Council of Europe Pompidou Group
Drug Prevention Support Network Programme
Planning and initiating
mutual self-help groups
in the field of
drug demand reduction
By Carol Ann Cortese
Arne Schanche Andresen
“Everybody wants to change society,
but no one wants to change himself.”
A manual on planning and initiating self-help groups in the field of drug demand reduction
About Parents in Partnership (PIP) 4
Meanings and social effects of mutual self-help principles 6
Self-help in the Russian context 8
Mutual self-help and community prevention 8
The role of grassroots initiatives in democratic societies 9
PART I – MUTUAL SELF-HELP
Why choose self-help? 12
What is mutual self-help? 13
Self-help and personal challenges-preparing oneself to make a choice
Group interdependence 20
Group structure 24
The group circle
Advantages and Disadvantages of Open-ended Groups
Why are groups ‘open’?
Where are we going?
How will you empower the group?
What will the group be like?
First steps towards group membership
Strategies for maintaining group integrity
General guidelines for practice
Roles and functions in perspective 39
Establishing an alliance with the group
The importance of visibility and anti-taboo work
Facilitating a meeting and how to take good care of each other 50
Establishing a formal organisation 52
Prepare the annual work plan
Special working groups 52
Contacts with media
Table 1-1 Developments in Mutual Self-help Thinking and Empowerment 15
Table 2-1 Tools for the Group Process 19
Table 2-2 Levels of Communication 23
Table 2-3 Group Norms 25
Table 2-4 Developmental Stages in Mutual Self-help Groups 26
Table 2-6 Pitfalls of Mutual Self-help Groups 37
Table 2-7 Do’s and Don’ts of Mutual Self-help Groups 38
Table 3-1 Types of People Facilitators Encounter 42
Annexe 3 Group Exercises / Role Play 60
Since the fall of communism in Russia little has been written on the relations between parents, or significant others, and the disintegrated family system in the wake of drug dependency. The rapid increase in the use and abuse of drugs, alcohol and other substances by people of all ages demoralises not only individuals who become dependent, but their parents and families as well. Long term use has a profound effect on the person’s self-esteem and meaningful identity. And its relationship to the proliferation to self-destructive tendencies is well-documented - such as loss of work and a gradual withdrawal from healthy activities toward unhealthy ones of stealing, criminal and aggressive behaviour and the spread of infectious diseases. One must examine this problem in relation to the psychological effects of cultural change on the individual as observed in longer periods of increased stress within the family system accompanied by crime, disillusionment and illness.
This manual concerns the self-help perspective, which is written mainly for professionals and specialists who are interested in initiating self-help groups as complementary to other interventions or therapies within the field of drug demand reduction. It is also written for practitioners or NGO workers on the community level who would like to teach laypersons how to organise a self-help group in their local area.
Why self-help? Compassion and commitment are important to this kind of group work because it entails communication skills required for motivating individuals in a group situation to make an effort to solve their problems with support from the group. The goal of self-help is to achieve a sense of “self”, or “I”, which refers to a sense of experiencing and acting on the world instead of letting the world act on “you”. With this in mind, creating caring relationships and healthy alliances with each other is crucial to finding a solution while new values and norms are learned.
Medical models have predominated in the health and welfare programmes, which have generally left this group psychologically vulnerable and otherwise hospitalised for detoxification. Doctors and other practitioners do not have the time to sit for long periods, and listen to the patient’s problems. However, the integrated use of mutual self-help groups for individuals affected by drug dependency in the family is an intervention that has proven very helpful for this problem. The self-help approach offers individuals the opportunity to increase control over their daily lives and improve their health by sharing their personal stories and experiences for the purpose of personal change and growth. Unlike AA group process, the mutual self-help process requires the voluntary disclosure of one’s story on a ‘deeper’ psychological level where group members dissolve their psychological defences. Individuals can perhaps achieve a synthesis of new values and beliefs in under the guidance of a self-help group.
