members to reinforce
each others’ gains is a good example of how group members serve as agents of change.

Using Round-Robin Discussions to Present Affirmations
An affirmation is a motivational interviewing strategy used to recognize clients’ strengths, suc-
cesses, and efforts to change. Affirmations can be used for individual clients within the group
and for the group as a whole.The following are two examples of how to use affirmations in a
group:
“Everyone has done a good job of completing their decisional balance homework for this
week. Now that we have discussed the good things and less good things about each per-
son’s substance use, let’s go around and see what one thing it would take for each person
to change right now.”
“When Mary came in she said she could not go a day without using cocaine. As we just
heard, she hasn’t used for a week. What does that say about her?”
Using Round-Robin Discussions to Present Reflections
and Open-Ended Questions
As in individual therapy, the group leaders can use open-ended questions and reflections to
encourage members to contribute to the group. When group leaders use open-ended questions,
members’ responses are usually richer or tell more of a story (e.g., “How do people feel about
that?” or “When you use cocaine, what does it do for you?”). Open-ended questions can be
asked with no particular member in mind, or they can be directed to a specific member if the
group leader feels that member can provide relevant comments to another member. The follow-
ing are some examples of group-focused questions and reflections.
EXAMPLES OF OPEN-ENDED QUESTIONS AND REFLECTIONS
FOR GROUP DISCUSSIONS
“That sounds like an important issue. Who else can relate to what Bill has said?”
“How does that relate to why each of you is here?”
“How have others handled similar situations?”
“Mary, it sounds like some of your friends have put a lot of pressure on you to drink. How
have others dealt with social pressure to drink?”
“Mary, that is one way of looking at how Bill can handle his mother-in-law. What other sug-
gestions can the group give Bill?”
On occasion, especially when group leaders are concerned about minimal participation
by members, questions and reflections can be directed to a particular member rather than the
entire group. For example, a group leader might say, “That sounds like an issue that many can
relate to. What about you, Bill?” At other times, the group leaders might reflect something that
is important to a particular member, such as, “Bill, you appear to be torn about wanting to
change.” They might also further explore a topic by saying, “Mary, can you tell the group about
what led to your decision to leave your job?”

Judicious Reflections Are at the Heart of Group Work
In motivational interviewing, reflections are the primary way of responding to clients. Reflec-
tions are important because they validate therapists’ understanding of clients’ behaviors and
they build empathy. When group leaders recognize that a member has said something sig-
nificant in the group, it is important to have the group (rather than the leaders) focus on what
has occurred. For example, the group leader can say, “Let’s spend some time thinking about
what Mary has just said.” In this way, the members have the responsibility for interpreting and
reflecting the client’s comment.
Group Leaders as Process Consultants
Group leaders have the unique role of acting as process consultants. In this regard, their respon-
sibilities include drawing the group’s attention to what is important and pointing out appropri-
ate behaviors for the rest of the group. The following are some examples of reflections that
group leaders can use for such purposes (see Chapter 2 for additional examples of how to use
reflections).
EXAMPLES OF HOW TO USE REFLECTIONS IN GROUP DISCUSSIONS
“Mary has just shared some very strong feelings with the group. Let’s go around and see
how others feel about [insert topic related to the discussion].”
“It sounds like most members are saying that balancing a career and raising children is very
stressful. Let’s go around and have those who have had such experiences share how they
have handled them and point out what were some of the biggest challenges.”
“That sounds like an important issue that Bill has raised. How have others handled similar
situations?”
Group leaders need to reflect group members’ responses that are most relevant to the target
behavior, and they need to do it in ways that will promote change talk by members. Summary
statements, a form of reflections, can also be used to (1) review and highlight relevant infor-
mation provided by the group, (2) relate a response by one member to an earlier comment by
another member, and (3) transition the group discussion from one topic to another.
Using Round-Robin Discussions to Roll with Resistance
Dealing with difficult or resistant clients in individual therapy is usually easier than handling
such clients in a group setting. In groups, the problem can be exacerbated if the group leaders
attempt to manage a resistant client individually within the group. Suggestions for handling
such situations follow. Group cohesion can also be damaged if members with strong personali-
ties monopolize the group or influence other members by discouraging them from talking. Spe-
cific ways to handle monopolizing or chatty clients are discussed in Chapter 8. Some disruptions
can be avoided by discussing acceptable group behavior (e.g., not talking over other members,
not raising voices) at the first group session.

Dealing with Resistance
Group leaders should avoid confronting members in the group. For example, when dealing with
an angry group member, the group leaders should pull other members into the conversation and
ask how they have dealt with such feelings (e.g., “Mary, it sounds like you feel you had no choice
in coming here and you are angry. If I recall, other group members have had some similar expe-
riences. Who can share with Mary how they have handled such situations?”). In the end, the
group leaders need to summarize what happened in the group (e.g., “Mary, although you would
rather not be in group today, it sounds like the alternative was jail. I think what the group was
trying to get you to think about is what alternative seems better for you now?”).
When dealing with resistant group members, it is important for group leaders to remember
two things: (1) “think Group” (Dies, 1994, p. 86) and throw questions and comments back to
the group (i.e., pull group members in and ask how others have dealt with such situations and
feelings); and (2) group leaders should not interpret any of the group members’ comments as a
personal attack. The group leader’s response (e.g., throwing it back to the group) should be in
relation to the leader’s role, and not in a personal role.
PREPARING POTENTIAL GROUP MEMBERS DURING THE ASSESSMENT
Prior to the ﬁrst group meeting, potential group members attend an individual assessment ses-
sion with a therapist, preferably a therapist who will be one of the group leaders. The assessment
procedures have been presented in detail in Chapter 3, but the following procedures should also
occur at the end of the assessment for potential group members. All potential group members
should be given the “Introduction to Groups” handout (Client Handout 5.1). Providing clients
with this handout is not only an essential component of group preparation, but it also represents
an opportunity to discuss the value of the group and address any concerns that clients may have
about group therapy.
THINGS TO MENTION TO POTENTIAL GROUP MEMBERS
AT THE ASSESSMENT
“We have a handout about group therapy that addresses some concerns people have had
about groups.”
“Many studies have found that group treatment works as well as individual treatment.”
“Group gives people an opportunity to do several things that they cannot do in individual
therapy, such as sharing experiences with other members and learning how others have
dealt with similar problems. Group members also receive support from others dealing with
similar problems, which in turn allows members to know that they are not alone in trying
to change.”
“Last, and very importantly, what members share in groups is conﬁdential: What is said in
group stays in group!”

GROUP THERAPY CAN BE LIMITED BY CULTURAL OR OTHER FACTORS
Although groups can be a highly efficient way to deliver clinical services, there will be some
situations in which the applicability of group therapy is limited by cultural or other factors. A
specific case we experienced concerns a sister study to the GRIN study that was conducted
in Mexico City using GSC materials translated into Spanish. In that study the overwhelming
majority of clients were male (Ayala et al., 1997, 1998). Although the individual therapy condi-
tion was replicated, it was not possible to replicate the group therapy condition. In fact, not a
single group was conducted in the group therapy arm of the study. According to the investiga-
tors, this occurred because nearly all of the potential clients were male, and they were not will-
ing to participate in a treatment in which they would be discussing their substance use problems
in front of others (which would conflict with the machismo aspect of the culture). Thus, although
group treatment is cost effective, in Mexico cultural factors prevented implementation of the
intervention with male Hispanic/Latino clients.
SUMMARY
The four handouts, 5.1–5.4, for group therapists at the end of this chapter are specifically
designed to help group leaders integrate motivational interviewing and cognitive-behavioral
strategies and techniques into group therapy, particularly using round-robin discussions. These
four group therapist handouts were adapted from the GRIN study protocol (see Sobell & Sobell,
2009). Readers will also find it helpful to refer back to Chapter 4, which describes the GSC
treatment components at length.
It is our hope that this chapter, coupled with the description of the treatment model in Chap-
ter 5, describes and illustrates the group adaptation of GSC in sufficient detail to allow thera-
pists to successfully integrate a motivational interviewing approach and cognitive-behavioral
techniques to achieve a cohesive therapy group. The remaining chapters further discuss how
to conduct effective groups and how to deal with challenges that may arise when conducting
group therapy.

164
THERAPIST HANDOUT 5.1
Objectives, Procedures, Client Handouts, Pregroup Planning,
and Sample Round-Robin Discussions
Group Session 1
INTRODUCTION
Each of the group therapist handouts for group sessions is intended to help group leaders integrate
cognitive-behavioral and motivational interviewing techniques and strategies into a group treatment
format. Throughout each session, leaders should look for and acknowledge commonalities among
members and encourage members to be supportive of other members’ changes.
If the group leaders want to keep copies of the group members’ homework exercises and self-
monitoring logs, they should develop a procedure that allows them to copy the information before or
after the group, as members will need the forms during the group.
In each round-robin discussion, there is a list of suggested questions and topics. Although several
topics and questions are provided, group leaders need not ask all questions or address all topics;
instead, questions and topics should be selected as they relate to what is happening in the group.
SESSION OBJECTIVES
Review and discuss members’ goal evaluations; provide guidelines or information on
contraindications for use if appropriate.
Review members’ self-monitoring logs with respect to their goals.
Provide members with personalized feedback based on assessment measures.
Evaluate and discuss members’ motivation to change.
Give homework and instructions for Session 2.
SESSION PROCEDURES
Introduce session, complete any remaining assessment inquiries.
Review and discuss members’ completed self-monitoring logs, copy or record data.
Give members personalized feedback from assessment forms and discuss.
Review and discuss members’ completed goal evaluation.
Review and discuss members’ completed decisional balance homework answers.
Ask members the ﬁve-million-dollar question; afﬁrm that changing is a “choice” people make.
End session: What stood out about today’s session? Remind members to do homework.
CLIENT HANDOUTS
Reading: Identifying Triggers (Client Handout 4.5)
Exercise: Identifying Triggers (Client Handout 4.6)
Copies of Client Handout 5.1 for the group members when discussing the group rules
(cont.)

165
and Sample Round-Robin Discussions (page 2 of 9)
PREGROUP PLANNING
Pregroup planning is seen as critical for several reasons: Retention of group members contributes
to members’ satisfaction, builds group cohesion, and results in positive group outcomes. Although
pregroup planning only takes 15 to 20 minutes, it is important to do it prior to every group. Pregroup
planning for the first session is more extensive and may take slightly longer than planning for other
sessions. It includes the following.
Review assessment information on all members.
Know something about each group member before the group starts, including their first names.
Use 3 5 cards to make brief notes about each member (e.g., age; first name; marital status;
problem type, length, and consequences; medical problems; referral reason).
On a separate sheet of paper draw a circular diagram for the group and write in the first names of
each member as they sit down at the first session; this allows you to know who is sitting where
and to be able to call on clients using their names.
Arrange the chairs in a circle for the number of expected group members and the two leaders; for
better communication, the group leaders’ chairs should be positioned opposite one another (to save
these chairs place a clipboard or other materials on them ahead of time).
Have new homework available for members (Client Handouts 4.5 and 4.6).
Prior to this session prepare and highlight key points in each group member’s “Personalized
Feedback Handout: Where Does Your Alcohol Use Fit In?” (Client Handout 4.1) or “Where Does
Your Drug Use Fit In?” (Client Handout 4.2).
Note to Group Leaders: To prepare these handouts, use information collected from the TLFB and
other measures administered at the assessment and discussed in Chapter 4 (go to www.nova.edu/
gsc/online_files for measures and forms).
Group leaders also need to decide who will take the lead for each of the major discussion topics in
this session (e.g., introduction, self-monitoring, homework, ending group).
FIRST ROUND-ROBIN DISCUSSION
Introduce group leaders and welcome members to group.
Have members introduce themselves.
To begin, one of the group leaders can say, “Why don’t we start by spending a few minutes talking
about the benefits of group therapy and what groups are about?”
In addition to presenting basic information about the group, the leaders can also say, “Another thing
that is important to think about is that each group member is an agent of change, and the goal is
to learn from each other and to be supportive of change. Another way of thinking about this is that
solutions come from group members, not from the therapists.”
After this initial discussion, group leaders can say, “Now that we have gone over the benefits of
group and what is expected of group members, what other concerns do group members have?”
After going over the basics, the group leader can start by saying, “Let’s go around and have each
member tell us what you expect to get out of group.”
Normalize members’ feelings about groups by saying, “Although it’s natural for members to initially
feel uncomfortable in groups, groups provide members an opportunity to learn from others with
similar problems. There are benefits to having members provide advice and feedback to one another.”
(cont.)

166
Further Discussion Focus: Leaders can ease members into talking in groups with general questions
such as, “Let’s go around and have everyone tell us [insert one of the following questions here; ask
one question one at a time].”
“What brought each of you into treatment?”
“Tell us two or three words that best describe you.” Next ask, “Now, thinking about those words,
how do they relate to why you are here?”
ROUND-ROBIN DISCUSSION
Topic: Group Rules
Because group rules are intended to shape appropriate group behaviors, promote positive group
norms, and reduce clients’ anxieties, one of the most important discussions that group leaders can
have with group members early in the first session relates to group rules. The group rules most
commonly advocated and their rationales are listed in Table 5.3. Although every group member should
have received a handout describing the group (Client Handout 5.1) at their assessment, each should
be given another copy of this handout at the first session.
Each group rule in Table 5.3 needs to be reviewed. They include: maintaining confidentiality,
not socializing outside of group, attending group on time and calling if you cannot come to a group,
not using alcohol or illicit drugs before group, not discussing absent members in group, completing
homework assignments and bringing them to group, participating regularly, and exhibiting appropriate
behaviors in groups (i.e., no yelling, no profanity, no use of cell phone during groups, no talking over
one another).
Topic: Group Treatment Program
Discussion Focus: Brief review of the GSC treatment program, including mention of the following.
There will be four 120-minute group sessions, typically with 6 to 10 members.
Homework exercises and readings will be assigned.
Members will participate in self-monitoring and goal setting for alcohol or drug use.
Group members will learn a general approach to problem solving that will help them guide their own
change and motivate them to take responsibility for their own change.
One of the group leaders will call each group member 1 month after the last session to check on
how everyone is doing and if more services are needed.
(cont.)

