By: Loretta Hartley-Bangs, LCSW
In the course of my day as clinical supervisor of an outpatient substance abuse treatment program, I have the opportunity to witness and facilitate group work among a varied population. As this program treats all ages with specialty tracks for seniors, as well as adolescents, my day can include running a recovery group for those 60 and older struggling with substance abuse, a therapy group for adult women in early recovery, as well as a group for adolescents with substance abuse issues attending an intensive outpatient program. In addition, I provide group supervision for the adolescent treatment team.
I am always struck by the commonalities among all these groups—the essentials, if you will, that are needed for all groups to function and how easy it is to overlook the basics.
Regardless of age, role, treatment need, or focus, all individuals in groups need the following:
• A safe place
• Respect for each other
• Clear boundaries
• Clear communication
• Clear roles
Safety is not only emotional, but physical. Social workers have always been confronted with utilizing space that may not have been designed with their work in mind. Flexibility and creativity is needed to make the best use of the space available to provide the best working environment to help our clients. Because this agency treats an array of ages, we need to be aware of the interaction of minors and adults. All ages share a building. Although they are not in treatment together generally, they encounter each other in the waiting room, hallways, and so forth. From an administrative perspective, this can be daunting. Because we treat minors, we have an additional responsibility to provide for safety that goes beyond the basic safety needs for clinical work. Couple that with the issues that arise among male and female adolescents in treatment.
However, as the result of this sharing, I was able to facilitate a one-session, intergenerational group with members of the Senior Recovery Program and the Adolescent Intensive Outpatient Program (IOP).
Seeing each other in the building, each group was curious about the other. This led to a wonderful dialogue between the two groups and identified for me the common issues for all persons in recovery despite their ages. The impact of substance use on families and the power of social peer pressure were identified by both age groups as their primary struggles in recovery. All clients involved seemed to have developed a new respect for the other age group through being able to identify with the other, thus dispelling myths. A new respect was apparent from seeing how they interacted and spoke about what they learned.
Boundaries are not only a clinical issue, but a physical one. Because of increasing demand to treat more clients with mental illness in addition to substance abuse (co-occurring disorders), the agency has had to develop additional services, including more groups. Once we are able to develop appropriate types of groups, we need to be aware of space issues. A newly-formed group for those with co-occurring disorders revealed the need to allow more space between members who may be struggling with paranoia, trauma histories, and anxiety disorders. A room that may be of sufficient size to hold a group of 10 members primarily dealing with substance abuse may be too small for 10 clients dealing with more psychiatric issues.
Members of all groups need to know that what they say stays in the room, literally. Most buildings are not acoustically designed to keep noise down, so we need to make accommodations such as sound machines or relocating group to a more private area, if available.
Clear communication is necessary not only within the treatment session, but throughout the building.
All rooms should be clearly identified. Because we treat older clients, as well, it is important that the building is handicapped accessible and all signs are large enough to enable visually impaired clients to read them. All staff needs to know what the room is being used for to prevent disruptions and delays because a clinician is using a room that a colleague was expecting to use at a certain time. Clients should expect to be seen in the same office or group room each session. Consider the disorganization that one’s mental illness can cause for them. The clinician and agency need to be organized, so we don’t add to the client’s stress level and ability to function well.
Appointment times need to be made clear and communicated directly to the client. This may mean writing down appointments and schedules for clients. If certain programs are held for specific populations multiple times per week, keep the times consistent, if possible. For example, if the schedule calls for daily groups, can they all meet at 9 a.m., as opposed to 9 on Monday, 10 on Tuesday, and 9:30 on Wednesday?
Overlaying all of these treatment sessions is the “professional group”—the staff. As a supervisor, it is helpful for me to view the staff as a group unto themselves. This is a much more diverse group. Even though they all have the same basic credential, MSW, they bring varied life and work experiences. These differences are seen in how they communicate, interact with others, and organize their work. As the supervisor, it is my role to facilitate this group, which beyond clinical supervision may involve mediating differences in communication, use of space, and other issues.
As clinicians, we hear about clear roles and think...of course I understand the importance of boundaries and roles with my clients...and that is accurate. However, how do we act out our roles in relation to our colleagues?
This begins with use of physical space. All of our clinicians share offices, requiring negotiation regarding when the office is used as well as how it is set up. Imagine the conflicts that can arise when clinicians do not clearly communicate what they need. Clinician A needs the office to see a client at 3 p.m., but I didn’t share this with her office mate until 2:50 p.m. Clinician B is in the middle of entering an intake into his computer. The result is frustration over the need for clinician B to find another location with an available computer to complete his paperwork. The worst outcome is that the client is kept waiting or is seen in a different office with a clinician who is a bit discombobulated after being displaced from his or her office. What is the role of the supervisor in this situation, especially when it is an ongoing issue? My immediate role is what some of my staff have jokingly annointed me—a traffic cop who needs to make sure clients are seen when and where they are scheduled. Later, my role is to utilize my understanding of systems to work with the clinicians to prevent this from happening again.
Once we get past the basics discussed, it’s time to begin the clinical work in which we utilize our knowledge of group dynamics and interpersonal relationships. How are boundaries set among the members of the therapy group? Is progress being made in communication among the members? Are the members gaining insight into their own behavior and transferring what is learned in group to other areas of life? Clients will not be able to do this work if they are experiencing anxiety because they feel a violation of personal space, what they say is broadcast outside of the office, they are anxious about the chaos they walked into because the clinician and room weren’t ready, they are having difficulty hearing other group members or are distracted by what they hear outside the door. Is the group facilitator distracted by the last minute changes needed to begin the group?
Whereas this is an issue for every clinician, agencies are confronted with increasing pressure to expand services to accommodate more diverse needs. Unfortunately, additional funding is often not provided to meet these demands. In addition, reimbursement from third party payers and managed care restrictions come into consideration when developing these needed services. In a perfect world, we would be providing all necessary services to clients in need. These services would be provided in agencies with ample space designed for the work we do. Since this is not the case, we, as clinicians, need to look to our own resources to do the best work we can. Remain flexible, treating colleagues with the same respect and consideration you treat your clients. Utilize the strength of your professional group. Your colleagues are a great support and source of information, so remember to develop those relationships. Remember that each person organizes differently, and we need to develop working relationships to allow the safest environment for our clients.
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Salmon, R., & Graziano, R. (eds). (2004). Group Work and Aging: Issues in Practice, Research, & Education. New York: Haworth Press.
Loretta Hartley-Bangs, LCSW, is clinical supervisor of the NorthShore Long Island Jewish Health System-Mineola Community Treatment Center. She also serves as Adjunct Professor in the Molloy College Department of Social Work and Gerontology, as well as Adjunct Professor at Long Island University CW Post Campus Department of Allied Health/Social Work.
This article appeared in THE NEW SOCIAL WORKER, Spring 2013, Vol. 20, No. 2. Copyright White Hat Communications. All rights reserved.