The manual focuses on the way health and welfare systems and NGOs can expand by integrating a self-help perspective into the already existing facilities, thereby providing further possibilities for socially excluded groups to create a strong network, particularly for vulnerable families. It places emphasis on encouraging the formation of mutual self-help groups for parents, family members and significant others primarily affected by problems caused by substance abuse. However, the self-help approach is also useful for other groups in society, such as those affected by HIV/Aids, anxiety, depression and tobacco use etc. The broader goal of the manual is to suggest that the self-help approach mediate between the immediate daily problems of the powerless parent and the street life of the powerless drug abuser and the empowering effect this social perspective as a whole has on communication and the learning process.
The aim of the manual can be summarised as follows:
1 to help practitioners and specialists in the field of narcology, psychiatry and social work etc. to become competent experts in the training of group facilitators in the mutual self-help process for parents and other populations in society. Group facilitators are defined as persons who participate in the self-help group on the basis that they share the same problem with group members;
2 to introduce a range of skills at the conceptual and practical levels enabling the specialist, practitioner and facilitators to involve group members in the mutual self-help process;
3 for each skill introduced, to provide a list of points and questions for the specialist/group facilitator to bear in mind when starting a group or when assessing it;
4 to help specialists and group facilitators deal with group situations, such as a crisis, where they may be required to make decisions and choices about group rules, norms and values regarding people’s behaviours;
5 to introduce the basic elements and components of self-help groups that should not be changed or adapted, with an emphasis on values and methods. The appropriateness of the values is derived from the needs of different contexts and different groups.
Meanings and social effects of mutual self-help principles
Historically, mutual self-help organisations descended from a prototype that has been used in all forms of urban communities. The traditional roots of this approach have incorporated both positive values and social goals that resemble those found in voluntary associations on the community level.
The self-help perspective can be traced to its roots in civic traditions in Europe in the late nineteenth century (Putnam 1993). The goal was to form co-operatives for artisans, craftsman, dairies and wine factories in Italy. This was the community’s response to poverty, which was to pull themselves together towards consensus and solidarity and form associations rather than resorting to conflict and competition. Putnam refers to the associations as “mutual aid societies.”
This form of organised solidarity among people who shared similar concerns and priorities has further been recognised as an important element in a wide selection of healing practices around the world. The principles of mutual self-help have for many years been applied in medicine, mental health and education, as well as in addiction therapy and residential drug-free treatment communities, such as San Patrignano in Italy, drug-free collectives in Scandinavia and therapeutic communities in the United States and elsewhere. Currently, mutual self-help concepts are more refined and tailored to meet the needs of particular populations as reflected in a variety of therapeutic groups, most of which have derived from Alcoholics Anonymous (AA), the world-wide self-help system (De Leon 2000).
The development of the manual addresses people’s concerns of the increasing misuse and abuse of drugs that draw drug abusers and their families into different social worlds. It marginalises neighbourhoods and stigmatises families, which in turn contribute to their mental and eventual physical suffering.
Everyone in the family is ashamed of the ‘best-kept secret’ because the problem is never discussed in a safe environment with others who share the same problem. In this environment, parents expose their hurt and pain to one another in a way that they understand exactly what the benefits of sharing are and, furthermore, they manage to communicate these experiences, making them meaningful to other parents. There is quite a difference between sharing the ‘family secret’ with another parent at the supermarket or on a park bench and talking about it in an organised and safe environment where boundaries are mutually respected.
Many parents who have not experienced mutual self-help groups ask themselves what, if anything, can be gained? The paradoxical message of self-help is that the person no longer needs to worry about it alone and a great burden is lifted. At the core of the mutual self-help message is reciprocity: I’ll help you if you help me: let’s face these problems together that none of us can face alone, regardless if the problem is poverty, drug addiction or mental illness. The message is associated with co-operation and sociability and with groups being organised for the mutual benefit of the community.