167
TABLE 5.3. Group Rules and Their Rationales
Confidentiality. Group discussions are confidential: What is said in group, stays in group!
Rationale: Confidentiality is the sine qua non group rule; without it, members are unlikely to share
or even come to group.
Do not socialize outside of groups. Although some interactions will occur outside of the group (e.g.,
waiting room conversations, riding home on public transportation), it is best to avoid having clients
socialize with one another while they are in the group.
Rationale: Socializing outside of the group can undermine clients’ treatment by blurring boundary
issues. Even if clients go out for coffee after a group, they form a relationship that others cannot
share, and the stronger the relationship, the more likely it is to interfere with group interactions.
Attend groups on time. Members are expected to make groups a priority and attend all sessions, arrive
on time, and remain for the entire session unless there is an emergency. Members who are unable to
attend a session are expected to call beforehand.
Rationale: Attendance is important, as each meeting builds on the previous session and missed
groups cannot be made up.
Do not use alcohol or illicit drugs before group.
Rationale: Coming to the group under the influence of alcohol or drugs can be disruptive to group
interactions and tends to put the focus on the intoxicated member rather than the group as a
whole.
Do not talk about group members who are not present.
Rationale: Members who are not in the group any longer or unable to attend a session cannot
speak for themselves. Discussions about absent members can undermine trust in the group.
Complete homework assignments and bring them to group.
Rationale: Because the completed assignments are discussed in the group, it is disruptive if some
members have not completed their assignments. To enhance compliance, therapists need to give
members an explanation about the rationale for and the importance of completing assignments
(see Chapters 5 and 6).
All members need to participate in all group sessions.
Rationale: It is important for members to actively participate in the group (i.e., share their
problems and feelings with others). Participation is very important, as each member is viewed as
an agent of change, helping other members, being supportive, and providing feedback to others.
Exhibit appropriate behaviors in groups. (1) Take turns speaking and do not talk over one another;
(2) respect the rights of others to express their opinions; (3) cell phones must be turned off during
the group; (4) profanity, screaming, and yelling are not appropriate; strong emotions need to be
communicated in a manner that is not disruptive and allows group members to help one another.
Rationale: Members should be respectful of one another and of the leaders. Individual outbursts
or disruptions take the focus off of the group process.
(cont.)

168
Topic: Review Members’ Completed Self-Monitoring Logs for Their Alcohol or Drug Use since the
Assessment Interview (Alcohol: Client Handout 3.2; Drug: Client Handout 3.3)
Discussion Focus
The discussion can start with a group leader saying, “Let’s go over the self-monitoring logs and look
at everybody’s alcohol and drug use in the past week.” Follow up by asking a member to begin the
discussion, “[Insert client name], give us a general picture of what your alcohol or drug use was like
this past week?”
Note to Group Leaders: Unless relevant, avoid specific details of a client’s drinking or drug use (i.e.,
do not have members present a day-by-day description, as this takes too much time and usually is
not that informative).
If major changes have occurred or if a member handled a difficult situation and did not use, the
group leaders can ask the group how they feel about the group member’s change.
Topic: Goal Evaluations (Abstinence: Client Handout 3.4; Goal Choice: Client Handout 3.5
Note to Group Leaders: When groups have members with both abstinent and low-risk limited drinking
goals, the group leaders can start by saying, “We are going to review each member’s goal form and
we want you to freely comment on each others’ goals and how realistic they are.”
Abstinence Discussion
Using a motivational interviewing approach, ask group members to discuss reasons for not using
alcohol and drugs.
Group members should provide sound reasons for being abstinent (e.g., relate it to what would be
risked by using substances).
The motivation for abstinence should be, “I have chosen not to use alcohol or drugs because that is
the best way for me to avoid future problems” rather than trait attributions (i.e., reasons should not
be statements such as “Because I have a disease” or “Because I have no will power”).
Framing abstinence as a choice, albeit a difficult one, allows discussion of how to accomplish change,
whereas a statement of inability to change can lead to a self-fulfilling prophecy
Goal Choice Discussion
This discussion should begin with the leaders explaining that persons with contraindications to
drinking are advised not to drink at all and describing the recommended guidelines for those who do
not have contraindications and choose a low-risk drinking goal. For any member who has selected
a low-risk drinking goal but has contraindications to drinking, the leaders can point out that the
member may not have been aware of the contraindication but should now take it into account.
Ask group members who have selected a low-risk drinking goal and do not have contraindications,
“Have you ever been able to drink at low levels and without problems before?”
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169
Group members can also be asked under what conditions low-risk drinking might pose a risk. This
discussion can be facilitated by giving members considering a low-risk limited drinking goal a printed
set of guidelines that outline risks that can be discussed.
Note to Group Leaders: If a group member’s goal exceeds the recommended guidelines or the person
wants to engage in low-risk drinking but has contraindications to alcohol use, group leaders should
engage other group members to comment on the risks the person would be taking. To prompt other
members to comment on those whose goal exceeds the guidelines, ask, “As we have been listening
to everyone describe their goal evaluation, we need to remember that recommended low-risk drinking
limits are very low. What advice can group members provide to each other in terms of how realistic
other members’ goals are?”
Additional Goal Evaluation Topics: With respect to members’ alcohol or drug use goals, group leaders
can use the following questions to get group members talking about their goals.
“How realistic is your goal?”
“What obstacles, if any, are you experiencing in trying to achieve your goal?”
For clients who have made significant changes in their alcohol or drug use, you can ask, “You made
some very major changes in your alcohol or drug use. How were you able to do that and how do you
feel about these changes?”
Members’ Goal Evaluations Related to Their Confidence in Achieving Their Goals and the Importance
of Their Goals
Group leaders can open the discussion by saying, “Now that we have discussed everyone’s goal,
let us look at the second part of the goal evaluation, where everyone was asked to evaluate the
importance and confidence of achieving their goal. To start, let’s look at what everyone put down
for the importance of their goal and why you chose your rating.”
During this discussion, the group leaders should look for commonalities. Several members will not
rate reaching their goal as the most important thing in their lives, but instead will rate other things
(e.g., health, job) as more important. With this discussion, the idea is to encourage members to
discuss the importance of changing.
After a discussion of the importance, the group leaders can move on to how confident members
are in achieving their goals by asking, “Okay, now let’s do the same thing for everyone’s confidence
ratings.”
Ask group members, “What number did you put down for how confident you are right now in terms
of reaching your goal, and why?” This could be followed up with, “What would have to happen for
your goal to go from a [insert current #] to a [higher #]?”
Topic: Discussion of Personalized Feedback Handouts (i.e., summaries of pretreatment alcohol use,
Client Handout 4.2; drug use, Client Handout 4.3)
Note to Group Leaders: Each member’s personalized feedback summary should have been prepared
in advance and highlighted (e.g., yellow marker) on the printout you will give all group members during
this discussion (i.e., highlight aspects of alcohol or drug use you want members to notice).
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170
Discussion Focus: The crucial aspect of the feedback is comparing group members’ personal alcohol
or drug use with normative data on substance use. Having members comment on their personalized
feedback engages them in a discussion about their current substance use and risk as opposed to
group leaders telling them such information. The intent is for group leaders to generate discussion so
members understand that their present alcohol or drug use is not normative and that if they continue,
such use is predictive of long-term risks (i.e., negative consequences).
Feedback Based on the Timeline Followback That Members Completed at the Assessment (Alcohol
Use: Client Handout 4.1; Drug Use: Client Handout 4.2)
Start by giving group members their personalized feedback summaries.
“If you remember, we asked each of you many questions about your alcohol and drug use at the
assessment, and one thing you did was to fill out a calendar describing your alcohol or drug use
prior to entering treatment. We will be giving everyone feedback today about your alcohol or drug
use so you can use this information to make more informed decisions about changing your alcohol
or drug use. Let’s have everyone look at the pie charts and tell the group what stands out about
these summaries for you.”
With alcohol clients, it is not unusual for them to be surprised at how heavy their drinking is
compared with the general population, especially if many of their friends also drink heavily. Similarly,
drug clients also report to us that they are surprised that so very few (e.g., 1%) people used many
of the illicit drugs such as heroin or cocaine in the previous year.
Feedback Based on the AUDIT (Client Handout 4.1) and DAST-10 (Client Handout 4.2)
“At the assessment interview, we also asked you about consequences you might have experienced
because of your alcohol or drug use over the past year. Your answers yielded a score that reflects
the severity of your alcohol (AUDIT) or drug (DAST-10) use. It is on the last page of your feedback
summary. Let’s look at these graphs and your scores and tell the group what stands out about this
feedback.”
For surprised members, group leaders can say, “A few of you look surprised at the feedback. What’s
surprising about it?”
Topic: Decisional Balance Exercise (Client Handout 3.1)
Discussion Focus: This exercise, a motivational tool designed to help clients understand their
ambivalence and why changing might be difficult, involves a discussion of group members’ reports of
good and less good things about changing their alcohol or drug use. Listing both the short- and long-
term costs and benefits in one place can help them justify and strengthen decisions about changing.
Throughout this discussion, group members are invited to comment on their perceptions of other
members’ statements about the good and less good things related to their alcohol and drug use and
what it would take to change. Possible group discussion topics include
“What did each of you get out of this exercise?”
“How did the use of a decisional balance exercise affect your thinking about your alcohol or drug
use?”
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171
“What good and less good things had you not recognized before doing this exercise?”
“What surprised you most about doing this exercise?”
Note to Group Leaders: Members’ discussion about their decisional balance exercises should include
some mention of the following.
What they recognized about their reasons for drinking or using drugs (i.e., good things about use)
Potential obstacles to change
Topic: Five-Million-Dollar Question (Client Handout 3.1)
Discussion Focus: After discussing members’ decisional balance exercises, ask the group, “What if
you were each offered five million dollars to not use alcohol or drugs for just one day? What would you
do?”
Note to Group Leaders: The Five-Million-Dollar Question is used to show members that for a price,
they would change their behavior. The important point from this exercise is that, although change
might be difficult, it is a choice people can make. This point can often be made after members report
why they would change.
Remember to invite group members to comment on each other’s responses to the Five-Million-Dollar
Question. To make the point that change is possible, group leaders can say, “Since we do not have
five million dollars, what would be your personal price for changing your alcohol or drug use?” or
“What would it take for each of you to tip the scale in favor of changing?”
Homework Assignments for Session 2: Identifying Triggers Reading (Client Handout 4.5)
and Exercise (Client Handout 4.6)
Give each group member the Identifying Triggers reading and exercise
Tell group members, “This is a short reading and homework exercise to complete for our next group
meeting. The exercise is intended to help you identify your high-risk situations for alcohol or drug
use and the consequences of use. Usually, the reasons for using are short-term consequences.
What we are asking you to do is explained in the handout. When you complete this homework and
bring it back to the next group, it provides an opportunity to talk more about these high-risk trigger
situations and to examine why they’ve been a problem for you. A future homework will help you
develop ways of handling those situations by doing things other than using alcohol or drugs.”
“The reading will help you understand how to complete the homework and also will help you
consider taking a long-term perspective on changing your alcohol or drug use. The reading and
exercise are easy to complete and should take about 10 minutes.”
Finally, tell group members that next week you will have them select one of their two high-risk
triggers from the exercise to discuss further.
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172
Topic: End of Session 1, Wrap-Up, and What Stood Out
Have each group member and the leaders comment on their group experience and one thing that
stood out about the group.
Discussion Focus: Tell members that this and all subsequent groups will end by asking each member
to comment on one thing that stood out for them in the group. Because the group leaders are part
of the group, they also summarize, but they go last. Comments by the leaders are intended to
reinforce behaviors they observed in the group or how certain issues were discussed and dealt with
by the group members Start the next two wrap-ups by calling on someone who volunteers. If no one
comments, ask one member to start.
What Was Group Like?: “Now that we have completed the ﬁrst group session, what we would like to
do is go around asking everyone how it felt to be in the group today, particularly in relation to what
you expected.”
What Stood Out?: Have each group member and the leaders comment on one thing that stood out in
the group. “We have talked about a lot of things in group today. What one thing stood out?”
Remind Group Members: (1) to attend all group sessions, (2) to call if they cannot make a session,
(3) to continue to use the self-monitoring logs and bring them and the homework exercise to the next
session, and (4) that one of the leaders will call the day before group to remind everyone about the
next group.
POSTGROUP DISCUSSION
The postgroup discussion typically takes about 5–10 minutes.
Discuss what happened in the group, both good and less good things.
Group leaders should make notes about what they want to highlight in the next session and about
anything notable about group members.
Prior to the next group session, for each group member prepare a Client Handout 4.7: BSCQ Proﬁle
of high-risk situations for alcohol or drug use.

173
Group Session 2
SESSION OBJECTIVES
Review members’ progress.
Identify high-risk situations for members based on homework and BSCQ.
SESSION PROCEDURES
Introduce session.
Review and discuss members’ completed self-monitoring logs; copy or record data.
Review and discuss members’ answers to Identifying Triggers homework exercise.
Give members BSCQ feedback proﬁles and discuss relationship to Identifying Triggers homework
answers.
Have members complete Where Are You Now Scale (Client Handout 3.6) and compare their
answers with their answers at the assessment.
End session: Ask what stood out about session; remind members to do their homework.
CLIENT HANDOUTS
Exercise: Developing Options and Action Plans (Client Handout 4.8)
Have the group members’ Where Are You Now Scale for them to check where they are at this
session.
PREGROUP PLANNING
Group leaders review what happened at the last group.
Group leaders decide who will take the lead on which discussion topics (e.g., self-monitoring,
homework).
Prepare and have BSCQ personalized feedback proﬁles for members based on assessment
interview.
Have new homework for members (Client Handout 4.8).
Have group members complete Where Are You Now Scale.
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174
Topic: Review Members’ Completed Self-Monitoring Logs for Their Alcohol or Drug Use since Session
1 (Alcohol: Client Handout 3.2; Drug: Client Handout 3.3)
Discussion Focus
discussion, “[Insert client name], give us a general picture of what your alcohol or drug use was like
this past week.”
Topic: Identification of High-Risk Trigger Situations for Alcohol or Drug Use (Reading: Client Handout
4.5; Exercise: Client Handout 4.6)
Discussion Focus
Discuss the reading and exercise on identification of high-risk trigger situations for alcohol and
drug use, including taking a realistic perspective on change (i.e., Mt. Change) and viewing slips as
learning experiences.
Probe group members’ understanding of the reading on identifying triggers of alcohol and drug use
(Client Handout 4.5). There are two parts to this exercise: (1) identifying and evaluating personal
high-risk triggers to alcohol or drug use and (2) a relapse prevention approach to change and taking
a realistic perspective on change.
A good question leaders can ask about the reading is, “The reading talks about taking a long-term
view of change and that there might be some bumps in the road. What do you think is meant by
this?”
Another topic for members is to have them discuss the Mt. Change diagram (see picture in Client
Handout 4.5). For example, the leaders could say, “What would you say is the major message of
Mt. Change in terms of dealing with your alcohol or drug use?”
Have clients select and discuss one of their two identified triggers from the exercise: “Let’s go
around and have each member tell us about one of the high-risk trigger situations they described
for their alcohol or drug use.”
Note to Group Leaders: As part of this discussion, look for and acknowledge commonalities among
members in terms of high-risk situations. Leaders can recognize commonalities with reflections: “So
it looks like a high-risk situation for both Bill and Mary is when they are angry. Who else feels at
risk when they experience strong emotions?”
Note to Group Leaders: With regard to the reading, members should recognize that for many people
change might be associated with slips but that the important thing if a slip occurs is to continue up
the mountain. However, it is also essential that the leaders not convey a self-fulfilling prophecy to the
group (i.e., that they will have slips). A good way of presenting the concept is to have one of the group
leaders ask, “Why do schools have fire drills?” Most members come up with the obvious response,
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175
“So you’re better prepared if a fire occurs.” The leaders can follow this with, “That’s the same idea
here. Hopefully you won’t have any slips, but it makes sense to be prepared in case they occur.”
It is also important for group members to recognize that, if slips occur, they should interrupt them early
and learn from them. If a group member brings up a slip in group, one of the leaders can say:
“Mary, can you tell the group what you think triggered the slip that occurred last Wednesday. What
was different about Wednesday?”
“How have others in the group handled a slip?”
“What is another way of looking at a slip than as a failure?”
Topic: Review Brief Situational Confidence Questionnaire (BSCQ) Feedback and Relationship to
High-Risk Triggers (Client Handout 4.7)
Discussion Focus
Give members copies of their BSCQ Profiles (Client Handout 4.7) that were prepared based on the
BSCQ they completed at the assessment.
Have group members compare their BSCQ profiles with their two individual high-risk situations from
the Identifying Triggers exercise. Ask how the two high-risk triggers in their homework exercise relate
to their generic BSCQ profile.
For a majority of members, their BSCQ profiles and triggers from the Identifying Triggers exercise
will be similar.
Point out for those whose BSCQ profiles and triggers are similar that the general BSCQ profile
names are a shorthand that can help them more easily identify situations that could trigger future
alcohol or drug use and that they should be vigilant in such situations. One of the leaders can ask,
“Why is it important to know the types of situations in which you might be at risk of heavy drinking
or drug use?”
Note to Group Leaders: In the discussion it will help members to recall their high-risk situations if the
leaders label the members’ BSCQ profiles with shorthand names of the different BSCQ profiles listed
in Table 4.2 (e.g., Good Time profile; Negative Affective profile; Testing Personal Control profile).
Topic: Review of Members’ Completed Where Are You Now Scales (Client Handout 3.6)
Discussion Focus
Give members the Where Are You Now Scale completed at the assessment and ask them to answer
the same questions again but for Session 2.
“When you first came in, we asked each of you to rate how serious you thought your alcohol or drug
use was on a 10-point scale. How would each of you rate your alcohol or drug use today on that
same scale, where 1 = the most serious concern and 10 = no longer a concern?”
Have members try to remember what number characterized where they were at the assessment
interview on this scale.
Ask members, “How did you go from a [# at Assessment] to a [# now]?”
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176
This scaling question is a motivational interviewing technique that allows members to give voice to
changes they have made.
As part of this discussion, look for and acknowledge commonalities among members, and
encourage them to be supportive of changes others are making.
For members who have not changed, the leaders can ask, “What would you need to do to move
up a number or two?” or “What kinds of things have gotten in the way of your changing?”
DEVELOPING NEW OPTIONS AND ACTION PLANS HOMEWORK ASSIGNMENT
FOR SESSION 3 (CLIENT HANDOUT 4.8)
Discussion Focus
Give each member Client Handout 4.8, which asks them to develop new options and action plans
for the two high-risk trigger situations they described in the exercise on identifying high-risk triggers
associated with their alcohol or drug use.
Group leaders can say to members, “This exercise is intended to help you learn how to handle those
situations you identiﬁed as high-risk triggers by doing things other than using alcohol or drugs. This
exercise will ask you not only to come up with some new options you could implement but also to
evaluate how well they might work to help you resist using alcohol or drugs. Then you decide which
are your best options and develop plans for how to put them into action. The exercise should take
about 10 minutes to complete.”
Finally, ask group members to complete the exercise at home and bring it to Session 3. Tell them
that next week each member will be asked to talk about the options and action plans he or she
developed for one of their two high-risk trigger situations.
Topic: End of Session, Wrap-Up, and What Stood Out
Discussion Focus
What Stood Out?: Have each group member and the leaders comment on one thing that stood out
in the group: “We have talked about a lot of things in group today. What one thing stood out?”
(3) to continue to use the self-monitoring logs and bring them and the homework exercise to the
next session, and (4) that one of the leaders will call the day before group to remind everyone about
the next group.
Postgroup Discussion
Discuss what happened in the group, both the good things and less good things.
Group leaders should make notes about what they want to highlight in the next session and about
anything notable about the behavior of group members.

177
Group Session 3
SESSION OBJECTIVES
Discuss members’ change plans.
Discuss new options and action plans for the high-risk trigger situations.
SESSION PROCEDURES
Introduce session.
Review and discuss members’ completed self-monitoring logs; copy or record data.
Have members complete second BSCQ.
Review and discuss members’ answers to homework exercise “Developing New Options and Action
Plans.”
Discuss possible opportunities for testing options before Session 4.
End session: Ask what stood out about session; remind members to do their homework.
CLIENT HANDOUTS
Homework: Request for Additional Sessions form (Client Handout 4.10)
Homework: Goal Evaluation form (Client Handout 3.4 for members with an abstinence goal; Client
Handout 3.5 for members with a low-risk limited drinking goal)
BSCQ form (Appendix D) to be completed in session by each group member
PREGROUP PLANNING
Group leaders decide who will take the lead on which discussion topics (e.g., self-monitoring,
homework).
Have new homework for members.
Request for Additional Sessions form (Client Handout 4.10)
Goal Evaluation form (Client Handout 3.4 for members with an abstinence goal; Client Handout
3.5 for members with a low-risk limited drinking goal)
Have a new BSCQ form for each group member to complete in this group session (Appendix D).
(cont.)

178
Topic: Review Members’ Completed Self-Monitoring Logs for Their Alcohol or Drug Use since Session
2 (Alcohol: Client Handout 3.2; Drug: Client Handout 3.3)
Discussion Focus
discussion: “[Insert client name], give us a general picture of what your alcohol or drug use was like
this past week.”
Topic: Discuss New Homework Exercise on Developing Options and Action Plans (Client Handout
4.8)
Discussion Focus
Ask each member to discuss the options and action plan for one of his or her two identified trigger
situations from the homework.
The goal is to use a motivational interviewing approach to have group members give voice to their
change plans.
“What kinds of options and action plans did you develop for your high-risk situations?”
“Which option did you select as the most realistic to implement and why?”
Note to Group Leaders: Tell members that it is important, when possible, to break action plans into
small steps so that progress can be identified.
Ask each member, “What trigger situations can you anticipate occurring between now and the next
session in which you could put into practice your options and action plans?” [This question is used
to identify possible future high-risk situations that group members might encounter and ways to deal
with those situations in advance.]
IN-SESSION ASSIGNMENT
Complete Brief Situational Confidence Questionnaire (Appendix D)
Discussion Focus
Give each member a BSCQ to complete during the session and tell him or her, “This form assesses
how confident you are at the present time that you can resist the urge to drink heavily or use drugs.
At the assessment you completed this form, and we want you to complete it again. Next week we
will discuss and compare your answers today with your answers when you first came in.”
(cont.)

179
GOAL EVALUATION FORM HOMEWORK ASSIGNMENT FOR SESSION 4 (ABSTINENCE:
CLIENT HANDOUT 3.4; GOAL CHOICE: CLIENT HANDOUT 3.5)
Discussion Focus
Give each member either Client Handout 3.4 (members with an abstinence goal) or Client Handout
3.5 (members with a low-risk limited drinking goal) and ask them to complete the form at home and
bring it to the next session.
“This is the same form you completed and brought into Session 1. We would like you to fill it out
again and bring it to the next session, where we will compare your answers with your answers when
you first came in.”
REQUEST FOR ADDITIONAL SESSIONS FORM HOMEWORK ASSIGNMENT
FOR SESSION 4 (CLIENT HANDOUT 4.10)
Discussion Focus
Give members the Request for Additional Sessions form (Client Handout 4.10) and ask them to
complete the form at home and bring it to the next session.
“As was mentioned at the assessment, next week will be our last group session. Some people will
feel they do not need any additional sessions as they have made sufficient progress, whereas others
will want to continue in treatment. Additional sessions will occur as individual sessions rather than
in groups. On this form you can indicate whether you want additional sessions, and if so, how many
and what you would like to accomplish. If you want more sessions, we can discuss your request
individually after the group next week.”
End of Session, Wrap-Up, and What Stood Out
Have each group member and the leaders comment on one thing that stood out in the group. “We
have talked about a lot of things in group today. What one thing stood out?”
(3) to continue to use the self-monitoring logs and bring them and the homework exercises to the next
session, and (4) that one of the leaders will call the day before group to remind everyone about the
next group.
Discuss what happened in the group, both the good things and less good things.
Group leaders should make notes about what they want to highlight in the next session and
anything notable about the behavior of group members.
For all members, prepare personalized comparative BSCQ profiles (assessment and Session 3) of
high-risk situations for alcohol or drug use (Client Handout 4.9).
For all members, prepare a personalized comparative (assessment to Session 3) feedback form of
their alcohol or drug use (Alcohol: Client Handout 4.3; Drug: Client Handout 4.4).

180
Group Session 4
SESSION OBJECTIVES
Revisit and review members’ motivation and goals.
Discuss end of treatment and aftercare call, or schedule further sessions.
SESSION PROCEDURES
Introduce session.
Review and discuss members’ completed self-monitoring logs in relation to goal; copy or record
data.
Discuss opportunities for testing options since last session and the outcomes.
Give members their personalized feedback comparisons of alcohol use (Client Handout 4.3) or drug
use (Client Handout 4.4) over the course of treatment and discuss.
Revisit goals, revise if necessary.
Revisit decisional balance exercise, revise if necessary.
Give members the BSCQ comparison (Client Handout 4.9) of assessment and Session 3 answers
and discuss.
Revisit and review members’ understanding of the Mt. Change diagram and taking a realistic long-
term perspective on change.
Have members complete the Where Are You Now Scale and compare it with their assessment and
Session 2 answers.
Discuss Request for Additional Sessions form (Client Handout 4.10) completed as homework by
members.
Ensure that the members know how to contact the program if they need further treatment. Also,
mention that one of the group leaders will contact them in about 1 month to check on how they are
doing and whether anything else is needed.
End session: Ask what stood out about the session.
PREGROUP PLANNING
Group leaders decide what discussion topics (e.g., self-monitoring, homework) each will take the
lead on for this session.
Have a copy for each member of his or her BSCQ comparative feedback proﬁles (assessment and
Session 3; Client Handout 4.9).
Have a copy for each member of their comparative (assessment to Session 3) feedback proﬁles for
alcohol use (Client Handout 4.3) or drug use (Client Handout 4.4).
Have the Where Are You Now Scale for members to complete again.
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181
Review Members’ Completed Self-Monitoring Logs for Their Alcohol or Drug Use since Session 3
(Alcohol: Client Handout 3.2; Drug: Client Handout 3.3)
Discussion Focus
discussion: “[Insert client name], give us a general picture of what your alcohol or drug use was like
this past week.”
Topic: Discussion of Comparative Personalized Feedback about Changes in Alcohol or Drug Use
Before and During Treatment (Alcohol Use: Client Handout 4.3; Drug Use: Client Handout 4.4)
Discussion Focus: Alcohol Use
Give members copies of their alcohol feedback handouts (Client Handout 4.3). This feedback form
allows members to give voice to changes in their alcohol use.
“These handouts display your alcohol use when you first came in and over the course of treatment.
The first graph compares how frequently each one of you drank during the 90 days preceding
your treatment and how frequently you drank during the time you were in the program up to last
week. The second graph compares how much you drank per day during the 90 days preceding your
treatment and during the time you were in the program up through last week. In looking at these
two graphs, how would each of you say your drinking has changed?”
Discussion Focus: Drug Use
Give members copies of their drug feedback handouts (Client Handout 4.4). This feedback form
allows members give voice to changes in their drug use.
“These handouts display your drug use when you first came in and over the course of treatment.
The graph compares how frequently each one of you used drugs during the 90 days preceding your
treatment and during the time you were in the program up through last week. In looking at these
graphs, how would each of you say your drug use has changed?”
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182
Topic: Comparative (Assessment and Session 3) Goal Evaluations (Abstinence: Client Handout 3.4;
Goal Choice: Client Handout 3.5)
Discussion Focus
This evaluation form was handed out as homework at the last session. The discussion will focus
on members’ alcohol or drug use during treatment and how it relates to their goals and possible
changes in their goals.
“First, let’s look at your new goal and compare it with your goal when you first came in. What
changes, if any, have you made and what led to these changes?”
“Looking at your self-monitoring logs, how consistent is your recent alcohol and drug use with your
second goal statement?” For members whose behavior is not consistent with their goals, ask the
group, “Who has some ideas about why things haven’t been working for [insert member’s name]?”
“How and why have your importance and confidence ratings changed?”
If change has occurred, ask, “How does the change feel and how has it affected your confidence
level compared with when you first came in to treatment?”
The leaders can get other members to comment by asking, “Who else has had similar experiences?”
Supportive comments from other members about members who have changed can be elicited by
asking, “Both Bill and Mary have made some major changes. How do others feel about what they’ve
done?”
Finally, group leaders can ask, “What do members have to do to maintain the changes they have
made?”
Topic: Revisiting the Decisional Balance Exercise
Discussion Focus
Have members look back at their decisional balance exercises from Session 1 and revisit what they
wrote down. The discussion relates to any additions or changes in members’ answers from Session
1.
“Let’s look at the decisional balance exercise each of you completed at the start of treatment. Are
there any new good or less good things that you did not identify earlier?”
“Have any of the original good or less good things proved to be different from what you expected,
and why?” [Often members will report that anticipated negative consequences of changing did not
occur after all.]
Topic: Discuss Changes in the Brief Situational Confidence Questionnaire (BSCQ; Client Handout
4.9)
Discussion Focus
Review the BSCQ personalized profiles of members’ high-risk situations for alcohol or drug use
completed at assessment and at Session 3.
(cont.)