Even though there is no single drug therapy that cures addiction, parents frequently use a form of “talk therapy” with their primary physician. All doctors, nurses and social workers practice it with their patients without calling attention to it. Talk therapy can be viewed as a broader and, perhaps, more familiar influence of self-help principles on the health system as practised by primary care practitioners. Most parents with drug dependency in the family have participated in some kind of talk therapy, which is a kind of self-help initiative on the part of the parent.
After major disasters such as plane crashes, environmental disasters or train accidents etc. where many survivors share the same fate and destiny, rescue experts immediately set to work to form groups so they can talk about their common experiences. Taking part in such ‘talking groups’ significantly reduces anxiety, which in turn helps individuals to go on with their daily lives and avoid depression and hopelessness. A family regularly affected by drug dependency over time can also be considered a ‘disaster area’. When people simply talk about it with others in a similar situation it reduces daily stress, eventually making an impact that can be felt in other areas of their lives because drug dependency in the family places restrictions on the social lives of every family member.
Establishing personal boundaries is another important message in mutual self-help groups. However, these are boundaries of communication that must be kept open in the group. In order for the group to work effectively each member learns how to manage his or her feelings so that when negative or ’bad’ feelings predominate in the group they are discussed openly and are turned into manageable and positive experiences. This means being in touch with one’s feelings and being able to interpret frustrating and difficult relationships with the support from others in the group.
The fact that mutual self-help is an activity that can be established and maintained with relatively low financial input should not lead people to believe that it has no effect.
Currently, this approach is growing fast in the mental health field all over the world, becoming an integrated part of the psychosocial health services in many countries. Few countries, if any, can offer free family therapy to its citizens. All over there is a need to develop cost efficient services that work. There is a also the need to include this approach more broadly in health and social services in order for the community to better understand the impact self-help has on people’s daily lives.
Self-help in the Russian context
Some Russian specialists have reported that there are misperceptions of the self-help approach that probably originate from the word ‘self’ associated with being selfish, which denotes too much the ‘I’ and too little the ‘we’. It is perceived as something negative due to the lack of sufficient information and, most importantly, a broader social perspective that incorporates the individual into a network, so she or he will not feel like the victim of another person’s (a significant other) circumstances. How de we respond to the deep scepticism regarding the motives of ‘selfish’ individuals and the possibility of them extending their perceptions to include broader social values?
Self-help does not mean that the individual is self-interested and only concerned with his or her problems and does not care about others. On the contrary, the self-help process involves sharing, interacting, instructing and confronting each other, and most of all borrowing the “I” strength from the group. This process enables individuals to help themselves experience their inner person as fundamentally good. In the self-help group, when a person is being nurtured, understood and accepted by others the inner person can emerge.
It is important for the Russian people to know that self-help is for the mutual benefit of everyone in society, and not just for the individual. ‘Mutual’ self-help groups are organised activities with principles and methods that can be adapted to the needs of different groups in societies, not only parents and families affected by drug abuse. But only if there is a structure and a set of rules and ethical boundaries that are followed. In effect, self-help is a locally organised form of welfare and has a crucial role to play in developing trust between people and their communities. Therefore we encourage communities, institutions and specialists to assist the parents in developing support networks and mutual self-help organisations by helping them with the basic material resources, such as a room and electricity, so that they can conduct their meetings.
Mutual self-help and community prevention
There is a notable difference between mutual self-help initiatives and other activities related to drug issues in society, such as community drug prevention, rehabilitation and grassroots actions for improved services. Community organisations address problems such as drug and alcohol abuse by becoming involved in prevention activities in their local communities or on the national level in order to support policy changes that will in turn strengthen activities on the community level. Even though some areas of concern may overlap with the principles of self-help, these groups have different functions from self-help groups because they address specific situations and apply specific tactics.
Prevention, action or advocacy groups are task-oriented with strategies, objectives and goals. Decision-making involves a centralised network, and the workload and responsibility cannot be shared in such a way that everyone participates equally in the process since the tasks are dependent on the competence and resources of particular individuals. This is in contrast to self-help groups, which stress the complementary relationship of the ‘self’ to the social and emotional aspects of experience and relationships, involving a decentralised and egalitarian network. All group members participate and share equally in creating the group process and taking personal responsibility for the problem.
The role of grassroots initiatives in democratic societies
“The political challenge for people around the world today is not just to replace authoritarian regimes by democratic ones. Beyond this, it is to make democracy work for ordinary people.”
Fidel Valdez Ramos
Many citizens in the former communist countries are still struggling with the ideas that have supported a totalitarian system. They have had little practice in exercising communication, dealing with the permissive advantages democracy supports, which is linked to concepts such as individual responsibility, community, citizenship and an open society. In other words, the strengths of democracy depend on a variety of influences. There is the need to understand people’s lives and the complexities that have made an impact on them, while new forms of social inclusion and freedoms are being established such as non-governmental organisations. This is a painful process that will take a generation or two since it is difficult for people to change their thinking, habits and practices, ideas etc. overnight.
People’s strategy under bureaucratic socialism was to get around the authorities and the ruling force. The state was an isolated fortress surrounded by people that were indifferent. And in contrast to the present situation, people did not have any organisations of collective action, which are equally strong forces in democratic as in nondemocratic societies. The state should take care of people’s lives and the individual had very little room to act on his or her own initiative – at least in those areas that were considered public, such as getting ‘the right kind of help’ for substance abusers. It takes time for the individual to get over feelings of dis-empowerment and to grasp the possibility of empowerment and participation in social institutions. Substance abuse and the problems it causes cannot be fully grasped merely in terms of the economic problems in Russia or Eastern Europe, but in the more immediate issue of a system that individual initiative was simply ruled out in many areas of everyday life. “In a democracy, people tend to get what they demand, and more crucially, do not typically get what they do not demand” (Sen 1999:156).
We must also take into consideration that – although there have been major changes in leading positions, many people in positions of power have not yet conceptualised any new perspectives in relation to policy and practice concerning drug dependency. One area where policy has effected practice is the fear among families and family members to be registered as drug addicts – a highly illegal activity. There are problems of trust not only in economy, but also in the health system. Can you trust the confidentiality of doctors? Or, do they have an obligation to report this information to the police or to the Ministry of Interior? In practice, when this trust is seriously violated, patients will not be open with the doctor. Under such circumstances, the drug problem goes ‘underground’ and the population of drug users becomes invisible; hence, the spreading of HIV/AIDS and any interventions for treatment becomes impossible.
In democracies, one way to influence policy change is to address people in positions of power and decision making in the local government. Indeed, the best way is to establish an organisation and build communication between different institutional levels such as the group and community. Without democratic engagement from the people, political systems will neither be transparent or accountable. There should be guarantees of total confidentiality between the clients and the health system, and drug users should not be reported to the authorities. In our opinion, it is not the health system’s responsibility to practice surveillance for other purposes than public health issues.
The manual consists of four main parts:
The first section refers to the mutual self-help traditions that were encouraged in parts of Europe to address both economic and social problems and would support co-operation and solidarity to further social democratic ideals. Then we go on to describe the application of self-help principles to different populations within the mental health field, which have developed out of the belief in the human potential to change. Self-help groups are different, depending on the population. Mutual help groups have proven helpful for parents and significant others of drug dependent persons, for youth at risk, for HIV-positive persons and their families and significant others for persons with depression and anxiety and other problems. It is important that the practitioner or specialist in the mental health field has a broad knowledge of the specific target population in question.
This section discusses the relationship of mutual self-help and the healing process with references to North American and Western European literature. The importance of pre-existing norms, values, rules and structure are essential elements, some of which must be selected, organised, conformed and adapted to by the members. The self-help process can only evolve when it is designed to address that particular group’s concerns, priorities and interests as well as their problems (e.g. medical, psychological or social). The focus is on the practical group work, examining the elements and tools that help define more clearly the mutual self-help system.