183
Give members feedback comparing their first and second BSCQ profiles. Using a motivational
counseling style allows group members to give voice to changes they have experienced in their
confidence to resist the urge to drink heavily or use drugs.
“What changes have you noticed in the situations you previously identified as high risk?”
“What led to your change in confidence?”
Topic: Discussion of the Implementation of Options to Deal With the High-Risk Trigger Situations
since the Last Session
Discussion Focus
“Who can tell us about an opportunity they had to put one of their action plans to work and how it
turned out?”
Topic: Revisit Mt. Change and Relapse Prevention
Discussion Focus
Revisit the concept of taking a realistic, long-term perspective on change. Look for statements that
change may be slow and that if a slip occurs one can learn from it, get up, and keep on going.
“Think back to Session 2 when we talked about Mt. Change and taking a long-term perspective
on change. Based on our previous discussions and group meetings, what does taking a realistic
perspective on change mean to you now?”
“How are you going to accomplish this?”
Topic: Review Members’ Where Are You Now Scale Answers over Treatment (Client Handout 3.6)
Discussion Focus
Give members the Where Are You Now Scale completed at the assessment and Session 2 and ask
them to answer the same questions again for Session 4.
“When you first came in, and again at the second session, we asked each of you to rate how
serious you thought your alcohol or drug use was on a 10-point scale. How would each of you rate
your alcohol or drug use today on that same scale, where 1 = the most serious concern and 10 =
no longer a concern?”
Have members try to remember what number characterized where they were at the assessment
interview on this scale and what number they put down at Session 2. Then ask, “How did each of
you get from where you were when you first entered treatment to where you are now, and how do
you feel about this?”
Look for and acknowledge commonalities, and encourage members to praise others for change.
(cont.)

184
REQUEST FOR ADDITIONAL SESSIONS
“Before we wrap up, last week we gave you a Request for Additional Sessions form to ﬁll out
and bring in today. For those of you who are requesting additional sessions, we’ll meet with you
individually after the group to discuss it.”
End of Session, Wrap-Up, and What Stood Out
Have each group member and the leaders comment on one thing that stood out in the group. “We
have talked about a lot of things in group today. What one thing stood out?”
Remind Group Members: “One of us will be calling each of you in about a month to ask about your
progress and to schedule additional sessions if needed.”
Discuss what happened in the group as a whole, both good things and less good things, and what
lessons the leaders can take away from the entire group experience.

185
CLIENT HANDOUT 5.1
Introduction to Groups
RESEARCH SHOWS THAT GROUPS ARE AS EFFECTIVE AS INDIVIDUAL THERAPY.
GROUPS GIVE YOU AN OPPORTUNITY TO
Share your experiences with others.
Learn how others deal with their problems.
Receive support from those who have similar problems.
Help others deal with their problems.
HOW TO BENEFIT FROM GROUPS
ATTEND ALL SESSIONS: Attend all sessions and arrive on time. If for some reason you cannot make
the group, call in advance and tell the group leaders.
DO THE READINGS AND HOMEWORK ASSIGNMENTS: You will be given readings, homework
exercises, and self-monitoring logs to complete at home and bring back to the groups. This helps use
the time in groups more efﬁciently. The assignments and self-monitoring logs will be discussed in the
group.
PARTICIPATE: To get the most out of the groups, members need to participate during every group
session and take turns speaking.
SELF-DISCLOSE: Use the group to help you with your own problems by sharing with the rest of the
group.
WORK TOGETHER: The group accomplishes more when members work together, much like a sports
team.
GROUP RULES
CONFIDENTIALITY: What is discussed in the group is not repeated outside the group.
DO NOT SOCIALIZE OUTSIDE OF THE GROUP
AVOID DISRUPTIVE BEHAVIORS
NO ALCOHOL OR DRUG USE: It is important not to use alcohol or drugs before coming to the group.
TURN CELL PHONES OFF DURING GROUPS

Client handout 4_6_exercise_on_identifying_triggers

PART III
Conducting and Managing Groups
Pregroup Planning, Group Cohesion,
and Difﬁcult Situations and Clients

189
CHAPTER 6
Building Group Cohesion
Music Comes from the Group
There is highly persuasive evidence that pregroup
preparation expedites the course of group psychotherapy.
—YALOM AND LESZCZ (2005, p. 294)
In group psychotherapy, the relationship between the leader
and the group member seems to be less important than the
group members’ relationships with each other as a group.
—SCHOENHOLTZ-READ (1994, p. 157)
GROUP PREPARATION AND PLANNING
Pregroup planning and preparation are critical to the retention of members in groups and
contribute to members’ satisfaction, group cohesion, and group outcomes (Burlingame, Fuhri-
man, & Johnson, 2001; MacKenzie, 1994; Rosenberg & Zimet, 1995; Satterfield, 1994; Yalom
& Leszcz, 2005). Research has shown that pregroup planning has many benefits, including
reducing dropout rates, increasing attendance, increasing self-disclosure by group members,
increasing group cohesion, facilitating early group participation, reducing overall apprehension
about groups, and, most important, increasing motivation to change (reviewed in Piper, 1993;
Rosenberg & Zimet, 1995; Satterfield, 1994; Yalom & Leszcz, 2005).
Selling the Group
As discussed in Chapter 1, although research has shown that groups generally are as effective
as their individual-therapy counterparts, many clients nevertheless believe that groups are not
as effective as individual therapy (Yalom & Leszcz, 2005). Because several studies (Budman et
al., 1988; Hofmann & Suvak, 2006), including the one in this book (L. C. Sobell et al., 2009),
have reported that clients overwhelmingly prefer individual to group therapy, it is important to
market groups to clients.
When possible, group leaders should meet with potential members prior to the first group
session to explain how groups work and to address concerns about participating in groups. Dis-

190 CONDUCTING AND MANAGING GROUPS
cussions with potential group members typically include (1) how the group works; (2) the role
and expectations of group members (e.g., to learn from their peers, to be supportive of other
members, to provide constructive feedback); (3) group rules; and (4) the importance of all mem-
bers participating at each group. Because most clients can be expected to be ambivalent about
attending group therapy, providing information about the benefits of groups and expectations
of members should be done in a manner that is consistent with motivational interviewing prin-
ciples (Miller & Rollnick, 2002). Potential members can be given a handout about the benefits of
groups (see Client Handout 5.1 for a sample), including practical information about the logistics
of groups such as parking or who to contact if a problem arises).
Group rules are intended to shape appropriate group behaviors, promote positive group
norms, and reduce clients’ anxieties. The group rules most commonly advocated and their ratio-
nales were listed in Table 5.3 (Bieling et al., 2006; MacKenzie, 1994; Yalom & Leszcz, 2005).
Among the most important are attending group on time, maintaining confidentiality, not using
alcohol or illicit drugs before group, not talking about group members who are not present,
participating regularly, not socializing outside of groups, completing homework assignments
and bringing them to group, and exhibiting appropriate behaviors in groups (i.e., no yelling, no
profanity, no use of cell phone during groups, no talking over one another).
Preparation Prior to Each Session
Pregroup planning includes everything from making sure the room where the group will meet
is ready and has the right number of chairs (MacKenzie, 1994) to discussing issues regarding
specific members. Generally, pregroup preparation and planning should take about 15 to 20
minutes. To facilitate nonverbal communication in the group, it has been recommended that
cotherapists sit opposite one another (Yalom & Leszcz, 2005). Before the group starts, when
the chairs are being arranged, the group leaders can place their handouts or a clipboard on the
chairs where they will be sitting. As described in Table 6.1, prior to each group the cotherapists
should complete several tasks (e.g., discussing the group’s objectives; determining how respon-
sibilities will be shared, such as who will keep track of time spent on different tasks; discussing
members’ progress and special issues, such as how to better engage silent members; housekeep-
ing tasks, such as having sign-in sheets and relevant homework assignments). Finally, when the
group is ready to begin, empty chairs should be removed from the circle.
TABLE 6.1. Tasks for Cotherapists Prior to Each Group Therapy Session
Specify the objectives and tasks to be accomplished and the topics to be discussed during the session.
Decide who is going to start and end the group and who will take responsibility for starting the discussions
related to specific session topics and homework exercises. For open groups, it is a good idea to think about
general discussion topics in advance so there is some structure.
Review notes from the previous session to identify topics that were to be followed up and discussed at the
next group session. Also, briefly review each group member’s participation in and progress over the course
of group sessions. If therapists use an ongoing logbook to make their postgroup notes, it will be easier to
recall what happened in the previous session.
Make sure that relevant paperwork needed for the session is available (e.g., sign-in sheets, confidentiality
forms, group rules, handouts).
Arrange chairs in a circle and have only enough for the number of anticipated participants plus the group
leaders.

Building Group Cohesion 191
Postgroup Discussions
Postgroup discussions are also important (Dies, 1994; Yalom & Leszcz, 2005) and usually last
10 to 15 minutes. Topics that can be discussed include how the group went and any concerns or
problems that arose from the group discussions. If something did not go as planned (e.g., discus-
sion of planned exercise), the cotherapists can discuss why and how to handle it next time. Based
on the postgroup discussion, a plan for the next session can be developed, including identifying
members and topics to address (Heimberg & Becker, 2002). If trainees are present, the post-
group discussion provides an opportunity for them to ask questions. Last, issues that need to be
followed up or addressed in the next session should be written in an ongoing group log so they
can be recalled prior to the next group meeting.
GROUP: A LIVING, LEARNING HALL OF MIRRORS
The group experience is a key part of the learning process for group members. Discussing one’s
successes or difficulties in groups allows other members to learn from such interactions, to
be supportive, and to offer suggestions for change. In this sense groups can be thought of as a
living, learning hall of mirrors in which members have the opportunity to practice behaviors,
see how they are perceived by others, and get feedback, both positive and negative, from other
group members (R. R. Dies, personal communication, February 19, 1996; Dies, 1992, 1994;
MacKenzie, 1994). Groups provide a context in which real-life experiences and situations can
be simulated in safe circumstances with feedback from others (e.g., “Bill, could you tell the
group how the meeting went last week that you and your wife had with your children’s coun-
selor?”). Group members, in contrast to the group leaders, can provide different perspectives
on members’ behaviors and offer social support and peer pressure to encourage members to
change. Groups also provide an opportunity to learn from other members through observational
or vicarious learning. In discussing the benefits of groups, Satterfield said, “Group interactions
also provide a natural arena to test social hypotheses, practice newly acquired skills, and cre-
ate a ‘therapeutic’ mirror’ showing the objective social consequences of a patient’s actions and
beliefs” (1994, p. 186).
MUSIC COMES FROM THE GROUP:
THERAPISTS AS ORCHESTRA CONDUCTORS
As discussed in the Acknowledgments section, several years ago we attended two workshops
presented by Dr. Robert Dies. During the trainings, he discussed two important concepts that
we feel are key to understanding how to successfully manage groups. The first, Think Group, is
intended to help therapists remember that the group itself is an agent of change and not to do
individual therapy in group settings (also see p. 86 in Dies, 1994). The second concept—Music
Comes from the Group and Therapists as Conductors—relates to the role of therapists in devel-
oping interactions among group members. In group therapy, the leaders’ task is to get the music
to come from the group, which involves the members accepting responsibility for change and
group processes driving the change. As we discuss subsequently, the concepts of Music Comes

from the Group and Therapists as Conductors are straightforward and visually communicative.
Over the years, we have found these two simple and eloquent concepts to be very effective in
communicating to trainees how to manage and think about group processes.
Most group therapy experts recommend having two leaders, or cotherapists. Cotherapists
can be likened to orchestra conductors, with group members being the instruments composing
the orchestra. The leaders’ task is to get group members to work together, helping each other
change. To apply the analogy Music Comes from the Group, an orchestra sounds good only
when the instruments play together appropriately. In group therapy, for the music to success-
fully come from the group, the members should be doing most of the talking (i.e., playing the
music) and interacting to facilitate change. Sometimes the conductor (i.e., group leader) will
want to hear from the entire orchestra and will invite the whole group to respond (e.g., “Who
else can identify with what Bill has said?”). At other times, the conductor/group leader will
want a particular section of the orchestra (e.g., trombones) to play (e.g., “Bill, can you help Mary
out?”) or will want to hear a different instrument (e.g., “Bill, we haven’t heard from you today.
Can you offer Mary some suggestions for how she can handle her situation at work?”). At other
times, the conductor/group leader may hear one instrument/group member play badly and will
ask another instrument/group member to demonstrate how to play the part (e.g., “Bill, that is
one way of handling things. Who can offer Mary another suggestion?”). Last, on rare occasions,
a conductor/group leader might feel that the sound from the entire orchestra is not good. When
this happens, the conductor/group leader may put down the baton and call a time-out, saying,
“A lot is happening in group right now, and I’m not comfortable with what I’m hearing. Let’s
stop and talk about what’s going on.” The ultimate goal of the orchestra conductor/group leader
is to enable the members of the orchestra/group to work together (i.e., cohesion) to produce a
harmonious sound.
COHESION: A POTENT FORCE IN GROUP THERAPY
Cohesion, a dynamic process that fluctuates over time, has been associated with positive out-
comes (Beal, Cohen, Burke, & McLendon, 2003; Burlingame et al., 2001; Rose, 1990; Satter-
field, 1994; Tschuschke, Hess, & MacKenzie, 2002) and with several key group attributes (Bur-
lingame et al., 2001; Satterfield, 1994; Stokes, 1983; Yalom & Leszcz, 2005). Those attributes
include: (1) productivity, (2) participation in and out of the group, (3) self-disclosure, (4) risk
taking, (5) regular attendance, (6) pregroup preparation, (7) feedback, and (8) compliance with
homework exercises. According to Yalom and Leszcz (2005), “group cohesiveness is not only
a potent therapeutic force in its own right. It is a precondition for other therapeutic factors to
function optimally” (p. 55). For these reasons, cohesion can be viewed as the glue that holds the
group together and as a sine qua non for effective group therapy.
Building Cohesion in Groups
To develop group cohesion, group leaders need to look for and highlight similarities among
members based on information from the assessments (e.g., types of problems clients have) and
from interactions during group sessions (e.g., how clients have handled or avoided problems).
Group leaders can use commonalities among members (1) to draw more group members into
the discussion, (2) to demonstrate that others have had similar experiences, and (3) to prompt