This section introduces the reader to the role and function of professional practitioners within the fields of narcology, psychiatry, psychology, medicine and social work, as well as laypersons who can act as initiators of mutual self-help groups. Furthermore, we also examine the role and function of the group facilitator. Group facilitators share the similar problem of the group and are guides involved in the continuous management and process of the group, often using their direct personal experience.
This section will provide information and advice related to launching a formal organisation for mutual self-help groups on the local level. This will demand special talents and resources among the group members such as social, administrative and economic skills, as opposed to the self-help group, which depends largely on social relations and self-identified common interests and shared problems. It is appropriate to denote boundaries and criteria in such organisations in order to decide who should be involved in given processes, such as facilitating self-help groups, decision-making processes, or a spokes-person for policy-related issues in the organisation etc. Such an approach to boundary setting is important particularly for the novice organisations to learn so they may challenge certain views and policies when appropriate.
PART I – MUTUAL SELF-HELP
Therapeutic Community proverb
Why choose self-help?
When parents seek professional help at all, most of them seek advice from doctors, narcologists, psychiatrists or psychologists and only when there is a crisis at home with the child as the identified patient; generally, when there are no crises most parents will not seek help or support. Their family life is often emotionally laden with guilt and shame and fear for the child. The family rapidly becomes dysfunctional due to the constant pressure and anxiety caused by the drug dependent family member.
The purpose of self-help groups is to learn coping strategies and boundary setting in order to reduce emotional stress in the family on a daily basis. Learning occurs in the group through the interaction between the individual and the support group. This way the entire family system can be less negatively affected by the drug dependent and feel mutual support. This is particularly relevant to contexts where there are few or no treatment or rehabilitation services available, or when the dependent person is avoiding any commitment to improve his/her health, or when the parent finds it difficult to supervise his or her teenage child.
Contact with public health services is largely dependent on the home situation of the parent, for example, if the child is sick or shows signs of out of control behaviour due to drug use, or perceived as potentially suicidal because of overdose. Indeed, most parents of drug users exhibit signs of depression or mood variation because they live with the constant fear and desperation that they may not see their child again. The parents typically focus on the negative in the environment and overlook the positive and tend to think in an all-or-nothing manner. For example, “things will not get better until my son is in rehabilitation.” These are the thoughts parents use in daily living that are generally too absolute and extreme, and too highly personalised. Self-help principles counteract this type of thinking which can lead to depression and hopelessness.
Kleinman and Good (1985) have examined depression in different cultures, asking whether depression is considered an illness category or an emotion. In many societies depression is associated with strong feelings of guilt, sadness, anger or anxiety. Generally, the psychosocial characteristics of depression are considered equally important as the physiological components, which suggest that it is a social illness that concerns emotions. From this perspective, it is imperative to establish stable groups for parents that meet on a regular basis to discuss, talk and share their experiences and feelings, helping to strengthen their personal and social identity. Establishing group affiliations or alliances that are sustainable by building on existing social networks can increase self-esteem and confidence and help them to begin dealing with these problems in a positive way. It is generally considered among writers of depression that patients do not cure themselves of depression (ibid.). Thus whether the nature of interaction is between the patient and practitioner or the individual and the (self-help) group, “interaction with others is a crucial factor in effecting a cure” (Beeman 1985).
In the literature, there are different definitions of mutual self-help, depending on the perspective of the author. Norwegian Self-help Forum (NSF), a user-based and grassroots organisation, defines self-help as:
“taking charge of your own possibilities and resources in order to take
personal responsibility for your life, and to lead your life in the desired
direction. Self-help is to start a process from being a passive bystander
to becoming an active participant in one’s own life.”
NSF underlines the importance between receiving support and building inner strength. From NSFs perspective, support is seen as something passive that does not create inner change. Whereas strength involves the inner person who actively participates and takes one’s own resources into use, placing oneself in an empowered position. The process of self-help places at least two major demands on the group members:
- Recognising that you have a problem (in this case being a parent/significant other of a drug dependent person)
- Being motivated (actively choosing to change your situation)
A professional definition characteristic of an ‘outsider’s’ perspective is Seim et al. 1997:
‘Self-help is a collective organisation that consists of people with
similar needs and problems that come together either to find solutions
or how to master a difficult situation.’