members to share how they have handled similar problems. Good group preparation by the
leaders is important for developing group cohesion. For example, if two or more members have
undergone a recent divorce and the topic comes up in group, one of the group leaders can say,
“If I recall, Mary is not the only one who has gone through a divorce. Who can share with Mary
how they’ve dealt with this?” A leader could also ask, “Who else has had similar experiences?”
or “Who else can identify with what Mary is feeling?” Although some group members will
mention similarities and differences with other clients, at times the group leaders will have to
prompt the group (“Who can offer Mary some advice about how they’ve dealt with being served
with divorce papers and having to look for an attorney?”). Although clients tell different stories,
there are common themes therapists can identify and ask others to comment on (“Perhaps oth-
ers who have dealt with [insert type of problem] can share with Mary how they handled the
situation?”).
Building group cohesion starts at the first group session, in which clients begin by talking
about relatively safe topics (e.g., introducing themselves, describing their expectations from the
group). As clients reveal their thoughts and feelings, it is important for the therapists to establish
a favorable climate by commenting on the similarities and reinforcing clients for relating to each
other and sharing their experiences. For example, following a member’s appropriate participa-
tion, the leader can say, “Mary, that is exactly what we are looking for. We want each of you
to share your experiences with the group.” It is also important that the leaders ensure that all
members have an opportunity to participate. As illustrated in Chapter 5, round-robin discus-
sions can be used to ensure that all group members participate regularly.
Cohesion: The Glue That Holds Groups Together
Burlingame and colleagues (2001, p. 373) have defined cohesion as “the therapeutic relationship
in group psychotherapy emerging from the aggregate of member–leader, member–member,
and member–group relationships.” Yalom and Leszcz (2005) consider group cohesion to be one
of the most important therapeutic factors in group therapy. In his book Group Dynamics, For-
syth (2006) asserts that “a cohesive group is a unified one, so members literally ‘stick together’”
(p. 136).
In sports psychology, group cohesion is also very important. Sports psychologists talk about
cohesion as integrating the members of a team (Moran, 2004). Interestingly, the concept has
been used to explain the success of sports teams that were not expected to do well. Two key
examples are the “Miracle on Ice” U.S. men’s hockey team that won the 1980 Olympic gold
medal and the 1997 Florida Marlins baseball team, a group of very young and inexperienced
players who started performing well, believed in themselves and in each other, and went on to
win the World Series.
The Group Is Greater Than the Sum of Its Parts
The importance of group processes is summed up in the observation that more can be accom-
plished by members working together as a group than as individuals (Forsyth, 2006; MacKen-
zie, 1994). Burlingame and colleagues (2001) have summarized and discussed six empirically
supported principles related to therapeutic relationships in groups. These six principles are
reproduced from the original article in Table 6.2. What is striking is that many of the member-
to-member and leader-to-member interactions discussed by Burlingame and colleagues are con-

sistent with the cognitive-behavioral strategies and the motivational interviewing approach used
in the GSC treatment model. In retrospect, the many parallels between the GSC approach and
group processes might explain why we were able to successfully integrate cognitive-behavioral
techniques and a motivational interviewing counseling approach into a group therapy format. In
the next two paragraphs, words and phrases common to the Burlingame and colleagues study
and the GSC treatment model are italicized.
Member-to-Member Interactions
Several member-to-member interactions have been shown to increase group cohesion and con-
tribute to successful groups (Burlingame et al., 2001): (1) being supportive of each other’s chang-
ing; (2) responding empathically (i.e., with genuine regard); (3) giving feedback to others in a
nonjudgmental manner (minimizing negativity is more likely to get members to accept feedback
and to be less resistant to change); (4) members assuming responsibility for their own change;
and (5) complying with structured behavioral activities in groups (e.g., homework exercises and
self-monitoring logs foster commonalities in terms of disclosures and shared feedback about
ways to handle problems, all of which lead to greater group cohesion).
Leader-to-Member Interactions
With respect to leader-to-member interactions, the following have been shown to produce posi-
tive results in groups (Burlingame et al., 2001): (1) reflective listening demonstrates that the
leaders have heard and understood members; (2) being empathic, accepting, and warm; (3) rein-
forcing effective interpersonal feedback; (4) communicating at the start of group that discomfort
and apprehension about being in groups is normal (i.e., normalizing behaviors that members
TABLE 6.2. Empirically Supported Principles Regarding the Therapeutic Relationship in Group
Treatment
Principle 1: Pregroup preparation sets treatment expectations, defines group rules, and instructs members in
appropriate roles and skills needed for effective group participation and group cohesion.
Principle 2: The group leaders should establish clarity regarding group processes in early sessions since
higher levels of structure are thought to lead to higher levels of group disclosure and cohesion.
Principle 3: Group leaders who model real-time observations, effectively guide interpersonal feedback, and
maintain a moderate level of control and affiliation may positively impact group cohesion.
Principle 4: The timing and delivery of feedback should be pivotal considerations for group leaders as they
facilitate this relationship-building process.
Principle 5: The group leaders’ presence not only affects the relationship with individual members, but also
with all group members as they vicariously experience the leaders’ manner of relating, and thus learn the
importance of managing one’s own emotional presence in the service of others.
Principle 6: A primary objective of the group leaders should be to facilitate group members’ emotional
expression, the responsiveness of others to that expression, and the shared meaning derived from that
expression.
Note. From Burlingame, Fuhriman, and Johnson (2001, p. 375). Copyright 2001 by the Division of Psychotherapy (29), American
Psychological Association. Reprinted by permission.

may think only they are experiencing); and (5) communicating the importance of completing
group assignments.
Measures of Group Cohesion
Most who have written about group psychotherapy have stressed the importance of measur-
ing cohesion. Although several different group cohesion questionnaires have been developed
(Kanas, Stewart, Deri, Ketter, & Haney, 1989; MacKenzie, 1983; Treadwell, Lavertue, Kumar,
& Veeraraghavan, 2001; Tschuschke et al., 2002), the assessment of group cohesion has not
received the research attention it deserves. In the GRIN study, we used the Group Cohesion
Questionnaire—Short Version (GCQ-S) because it was brief and easy to score (Kanas et al.,
1989; MacKenzie, 1983; Tschuschke et al., 2002).
The 12 items on the GCQ-S are rated on 7-point Likert scales. The measure yields three
scores: (1) Engagement (5 items, range = 0–30), a positive atmosphere within the group, or
cohesiveness; (2) Conflict (4 items, range = 0–24), interpersonal friction within the group; and
(3) Avoidance (3 items, range = 0–18), members not taking personal responsibility for group
work. In terms of group cohesion, desirable group characteristics on the GCQ-S would include
high engagement, very low conflict, and relatively low avoidance.
In the GRIN study, all group clients were asked to complete the GCQ-S at their last ses-
sion (Session 4). After only four sessions, the GRIN study found that the GSC group treatment
resulted in high feelings of group cohesiveness and engagement, low levels of interpersonal con-
flict, and low avoidance of group work (L. C. Sobell et al., 2009). We have postulated that several
factors may have contributed to the high cohesiveness: (1) as part of the pregroup preparation,
all potential group members were given an introduction that described the group, its benefits,
and the expectations of members (Client Handout 5.1); (2) because brief treatments necessi-
tate focusing on specific goals, the development of group processes may have been facilitated
because members and leaders knew that the group would meet for only four sessions; (3) group
leaders were instructed to reinforce and support the discussion of commonalities and appropri-
ate interactions among members; and (4) the homework exercises and weekly self-monitoring
logs of substance use that clients completed outside of the sessions served to focus the group
discussions on common themes.
SUMMARY
In this chapter we have focused on three important topics: (1) pregroup planning and prepara-
tion, (2) Music Comes from the Group, and (3) building group cohesion. Developing group cohe-
sion is essential because it is associated with positive outcomes. Perhaps nothing better captures
the importance of group cohesion than the phrase it is the glue that holds the group together. As
discussed throughout this chapter, there are several ways group leaders can foster the develop-
ment of cohesion: (1) pregroup planning and preparation, including helping potential members
understand their roles and group expectations before joining the group; (2) ensuring that all
members have an opportunity to contribute to group discussions; (3) getting members to discuss
commonalities and comment on similar experiences they have had; (4) promoting self-disclosure
by members; and (5) encouraging members to reinforce other members’ behavior changes.

196
CHAPTER 7
Managing Groups
Structural Issues
Group therapy is unique in being the only therapy that offers clients the
opportunity to be of benefit to others. It also encourages role versatility,
requiring clients to shift between roles of help receivers and help providers.
This chapter and Chapter 8 are concerned with managing groups, but from different perspec-
tives. This chapter addresses a multitude of structural issues (e.g., composition, attendance, role
of cotherapists, breaking eye contact) that are critical for group leaders to understand when
conducting group therapy. In contrast, Chapter 8 addresses ways to manage difficult clients in
groups.
When comparing group with individual therapy, there are advantages and disadvantages,
many of which are structural in nature (Morrison, 2001; Piper & Joyce, 1996; Satterfield, 1994;
Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003; Yalom & Leszcz, 2005). The major dif-
ferences between the two formats are listed in Table 7.1. Although managing groups is more com-
TABLE 7.1. Advantages and Disadvantages of Group versus Individual Therapy
Advantages
More clients can be treated in groups, thus reducing costs to clients and payers.
Groups can provide peer support that cannot be achieved in individual therapy.
Group members can provide emotional support and reinforcement to each other.
Groups can help members recognize that others have similar problems.
Group members can learn from one another (e.g., serve as role models; offer suggestions for changing).
Disadvantages
More difficult to manage because of simultaneously working with multiple clients, the greater potential
for nonparticipation by some members, and the potential problems managing members’ behavior (e.g.,
monopolizing, disruptions).
Higher dropout rates at entry and over treatment.
Generally, less client satisfaction with groups.
Special training and skills needed by therapists to handle complex group dynamics and interactions.
Attendance issues: missed group sessions cannot be rescheduled; if too many members drop out or miss
groups, it can become difficult or impossible to run the group.
Group members may feel that their confidentiality and/or privacy is less protected.

Managing Groups 197
plex, demanding, and challenging than conducting individual therapy, the structure of groups
has several important advantages over individual therapy. These advantages, correspondingly,
afford members opportunities (e.g., social support) not available in individual therapy.
ASSEMBLING GROUPS
Open Groups
Open groups do not have a fixed number of sessions and, consequently, do not usually have start
or stop dates. Space permitting, new members can join at any time. At any given time, because
of the nature of open groups, some members will have attended many sessions, others just a few
sessions, and others will be new to the group. The mix raises several issues: (1) whenever a new
member enters, group rules and expectations must be reviewed; one way to address this is to
ask a senior group member to introduce new members to the group and to explain the group
rules; (2) session-to-session continuity is harder to maintain; and (3) because of constant member
turnover, open groups are not as amenable to structured tasks as are closed groups.
Closed Groups
Closed groups meet for a preset number of sessions with explicit start and stop dates. After
the first session, closed groups typically do not add new members. Because all members start
simultaneously, to maximize treatment gains closed groups often use structured activities (e.g.,
homework assignments) and specific topics for different sessions. When the number of group
sessions is few, group leaders need to develop group cohesion early (i.e., starting at the first ses-
sion). A serious issue with closed groups is getting and maintaining a critical mass. We and oth-
ers have found three things that can help maximize attendance: (1) conduct a pregroup meeting
in which potential members are told about the benefits of the group and are given a brochure
describing the benefits and the group rules (Client Handout 5.1)—this can be done in a group
or individually; (2) stress the importance of attending all group sessions and on time; and (3) very
importantly, as a reminder call or e-mail clients the day before each group.
Starting and Stopping Groups on Time
It is imperative to start groups on time even if only a few clients are present rather than waiting
for more to arrive because to do otherwise undermines the norm the leaders are trying to instill
(Bernard, 1994). Stopping groups on time is similarly important. Although a crisis can occur
near the end of group, they are rare and usually can be managed by the leaders after the group.
Occasionally, however, members will wait until the end of the group before bringing up a topic.
For example, for clients who wait until the last few minutes of group to bring up important, but
not crisis-related, issues (e.g., losing a job, getting a C in a class), we recommend that the group
leaders respond by saying something like, “Mary, it sounds like losing your job is an important
issue. We want to be able to devote enough time to discussing it in the group, but with only a few
minutes left before the group ends, this will be difficult. Do you mind if we discuss it at the start
of group next week?” Most clients will agree with such a request, and one of the group leaders
needs to make a note to remember to bring the matter up for discussion at the next session.

Attendance Problems
Attendance problems are not unique to therapy groups. It is common practice, for example, for
many professionals and businesses (e.g., doctors, dentists, hairdressers) to call clients or patients
to remind them of their appointments. One way to reduce attendance problems is to discuss the
importance of attending groups when recruiting potential group members. When clients are
constantly late or miss appointments, such behavior can be disruptive and must be addressed.
However, it is best to have the group address the issue (i.e., let the “Music Come from the
Group”) rather than having the group leaders confront members. With clients who repeatedly
come late or barge in and disrupt the group, therapists can get the group involved with a com-
ment such as “This is the third time Mary has been late. I’m wondering how the group can help
Mary get to group on time.” Our experience has been that comments from group members are
more likely to affect the client’s behavior than the therapists’ comments.
Missing Groups
When clients fail to attend individual therapy sessions, it is costly for practitioners (i.e., lost
time and revenue). However, whereas individual therapy sessions can be rescheduled, if a client
misses a group, that group will continue to meet, and there is no way to capture the essence of the
group’s interactions in a makeup session. Thus, calling clients the day before group sessions can
help reduce the number of missed group sessions, and it only takes a few minutes. With clients’
permission, a short message about the group can be left on an answering machine or a cell phone.
In the GRIN study, the therapists called all group clients the day before their upcoming sessions.
It would have required a separate study to evaluate a causal relationship between those calls and
attendance, but it is striking that the group members in this study missed far fewer sessions (n =
25) than clients in the individual-treatment condition (n = 210; L. C. Sobell et al., 2009).
Members Who Rabbit: Leave an Ongoing Group Session
Although it is not common, eventually most group therapists will encounter a group member
who walks out of group prematurely, either dramatically or quietly. Although leaving group
early should have been discussed as part of the group rules (i.e., members do not leave before
the end of the group unless it is an emergency), this will not prevent its occurrence. If a group
member attempts to leave or walk out, one of the cotherapists should go after the person to find
out why the person left. Group members can walk out for different reasons (e.g., to get atten-
tion; because they are angry about what occurred in group). For example, one group member
who walked out in the middle of a group session told us that she left because the group discus-
sion brought back vivid memories of an assault she had suffered years earlier. Whatever the
reason, one of the cotherapists needs to also leave the group and find out the member’s reason
for leaving, deal with the situation, and, if appropriate, get the individual to come back to the
group. The therapist who remains in the group must trust that if the group member returns, the
cotherapist will have the situation under control. The reason that the member chose to leave
the group does not necessarily need to be discussed with the rest of the group when the person
returns. In addition to not forcing uncomfortable self-disclosures, there is a need to maintain
and respect the flow of what has been happening within the ongoing group. Therefore, what has

Managing Groups 199
occurred (i.e., the member’s leaving) should not be a topic of group discussion unless the leaders
feel it is important for group cohesion.
SESSION STRUCTURE: LENGTH AND SIZE
Most outpatient groups meet weekly, and their length typically ranges from 90 to 120 minutes.
Although there is no consensus on what constitutes an ideal group size, recommendations vary
from 6 to 12 clients with two therapists. One issue for all groups is group size, which can vary
from week to week, creating what has been characterized as feast or famine. If only a few clients
(e.g., one to three) show up for group, our suggestion is to ask them if they want to hold the group.
If it is decided that a meaningful group cannot be conducted, then at a minimum we recom-
mend that the group leaders meet with those present for 15–20 minutes to allow them to share
how their week went since the previous session and to address any outstanding concerns.
THE ROLE OF COTHERAPISTS/GROUP LEADERS
The consensus among group psychotherapy experts is that using two therapists, called cothera-
pists, facilitates the conduct of group therapy (Dies, 1994; Yalom & Leszcz, 2005). One therapist
typically assumes the active role while the other attends to the nonverbal behaviors of the group
members and manages the group activities. In addition, cotherapists can switch roles during the
group. There are several advantages to using cotherapists: (1) it is easier to manage and address
structured exercises; (2) tasks can be shared—one therapist can manage the clinical tasks (e.g.,
homework, forms) while the other manages time allotment so all session topics and exercises get
discussed; and (3) if one therapist is stuck or uncertain how to proceed, his or her cotherapist
can jump in to provide direction.
During all phases of the group, communication between cotherapists is critical (Bieling et
al., 2006; Yalom & Leszcz, 2005). For example, during group round-robin discussions one of the
cotherapists can monitor the time spent on a topic, while the other therapist is responsible for
getting members to participate and share their experiences with each other (see Chapter 5 for
speciﬁc examples).
Although it is rare for cotherapists to cross-talk or follow one another in a discussion, both
need to be communicating, verbally and nonverbally, with each other during sessions (Ber-
nard, 1994). If there is some confusion about what is happening in the group, it is important for
cotherapists to check signals with each other. For example, one cotherapist can say to the other,
“Doug, is it okay if we stay on the topic of how to handle relapses a bit longer?” or “Doug, help
me out. I’m confused about where the group is going with the topic of grief.” Last, although
therapists will have different styles and orientations, at times cotherapists may have different
ideas about how to proceed. Although this is to be expected, open conﬂict between cotherapists
should be avoided at all costs. If one therapist contradicts the other in front of group members,
this can lead the members to question the value of the group and undermine group cohesive-
ness. The cotherapists can discuss these issues at the postgroup discussion, when group mem-
bers are absent (reviewed in Morrison, 2001).

Changing Therapists in Open Groups
Because open groups have no start or stop dates, it is conceivable that a cotherapist might leave
the group, particularly if one of the cotherapists is a trainee. In such cases, there is a need to
be sensitive to the transitioning of both old and new therapists. An important reason for being
sensitive to the changing of group therapists is that clients are sharing intimate information with
the group, including the therapists. It has been our experience that abrupt changes in group
leadership can be disconcerting to clients and should be avoided whenever possible. Ideally, the
transition should be gradual, and group members should be informed in advance about when
the change in cotherapists will occur. In the open groups that we currently run, we transition
our doctoral students as cotherapists every 3 months. Group members are informed in advance
about these changes and their rationale, and they also know that one of the two cotherapists will
remain, and this provides some stability. In terms of the actual transition, we have found that it
works well when we are able to overlap the new therapist with the old therapist for a few weeks.
Last, during the transitioning of the old and new cotherapist, it is important to gently work the
new cotherapist, especially a trainee, into the flow of the group by having him or her progres-
sively contribute more each session.
SELECTING GROUP MEMBERS: COMPOSITION AND BALANCE
Yalom and Leszcz (2005) have asserted that the fate of a group is related to client selection. Choos-
ing clients who fit common criteria (e.g., divorced clients, trauma victims, problem drinkers) pro-
vides a greater potential for bonding between members and for developing cohesion. Moreover,
the degree of homogeneity among members is a criterion that has been found to be associated
with good group functioning and positive outcomes. In practice, homogeneity allows the leaders
to use inherent similarities among group members (e.g., PTSD, substance abuse, relationship
issues) to build cohesion by asking them to discuss shared experiences. In seeking harmony in
groups, Dies (R. R. Dies, personal communication, February 19, 1996) has suggested applying
the principle of Noah’s Ark (trying to have at least two members who share a major characteristic).
Having at least two members who share a major characteristic is particularly important in some
instances (e.g., having more than one woman in a group of male substance abusers).
OTHER SIGNIFICANT GROUP ISSUES
Silence Is Golden
Some therapists, especially new group therapists, have difficulty with silence (Dies, 1994). In
this regard, it is important to recognize that silence is a behavior. If no one is speaking for an
extended time, something is happening, and the leader might say, “It’s very quiet in here. I’m
wondering what is going on?”
Breaking Eye Contact with Clients
In group therapy, the goal is to have group members mainly talking to other group members
and not to the group leaders. When members are new to a group, they often try to maintain eye

Managing Groups 201
contact with one of the leaders when speaking. When this occurs, the leader needs to break eye
contact with the client. Although this feels awkward and unnatural, our experience has been
that when a group leader breaks eye contact, clients will look at another group member and
eventually get accustomed to speaking to the entire group. Although breaking eye contact is
difficult, it is helpful for building group cohesion.
Clients Speak with Their Bodies
People speak with their bodies, such as smiling, nodding, looking away, or crossing one’s arms.
Nonverbal cues are especially important in groups in which members may be reacting to inter-
actions among members. Although most nonverbal cues relate to body language (e.g., shrugs,
smiles, rolling of the eyes), sometimes they will be more obvious (e.g., group members moving
their chairs out of the group circle). Group leaders need to be constantly vigilant and acknowl-
edge any significant nonverbal behavior. The following are some examples of how the leaders
can bring nonverbal behaviors to the group’s attention.
EXAMPLES OF ADDRESSING NONVERBAL RESPONSES
“When Mary just talked about her recent divorce, a few of you nodded.” [Note: Often
when therapists leave their response at this, group members will respond. If there is pro-
longed silence, the group leader can follow up with, “What are the nods about?”]
“Several people in the group are smiling. What do the smiles mean?”
“Bill has been sharing some difficult feelings with us, and many of you are looking down.
I’m wondering what’s happening.”
Clients Who Do Not Complete Their Homework
Another issue related to the group leaders’ maintaining control of the group is communicating
to members the importance of doing their homework and bringing it to each group session. As
discussed in Chapter 3, we (L. C. Sobell et al., 2009) and others (Dies, 1994; Garland & Scott,
2002; Kazantzis et al., 2005) have found that clients will complete homework assignments if
they understand their rationale and that the assignments relate to the problems for which they
are seeking treatment. Clients can be reminded to bring their homework at the same time the
therapist calls them about the group meeting. For clients who regularly fail to bring their home-
work to the group, therapists can turn the issue over to the group by saying, “Bill seems to be
having trouble completing his homework assignments. What suggestions does the group have
for him?”
Transitioning to a New Topic
As in individual therapy, there will be times when a discussion rambles, gets sidetracked, or
continues too long, and this can interfere with addressing other matters. An easy way to address
this is to say, “It sounds like the group has a lot to say on this topic. We have a few more things
to cover this session, so let’s switch gears and we can come back to this topic later.”

Coming to Groups under the Influence of Substances
Clients who come to groups under the influence of alcohol or illicit drugs not only challenge the
group rules but also invite disruptions if they remain in the group. Clients who come to groups
under the influence should be reminded that one of the group rules discussed previously was to
not use alcohol or drugs on the day of groups. When a client is asked to leave, it is essential that
therapists ensure that he or she does not drive home under the influence.
TERMINATION OF GROUPS
The issue of treatment termination is important whether it involves individual or group therapy.
Termination involves two critical considerations: addressing unfinished business and helping
members plan for what they are going to do after treatment (Dies, 1992). With time-limited
groups, the topic of termination should be addressed early in treatment so clients are aware
of when the group will end and can plan for what to do if they need additional treatment
(Heimberg & Becker, 2002; Yalom & Leszcz, 2005). For many clients, a brief treatment will
sufficiently address their needs and result in positive outcomes. For clients seeking additional
services, the available alternatives can be discussed with them individually.
Aftercare Calls
As discussed in Chapter 4, part of the GSC treatment model includes having therapists make
aftercare phone calls to clients 1 month after the last group or individual session. These calls
are intended to be supportive of change while at the same time providing an opportunity for
clients to talk about any difficulties they have experienced and to request additional treatment
if necessary. In the GRIN study (L. C. Sobell et al., 2009), at the 1-year follow-up, 64% of the
substance abusers interviewed said they felt that the aftercare calls were helpful, and 23% said
they would have liked more calls.
SUMMARY
This chapter discussed several structural issues involved in the conduct of therapy groups.
These issues ranged from differences between open and closed groups to group composition
to how to handle members who miss groups, routinely come late, or leave during an ongoing
session to breaking eye contact. The complementary roles of cotherapists were addressed. By
working together, cotherapists can effectively manage a group while simultaneously observing
important features of the developing group process (e.g., nonverbal behaviors). A host of other
circumstances that can make conducting therapy groups difficult were discussed, including
ways of dealing with those situations. Finally, the major advantages and disadvantages of con-
ducting groups compared with individual therapy are listed in a tabular presentation.

203
CHAPTER 8
Managing Difficult Clients in Groups
A questionnaire sent by the American Group Psychotherapy Association
to practicing group therapists inquired about the critical issues necessary
for group therapists to master. Over fifty percent responded, “Working
with difficult clients.”
Group clients bring the full range of their psychopathology to treatment;
in addition, the interpersonal, subgroup and group-as-a-whole dynamics
that are played out in the group treatment setting result in an enormous
range of problematic situations over the course of time.
—BERNARD (1994, p. 156)
Over the years, group therapy experts have commented that therapists can expect to encounter
challenging clients and difficult situations when running groups (Bernard, 1994; Bieling et al.,
2006; Yalom, 1985). In fact, in their book, Bieling and his colleagues (2006) stated that in their
experience “each group a therapist conducts is likely to have at least one client that presents a chal-
lenge to group process, to other group members, and to group leaders” (p. 104). Our experience
has been similar to that of Bieling and colleagues. It is not uncommon to encounter difficult and
challenging clients in groups. Consequently, this chapter addresses ways to manage difficult cli-
ents in groups. To help readers picture and remember the clients and behaviors being addressed,
we refer to difficult client types with the following shorthand labels: Silent Sam, Late Laura,
Tommie Therapist, Chatty Cathy, Monopolizing Mike, Resistant Roberta, and Interrupting Ivan.
Although a discussion of difficult clients is woven into this chapter, Table 8.1 contains specific
sample dialogues to give readers a quick reference for ways to respond to such clients in groups.
THINK GROUP: INTERRUPTING CLIENTS FOR THE GREATER GOOD
Interruptions occur frequently in everyday conversations, and as might be expected, they occur
during group therapy. However, interruptions during group therapy can interfere with the
development of group cohesion. Although isolated interruptions will occur, when clients repeat-
edly disrupt the group, group leaders need to have the group address the disruptive behaviors,
but in a constructive manner.
The following is an example of how group leaders can deal with Chatty Cathy or Monopo-
lizing Mike clients who dominate the group discussion. In such cases, these clients are often

TABLE 8.1. Suggestions for Responding to Difficult Clients in Groups
Silent Sam
With such clients the goal is to find a way to get all members, especially those who are less verbal, to
participate in all group sessions.
“Mary, we haven’t heard from you tonight.”
“Mary, I noticed that you haven’t said much tonight. How has your week gone?”
“Bill has just shared his frustrations with the group. Mary, I know you’ve said you felt frustrated in
similar situations. What advice can you give Bill?” [This example directly targets a silent client by
asking him or her to offer advice or suggestions to another client.]
Late Laura
Although most clients who come late to groups are aware of their behavior, some fail to understand the effect
their behavior has on the group. Having the group respond to such clients is more likely to result in changes
(e.g., coming to subsequent groups on time) than is being told they are late by group leaders. The following
responses would be used only with clients who are repeatedly late or who miss several group meetings.
“This is the third time Mary has been late. What suggestions can the group provide to help her get here
on time?”
“I’m wondering how others feel about Mary being late for group several times.” [Although this response
is more direct than the first example, open discussion of some issues can increase members’ sensitivity
to their own behavior, as well as help them understand how their behavior affects the entire group.]
Tommie Therapist
Such clients may have been attending a group for several sessions, or they may have considerable prior
therapy experience. At times, such clients’ interactions in groups will parallel those of a therapist. Although
such advice can sometimes be helpful to group members, on other occasions the advice can be disruptive or
too direct.
“Bill, your comments have been helpful. Let’s see how others view Mary’s concerns.”
“Bill, that is one way of looking at how Mary can handle the situation. What additional options can
others offer Mary?”
Chatty Cathy and Monopolizing Mike
Such clients dominate group discussions. Group leaders need to find effective ways to interrupt such clients,
as they are often unaware of the impact that their behavior has on the group. A strategy that group leaders
can use when a Chatty Cathy client is talking is to direct questions to the group as a whole. For example:
“Bill, it sounds like a lot has happened with you this week. I am wondering what has happened with
other group members.” (The group leader then calls on another member.) “Mary, how did your week
go?”
“Mary, you seem to have had a lot going on this past week. Let’s take a look at what’s been happening
with you for a few more minutes, and then let’s see how others have been doing this past week.”
Interrupting Ivan
The behavior of such clients in groups is disruptive, as they frequently interrupt ongoing group discussions.
“We seem to be having an active discussion about [insert topic] today, but several members are talking
at the same time. I’m wondering how this is affecting the group and what the group thinks we should
do.”
“I know we all have important things to say, but we need to respect each other and let others finish
what they are saying before the next person speaks.”
Resistant Roberta
Clients who feel they are forced or coerced to attend groups (e.g., by a spouse, probation officer, employer)
are often not happy and, consequently, participate minimally, if at all.
“Bill, as with many people, it appears that you are upset about your probation officer telling you that
you have to come to treatment. What suggestions does the group have for Bill?”
“Mary, it sounds like you feel you had no choice in coming to group and you are angry. Who else with
similar experiences can share with Mary how they’ve handled such situations?”

Managing Difficult Clients in Groups 205
unaware of the impact their behavior has on the group, and thus group leaders need to find
effective ways to interrupt them.
TAKING CONTROL OF THE GROUP
“Mary, you seem to have had a lot going on this past week. Let’s keep looking at what
you’re saying for a few more minutes, and then let’s see how others have been doing.”
After a few minutes, the group leader can pull other members in the discussion by saying,
“Mary, clearly a lot has happened with you over the past week. Let’s find out how the week
has gone for others.” [Note: After this comment, the group leader can direct the group
discussion by calling on another member.] “Bill, how did your week go?”
Over the years, we have found that group leaders may be hesitant to interrupt clients
because they are worried about what the other group members will think. In most instances,
group leaders need to trust their own feelings as a barometer of what is happening in the group.
More often than not, if the group leaders are not comfortable with a member constantly inter-
rupting or talking over other group members, the other members will feel similarly. Moreover,
it is unlikely that this is a one-time occurrence (i.e., such clients have been engaging in similar
behaviors for some time). With Interrupting Ivans, group leaders need to interrupt them, thank
them for sharing their experience, and then pull other members into the discussion. One way
to pull other members in when an Interrupting Ivan or a Chatty Cathy is talking is to direct a
question to the group as a whole. At such times, it is important for the group leaders to remem-
ber to Think Group. If the group leaders let one group member go on and on, the rest of the
orchestra cannot play well. However, group leaders also must remember to deal with disruptive
clients in a way that does not create anger or conflict within the group.
At other times, a group discussion may result in several members speaking at once, and the
resulting sound is not music to anyone’s ears. On such occasions, the group leaders may find it
necessary to call a time-out. In this regard, the group leader acknowledges that there is some
confusion and stops the group to figure out what is going on and regroup.
THINK GROUP: BRINGING ORDER TO CHAOS
“We seem to be having an active discussion about [insert topic] today. There are a lot of
folks talking at once. I’m wondering how the interruptions are affecting the group, and
what the group thinks we should do?”
If several members are talking at once, the leader could say, “I know we all have important
things to say, but we need to respect each other and let others finish before the next per-
son speaks.”
BALANCING VOICES IN THE GROUP
A major goal for group leaders when conducting groups is having all clients participate regu-
larly. With Silent Sam clients it is important for group leaders to make active and continuous

efforts to get them involved in the group. Such efforts are important for developing group cohe-
sion. To do this, the group leaders must orchestrate opportunities to prompt reluctant or shy
group members to participate. For example, the group leader could say, “Mary, we haven’t
heard from you tonight” or “Mary, you have been quiet tonight. How did your week go?” A good
way of getting silent clients to participate is for the group leaders to recognize commonalities
and steer the discussion in that direction: “Bill has just shared his frustrations with the group.
Mary, I know you’ve told us you have felt frustrated in similar situations. What advice can you
give Bill?” Not all group members have to speak at length on every topic, but it is desirable to
have a balance of voices in the group.
Time management is an issue that makes balancing voices very important, particularly for
time-limited groups (Heimberg & Becker, 2002; MacKenzie, 1996). A good example is handling
clients known as storytellers. Such members, if left unmanaged, can derail a group with long,
rambling stories. In time-limited groups, group leaders need to be vigilant in attending to group
processes, and when the group gets sidetracked, one of the group leaders needs to bring the
group back on topic.
Sometimes the issue of balancing voices involves the roles clients take on rather than the
amount of time that they speak, such as with a Tommie Therapist client. Such clients may have
been attending a group for several sessions, or they may have considerable prior therapy experi-
ence. Whatever the reason, at times they attempt to take on the role of therapist. On occasion,
this can be very helpful. For example, in an open group, a senior group member can explain
group rules to new members and help ease their transition into the group. Such clients, how-
ever, can also be disruptive if they start to give advice freely or provide their opinions as if they
were trained therapists. In such cases, a group leader could say, “Bill, that is one way of looking
at how Mary can handle the situation. What additional options can others think of for Mary?”
Another issue relates to group members who feel they are forced or coerced to attend
groups (e.g., by a spouse, probation officer, employer). Resistant Roberta clients are often not
happy, and consequently they participate minimally, if at all, in groups. Like clients who are
late, clients who are forced to come to group are best managed by the leaders using the group
as the agent of change. With such clients, the group leader can ask the group to comment about
a member’s behavior. For example, the group leader could say, “Bill, as with many people, it
appears that you are upset about your probation officer telling you that you have to come to
treatment. What suggestions does the group have for Bill?” In such situations, other group
members are likely to share how they have coped with circumstances in which they have had
little choice. Such responses can also be directly encouraged by the leader saying, “Mary, it
sounds like you feel you had no choice in coming to group, and you are angry. Who else with
similar experiences can share with Mary how they’ve handled such situations?”As discussed in
Chapter 6, having the “Music Come from the Group” typically will be more effective than hav-
ing the group leaders isolate or lecture a group member.
MANAGING CONFLICT AND CALLING TIME-OUTS
Yalom and Leszcz (2005) state that, “To some degree, certain tensions are always present in every
therapy group” (p. 169). In fact, most group psychotherapy experts acknowledge that some degree
of conflict in groups is normal and unavoidable. Such is not at all surprising when we remember
that groups consist of multiple clients with different personalities. When conflicts do arise, how-

ever, cotherapists must recognize them and manage them to a successful resolution. Many clients,
particularly in a group setting, will feel uncomfortable with conflict or anger expressed in a group.
At such times, one of the group leaders needs to address the discomfort with the group as a whole.
For example, the group leader might say, “There is a lot going on right now, some of which feels a
bit uncomfortable. Let’s talk some about what we think this is about.” Alternately, the group lead-
ers can ask specific clients to comment: “Bill and Mary, a lot has been happening in group tonight,
and you both look a bit uncomfortable. What do you think is going on?” Sometimes when a group
leader interrupts the group’s discussion to reflect back what is happening, it can have a secondary
gain by allowing group members who are upset to calm down.
Therapists Should Use Their Feelings as a Barometer
Group leaders need to use their own feelings as a barometer of what is happening affectively in
the group (Dies, 1994). For example, if the group leaders are reacting to the member-to-member
interactions, then it is likely that other members are having similar feelings. Although some con-
flict in groups is to be expected, the best way to manage group conflict is for the group leaders
to throw it back to the group. There are times, however, when dealing with the conflict might
not be immediately productive, and on these occasions, time-outs can be helpful.
Time-outs are typically called in relation to very strong emotional reactions the group
has had to what a member has said. In such cases, the group leader calls a time-out by saying,
“Okay, let’s take a time-out. It seems like a lot is going on in group right now. Let’s all step back a
minute and process what just happened.”On rare occasions, leaders may have to get the group’s
attention by calling a time-out similar to that of a basketball coach by forming their hands into a
“T.” During the time-out the group leaders need to focus the discussion on the group’s affective
response to the situation, rather than the topic being discussed. For example, suppose the topic
was domestic violence, and one member asserted that his partner deserved to be hit. This could
easily escalate as other members react strongly and negatively to what the one member said.
Likewise, there may be times when members are so upset that the most prudent thing to do is
to let them calm down. Here a group leader might say, “Right now things seem very emotional.
I think it might be best for us to come back and revisit this topic next week when we’ve all had
some time to reflect on what happened in group today.”
In summary, when calling a time-out or when responding to an interruption, it is important
to focus on the affect that members are experiencing rather than the issue at hand. In the end,
the group leaders need to remember to be supportive of all group members for their contribu-
tion to the group. In this regard, the group leader could say, “Sometimes difficult issues get
raised in groups. However, we can learn from different perspectives and by addressing difficult
issues in a reasoned, calm manner as we have done here.” Such an approach also allows the
disruptive member or members to observe appropriate ways to discuss sensitive topics.
SELF-DISCLOSURE
Self-Disclosure by Clients
Although there may be disagreement about what to disclose, experts in group psychotherapy
such as Yalom and Leszcz (2005) and Dies (1992) agree that “self-disclosure is absolutely essen-
tial in the group therapeutic process” (Yalom & Leszcz, 2005, p. 130, original emphasis). How-

ever, if a client discloses embarrassing or sensitive information and the group is not supportive
or no one responds, this can affect whether members self-disclose in the future or even return
to the next group session. Members may not respond because they do not know what to say or
because they feel very uncomfortable about what was disclosed. In either case, the group lead-
ers need to reﬂect what happened and reinforce self-disclosure. For example, “Mary just told us
about a very personal situation in her life, and no one said anything.” When group leaders say
something along these lines, it gives those in the group permission to comment. Another way
group leaders can attempt to get members responding if one member self-discloses and no one
responds is to say, “I am wondering how we can offer Mary support with respect to what she
has told us?” In terms of reinforcing a client’s self-disclosure in group, one of the group leaders
might say, “I notice that Mary has taken a big step by revealing some very personal things about
herself. This must have been difﬁcult. How do others in group feel about what Mary just said?”
Finally, the group can also be prompted to use self-disclosure as a starting point for sharing:
“Bill took a big risk in sharing what happened to him over the past week. Who else can relate
to what happened to Bill?”
Inappropriate Client Self-Disclosure
Another issue for consideration relates to members bringing up topics (e.g., abuse) that are not
deemed appropriate for the group discussion. Frequently, such issues relate to only one client
and are not appropriate for the group unless the entire group is dealing with similar issues
(e.g., a PTSD group). In addition, when inappropriate topics are disclosed in group, they can
negatively affect group cohesion. For example, when trauma survivors disclose details of their
traumatic incident, it can lead to concern about how the other group members perceive them
and to their decompensating. In addition, if the group members respond with little or no empa-
thy or if they sound judgmental, it can add to the blame or guilt that these clients (i.e., trauma
survivors) might be experiencing.
The introduction of inappropriate topics is usually easy to recognize (e.g., other members
will look down and/or there is total silence). When group leaders recognize that a topic is not
appropriate for the rest of the group, they can say, “Mary, although it sounds like that is an
important issue for you, often such concerns are better handled in individual therapy. Let me
follow up with you after the group.” There are, of course, several kinds of issues that might be
inappropriate for groups. More often than not, such issues do not relate to what brought the
group members into treatment (e.g., upcoming political elections; political views; discussing
how one feels about gays and lesbians in a smoking cessation group). In the end, decisions about
the appropriateness of topics rest with the judgment of the group leaders.
Self-Disclosure by Therapists
In group therapy, the phrase self-disclosure by therapists has a different meaning from the
way that phrase would be used in individual therapy (Dies, 1994). In individual therapy, self-
disclosure usually refers to therapists’ revealing information about themselves (e.g., “I’ve been
divorced twice” or “I’ve smoked marijuana once, too”). In contrast, self-disclosures by cothera-
pists in a group typically are expressions of here-and-now feelings about what is happening
in the group. For example, a group leader might say, “I’m feeling uncomfortable with what
has just happened. Who else is feeling that way?” Of course, self-disclosures by group leaders

could involve revealing personal information to the group. However, in such cases the disclo-
sure should have a specific intent or therapeutic rationale, as would be the case in individual
therapy.
Therapist self-disclosure of feelings about the group can provide a good way of dealing
with dilemmas around difficult topics and issues, especially when the leaders are having trouble
gauging the group’s reaction. Following are some examples of how this can be accomplished.
EXAMPLES OF THERAPIST SELF-DISCLOSURES RELATED TO FEELINGS
ABOUT THE GROUP
“It feels like there is some tension in the room after what just happened. I wonder how
others are feeling?”
“I get the feeling that everyone would like to say more about the situation, but many of you
seem to be a bit anxious talking about [insert sensitive topic].”
“What does the group think is happening?”
“Mary, we can’t imagine what that must have been like for you. Can you share how you are
feeling right now with the group?”
“It sounds as if everyone is feeling a bit anxious.”
PERSONALIZING PROBLEMS USING AFFECT
Another key way of encouraging members to become more involved in the group is to per-
sonalize problems and get members to discuss their feelings (Dies, 1994). Following are a few
examples of how therapists can encourage such discussion while centering on affect.
EXAMPLES OF GETTING MEMBERS TO PERSONALIZE PROBLEMS
USING AFFECT
“Mary, how would it feel to be in that situation?”
“Bill, that sounds like it has been difficult for you. Who else has had similar experiences?”
“How have others felt when similar things have happened to them?”
“How would you feel if that were to happen to you?”
“How does that relate to why you are here?”
SUMMARY
In several chapters throughout this book, including the present one, we have discussed skills
therapists need to effectively conduct and manage groups. These skills include (1) building cohe-
sion by looking for commonalities among members; (2) using reflective listening; (3) ensuring that
all group members participate regularly; (4) managing multiple clients at one time; (5) managing
resistance and dealing with conflict; (6) turning difficult situations into learning opportunities
for group members; and (7) most important, letting the “music come from the group.”

210
CHAPTER 9
The Way Ahead
Savings from transitioning to the most cost-effective treatment modality may
free resources that could be reinvested to improve access to substance abuse
treatment for a larger number of individuals in need of such treatment.
—MOJTABAI AND ZIVIN (2003, p. 233)
Knowledge of individual psychopathology and clinical interventions is
necessary but not sufficient to become a skilled group therapist.
—MARKUS AND KING (2003, p. 203)
Health and mental health care costs have risen steadily over the past decade (Cummings,
O’Donohue, & Ferguson, 2002; Orszag, 2008). Rising costs put increased pressure on health
and mental health providers, insurance companies, policy makers, and politicians to monitor
and provide information about the efficacy and efficiency of services provided. Part and parcel
of such scrutiny is an increased concern for accountability.
For all areas of health and mental health, central planning issues concern cost containment
and how to allocate limited resources. Cost-effectiveness is the intersection of efficacy and effi-
ciency. From this perspective, evidence-based treatments are the starting but not the end point
of cost containment considerations. For example, cost-effectiveness can be expected to play a
major role in funding decisions when comparing two or more equally effective treatments. In
practice, this means that for more expensive or resource-intensive treatments to be selected,
they must produce outcomes much better than less costly treatments in order to justify the
additional costs. This suggests that group therapy will increasingly be the treatment of choice
except when there is evidence of superior outcomes with individual treatment. Presently, dem-
onstrations of such superiority are lacking.
PUTTING COST-EFFECTIVE TREATMENTS INTO PRACTICE
There is considerable evidence that brief treatments should, in most cases, be the first treatment
of choice for those with SUDs. Studies evaluating different treatment formats and lengths have
favored briefer, less resource-intensive treatments and services, whether they have compared
outpatient with inpatient treatment, outpatient detoxification with inpatient detoxification, or

The Way Ahead 211
brief treatments with a few minutes of physician advice (Feldman, Pattison, Sobell, Graham, &
Sobell, 1975; Fleming et al., 1997; French, 2000; Heather, 1989; Holder, Longabaugh, Miller, &
Rubonis, 1991; Longabaugh et al., 1983). In addition, although intensive treatments for SUDS
have not been shown to be any more effective than less intensive treatments, they are more
costly (Mojtabai & Zivin, 2003). In this regard, although some individuals in brief treatments
will not improve and will need additional services, such concerns can be addressed using a
stepped-care model of treatment similar to that used in the medical field (Davison, 2000; M. B.
Sobell & Sobell, 2000).
Stepped-Care Treatment Model
As shown in Figure 9.1, when using a stepped-care model the first intervention is evidence-
based, usually the least intensive and intrusive, and has consumer appeal and a reasonable
chance of success. If the first treatment produces satisfactory results, monitoring and follow-
up visits may be all that are necessary. If the intervention does not produce positive results,
treatment can be “stepped up” by extending the same treatment (i.e., more sessions) or imple-
menting a different and perhaps more intensive intervention (e.g., pharmacotherapy for smokers
in behavioral treatment that is not currently effective). Using a stepped-care model, decisions
about further treatment are based on a person’s response to previous treatments. In this way,
only those needing services that are more intensive receive the more costly treatments.
The substance abuse field, albeit slowly, has been moving in the direction of less intensive
treatments. For example, in the early 1980s the vast majority of alcohol and drug treatment
programs were inpatient or residential, but today such treatment programs are in the minority
(Substance Abuse and Mental Health Administration, 2003; Swift & Miller, 1997). As cost con-
tainment continues, it can be expected that services will be evidence-based and cost-effective.
In this regard, the time-limited group treatment described in this book is evidence-based, con-
sistent with a stepped-care model of service delivery, and would be a good first treatment of
choice for many individuals with SUDs.
FIGURE 9.1. Stepped-care model of treatment. From M. B. Sobell and Sobell (1993b, p. 150). Copyright
1993 by Sage Publications, Inc. Adapted by permission.

ARE GROUPS COST-EFFECTIVE?
As discussed in Chapter 1, the number of studies that have evaluated the cost-effectiveness (i.e.,
presented cost and time figures) of group therapy is limited. However, as seen in the following
example, it is easy to make a prima facie case that groups have a cost-effectiveness edge over
individual therapy.
COST EFFECTIVENESS OF GROUP VERSUS INDIVIDUAL THERAPY
Example: Eight clients seen for six weekly sessions
Individual therapy: 1-hour session conducted by 1 therapist
Group therapy: 2-hour sessions conducted by 2 therapists
Therapist time for individual sessions: 48 hours [8 different clients x 6 sessions each
(1 hour per week) x 1 therapist]
Therapist time for group sessions: 24 hours [6 group sessions (with 8 clients per
group) x 2 hours per group session x 2 therapists]
The preceding example results in a 50% savings of therapist time for group therapy versus indi-
vidual therapy. Moreover, the efficiency advantage for all groups is greater with more clients per
group. Consider the preceding example with 10 rather than 8 clients. The individual therapist
time would be 60 hours, whereas the group therapist time for 10 clients (i.e., 6 sessions × 2
hours per group session × 2 therapists) would still be 24 hours, which is a 60% savings in thera-
pist time. In fact, in the randomized controlled trial of group versus individual GSC treatment
described earlier in this book, a similar analysis found that group therapy produced a savings of
41.4% in the therapist’s time (L. C. Sobell et al., 2009). In addition, if a member misses a group,
the group session still takes place. However, when clients fail to attend individual sessions,
therapists cannot use this time to see other clients. Thus, even in the absence of studies of cost-
effectiveness, there is a significant advantage to group therapy. As cost containment continues
to be a priority in the provision of health services, it is likely that groups will be favored over
individual therapy unless there is a specific justification for individual therapy.
WHERE IS THE TRAINING?
Over the years, as experts in the field of group therapy have commented on the challenges
and complexities of conducting groups (Dies, 1980; Fuhriman & Burlingame, 2001; Markus &
King, 2003; Piper & Joyce, 1996; Scheidlinger, 1994), they have also acknowledged the need
for adequate training (Fuhriman & Burlingame, 2001; Markus & King, 2003; Thorn, 2004). In
a survey of training in group therapy provided by accredited programs in psychiatry, psychol-
ogy, and social work, several notable shortcomings were identified (Fuhriman & Burlingame,
2001). For all three disciplines, there was a significant gap between trends occurring in the field
of group therapy and what was taught in their graduate programs. For example, although 83%
of psychologists surveyed conduct group psychotherapy, only 21% had been required to take a
group therapy course or practicum as part of their training.

The Way Ahead 213
If, as predicted, the prevalence of group therapy continues to increase over the next several
years, a serious priority will be to ensure that there are competently trained therapists to con-
duct groups. Because of the challenges and complexities of conducting group therapy, training
needs to include more than didactic seminars (Markus & King, 2003). Rather, there should be
a major focus on group therapy as a part of professional training, analogous to how training is
provided for individual therapy.
GROUP THERAPY: THE WAVE OF THE FUTURE
For 20 years, Norcross and colleagues have been conducting Delphi polls using a panel of
experts to predict trends in psychotherapy. In the most recent survey (Norcross, Hedges, &
Prochaska, 2002), experts predicted that four therapy formats would increase, two of which
are group and short-term therapy. If one were to speculate as to why these two formats were
included, it would likely relate to their economic advantage over long-term therapy formats that
were judged to be on the decline. It also might reflect an increasing recognition that change
often occurs early in treatment.
Group Therapy in the Health Care System of the Future
As discussed in Chapter 1, the literature provides evidence of equal effectiveness and lower costs
for groups compared with individual therapy. This is consistent with the outcome of the GRIN
study. The similar outcomes for group and individual therapy will make it difficult for practitio-
ners to ignore groups as an effective and cost-efficient treatment modality in the future.
Based on what we have presented in this book, the following comments are offered with
respect to group therapy and its place in our future health care system.
Pressures to contain rising health care costs will continue to increase, with an emphasis
on providing less costly, evidence-based services, including group therapy.
Although health care cost containment is necessary, it must not jeopardize quality of
care.
Group therapy is complex and challenging, and group therapists need to be adequately
trained.
Most graduate training programs need to change their curricula to ensure that practitio-
ners are competently trained to provide group therapy.
More research is needed on how to make groups more acceptable to clients.
Treatment services should be provided consistent with a stepped-care treatment model
in order to maximize efficiency without sacrificing individualized care.
SUMMARY
In this final chapter, we suggested that time-limited group therapy is a cost-effective interven-
tion in a stepped-care model of treatment. Throughout this book we have made the case, as
have other group therapy experts, that conducting group therapy is complex and challenging.

To this end, however, adequate training in how to effectively conduct and manage the dynamics
of interpersonal interactions in groups is lacking at many levels. Nevertheless, as pressure for
health care cost containment continues to mount, time-limited group therapy will be viewed as
cost-effective in general and an approach particularly well suited for helping individuals whose
health and mental health problems are not severe. In summary, as the popularity of group
therapy has grown over the past decade, a major challenge will be to ensure that there are com-
petently trained practitioners to conduct such groups.

217
APPENDIX A
AUDIT Questionnaire
1 Standard Drink is Equal to
One 12 oz. can/
bottle of beer
One 5 oz. glass
of regular (12%)
wine
1½ oz. of hard
liquor (e.g., rum,
vodka, whiskey)
1 mixed or
straight drink
with 1½ oz.
hard liquor
These questions refer to your use of alcohol. Please circle the answer that is correct for you.
1. How often do you have a drink containing alcohol?
0 1 2 3 4
never monthly or less 2 to 4 times/month 2 to 3 times/week 4 or more times/week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
0 0 1 2 3 4
none 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3. How often do you have six or more drinks on one occasion?
0 1 2 3 4
never less than monthly monthly weekly daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you
had started?
0 1 2 3 4
5. How often during the last year have you failed to do what was normally expected from you
because of drinking?
0 1 2 3 4
6. How often during the last year have you needed a ﬁrst drink in the morning to get yourself going
after a heavy drinking session?
0 1 2 3 4
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
0 1 2 3 4
8. How often during the last year have you been unable to remember what happened the night
before because you had been drinking?
0 1 2 3 4
9. Have you or someone else been injured as a result of your drinking?
0 2 4
no yes, but not in the last year yes, during the last year
10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or
suggested you cut down?
0 2 4
no yes, but not in the last year yes, during the last year
AUDIT Score:
(cont.)
From Saunders, J. B., Aasland, O. G., Babor, T. F., De La Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disor-
ders Identiﬁcation Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II.
Addiction, 88, 791–804. The AUDIT is copyrighted by Wiley-Blackwell but can be reproduced without permission.

218
AUDIT Questionnaire (page 2 of 2)
AUDIT SCORING KEY
The Alcohol Use Disorders Identiﬁcation Test (AUDIT) was developed by the World Health
Organization to evaluate a person’s use of alcohol and the extent to which drinking is a problem.
The AUDIT contains 10 questions. Most questions relate to the past year while a few ask about
lifetime use.
Questions are scored from 0 to 4. Scores can range from 0 to 40.
Higher scores typically reﬂect problems that are more serious.
If a person’s score is 8 or greater, it is suggestive of an alcohol problem.
The AUDIT is available in several languages and can be freely used as it is in the public domain.
SCORES RELATED TO SEVERITY OF ALCOHOL USE
Score Degree of Alcohol Problem Severity
0 None
1–7 Low
8–16 Moderate
17–25 High
26–40 Very High

219
APPENDIX B
Drug Use Questionnaire (DAST-10)
The following questions concern information about your potential involvement with drugs excluding
alcohol and tobacco during the past 12 months. Carefully read each statement and decide if your
answer is “No” or “Yes.” Then fill in the appropriate box beside the question.
When the words “drug abuse” are used, they mean the use of prescribed or over-the-counter drugs in
excess of the directions and any nonmedical use of drugs. The various classes of drugs may include
cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants
(e.g., speed), hallucinogens (e.g., LSD), or narcotics (e.g., heroin). Remember that the questions do not
include alcohol or tobacco.
Please answer every question. If you have difficulty with a statement, then choose the response that is
mostly right.
These questions refer to the past 12 months: No Yes
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you always able to stop using drugs when you want to?
4. Have you had “blackouts” or “flashbacks” as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your spouse (or parents) ever complain about your involvement
with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you
stopped taking drugs?
10. Have you had medical problems as a result of your drug use (e.g., memory
loss, hepatitis, convulsions, bleeding, etc.)?
(cont.)
Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behaviors, 7, 363–371. The DAST-10 is in the public domain and
can be freely copied.

220
Drug Use Questionnaire (page 2 of 2)
DAST-10 SCORING KEY
SCORING: For every “Yes” answer to Questions 1–2 and 4–10 score 1 point, and for Question 3 score
1 point for a “No” answer.
SCORE
DEGREE OF PROBLEM
RELATED TO DRUG ABUSE
0 No Problem Reported
1–2 Low Problem Level
3–5 Moderate Problem Level
6–8 Substantial Problem Level
9–10 Severe Problem Level

221
APPENDIX C
Drug Use History Questionnaire
DRUG CATEGORY
(Includes nonmedical drug use)
Note: Use card sort with drug
category names to ﬁrst determine
which drugs have ever been used,
then ask for information for the
drugs ever used
Ever Used
Circle
Yes or Noa
Total
Years
Usedb
Intravenous
Drug Use
NA = Not
Applicable
Year Last
Used
(e.g.,
1998)
Frequency of Use
Past 6 Monthsc
ALCOHOL No Yes NA
CANNABIS: Marijuana, hashish,
hash oil
No Yes NA
STIMULANTS: Cocaine, crack No Yes No Yes
STIMULANTS:
Methamphetamine—speed, ice,
crank
No Yes No Yes
AMPHETAMINES/OTHER
STIMULANTS: Ritalin, Benzedrine,
Dexedrine
No Yes NA
BENZODIAZEPINES/
TRANQUILIZERS: Valium, Librium,
Xanax, Diazepam, Rooﬁes
No Yes NA
SEDATIVES/HYPNOTICS/
BARBITURATES: Amytal, Seconal,
Dalmane, Quaalude, Phenobarbital
No Yes NA
HEROIN No Yes No Yes
STREET OR ILLICIT METHADONE No Yes NA
OTHER OPIOIDS: Tylenol #2
& #3, 282’s, 292’s, Percodan,
Percocet, Opium, Morphine,
Demerol, Dilaudid
No Yes NA
HALLUCINOGENS: LSD, PCP,
STP, MDA, DAT, mescaline, peyote,
mushrooms, ecstasy (MDMA),
nitrous oxide
No Yes NA
INHALANTS: Glue, gasoline,
aerosols, paint thinner, poppers,
rush, locker room
No Yes NA
aIf EVER USED is NO for any given
line, the remainder of the line should
be left blank.
bInfrequent Use (= 2 x/year) or Brief
Experimental Use (< 3 months lifetime
use) = write 87
cFrequency Codes:
0 = no use 4 = 1x/wk.
1 = < 1x/mo. 5 = 2 to 3x/wk.
2 = 1x/mo. 6 = 4 to 6x/wk.
3 = 2 to 3x/mo. 7 = daily
From Sobell, L. C., Kwan, E., & Sobell, M. B. (1995). The reliability of a Drug History Questionnaire (DHQ). Addictive Behaviors,
20, 233–241. Copyright 1995, with permission from Elsevier.

222
APPENDIX D
Brief Situational Confidence Questionnaire (BSCQ)
Listed below are eight types of situations in which some people experience an alcohol or drug
problem. The questions are to be answered in relation to your alcohol or primary drug problem.
Imagine yourself as you are right now in each of the following types of situations. Indicate on the scale
provided how confident you are right now that you would be able to resist drinking heavily or resist the
urge to use your primary drug in each situation by placing an “X” along the line, from 0% “Not At All
Confident” to 100% “Totally Confident,” as in the example below.
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
Right now I would be able to resist the urge to drink heavily or resist the urge to use my primary
drug in situations involving ...
1. UNPLEASANT EMOTIONS (e.g., If I were depressed about things in general; If everything was
going badly for me).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
2. PHYSICAL DISCOMFORT (e.g., If I would have trouble sleeping; If I felt jumpy and physically
tense).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
3. PLEASANT EMOTIONS (e.g., If something good would happen and I would feel like celebrating;
if everything was going well).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
(cont.)
From Breslin, F. C., Sobell, L. C., Sobell, M. B., & Agrawal, S. (2000). A comparison of a brief and long version of the Situ-
ational Confidence Questionnaire. Behaviour Research and Therapy, 38(12), 1211–1220. Copyright 2000, with permission from
Elsevier.
X

223
Brief Situational Confidence Questionnaire (page 2 of 2)
Right now I would be able to resist the urge to drink heavily or resist the urge to use my primary
drug in situations involving ...
4. TESTING CONTROL OVER MY USE OF ALCOHOL or DRUGS (e.g., If I would start to believe
that alcohol or drugs were no longer a problem for me; If I would feel confident that I could
handle drugs or several drinks).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
5. URGES AND TEMPTATIONS (e.g., If I suddenly had an urge to drink or use drugs; If I were in a
situation where I had often used drugs or drank heavily; If I began to think of how good a rush
or high had felt).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
6. CONFLICT WITH OTHERS (e.g., If I had an argument with a friend; If I were not getting along
well with others at work).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
7. SOCIAL PRESSURE TO USE (e.g., If someone would pressure me to “be a good sport” and
drink or use drugs with them; If I would be invited to someone’s home and they would offer me
a drink or drugs).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident
8. PLEASANT TIMES WITH OTHERS (e.g., If I wanted to celebrate with a friend; If I would be
enjoying myself at a party and wanted to feel even better).
I feel ...
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Not At All
Confident
Totally
Confident

225
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