The most general goal of any kind of therapy or intervention is to bring the individual to the point at which he or she can function independently and no longer needs help; but can a person be taught not to need help by giving him help? Self-help contains the fundamental paradox of therapy, which is how “can a person be taught not to need help by giving him help” (Seltzer 1986:184). Of course, therapists may be able to help clients help themselves, but therapists cannot ‘activate’ the solution to the problem nor can the therapist take the responsibility to solve the problem.
Self-help is a broad and profound concept that has included a range of treatment modalities, serving a variety of populations, and activities that have covered different aspects of people’s lives (social and psychological) and different levels of decision making and activity (political and economic). Due to the broad interpretation and application of the concept, there is really no universal or academic ‘definition’ of self-help because mutual self-help is a message of empowerment thinking and responsibility that emerges through peer support and egalitarianism when ‘using the group process’. The closest we come to a definition of self-help is that the individual over time comes to recognise his or her personal responsibility for the problems that have precipitated the ‘treatment’ solution, intervention or choice.
Experiential learning is one of the primary elements used in mutual self-help groups. Since the self-help approach is more often associated with grassroots initiatives (i.e. based on personal experiences) than with psychiatry or medicine, it is treated as ‘soft’ data and not ‘hard’ data (statistics). The way personal experiences are perceived and communicated in the group as a source of learning is also a source of ambivalence for both researchers and politicians alike in terms of generating scientific facts about behavioural change. For example, how many people have been cured by the self-help method? We do not have statistics to answer this question because much of the information like AA is based on people’s testimonies and personal stories. That is to say that personal experience does not count for much and is placed at the bottom of the list of potentially influencing forces in relation to increasing the quality of mental health that encourages the choice of healthier lifestyles in the general population. However, on the other hand, human experience and communication as perceived in cultural norms and values has widened human potential for change, specifically within the framework of building social networks from the basic principles of mutual self-help that focus on the individual’s ability to solve everyday problems.
Self-help emphasises the importance that human beings in most circumstances can contribute to their well-being and take personal responsibility for their own lives. From the perspectives of drug demand reduction and social development, the mutual self-help approach is applied in drug treatment and rehabilitation facilities and in the general mental and public health services. It is currently being used on families of primary patients, patients with certain psychiatric diagnosis and on families of clients in drug treatment programmes to increase their knowledge of the problem and their experience and participation in the recovery and healing process of the respective family member.
Within the field of drug treatment and rehabilitation, self-help emerged at the grassroots level as a reaction to the traditional and, somewhat, authoritarian medical model where the patient had little influence on the type of treatment provided. On the one hand, exists the predominantly passive role of the receiver of help – “doctor, please help me and make me well”. On the other hand, there is the active patient or client taking responsibility and ownership for finding solutions to problems by summoning up the courage to resolve them. Another major difference between the medical approach and mutual self-help is not merely due to the status of the doctor as the ultimate expert; rather self-help emphasises social interactions between the person and the group, who represents the person’s social network. By using the group as a social network the person is capable of interacting with others and feels empowered to change the present situation. The group motivates and challenges individuals to make the painstaking decisions that many do not want to face, namely taking responsibility for the problem.
Alcoholics Anonymous (AA) and the 12-step programme are other world-wide networks where self-help methodology has been the core activity to attain sobriety. Trust and empathy and other elements of group support have been used to re-socialise and persuade drug and alcohol dependent persons to go through the painful experience of withdrawal and rehabilitation. A milestone in the development of mutual self-help groups in drug-free treatment became known as “the miracle on the beach” in Los Angeles, California. The miracle refers to a group of heroin addicts who decided to change their lives by “kicking the habit” without the help of either the mental health services or other external assistance. At the time, they felt that the conventional services offered in the county mental hospitals did not help them master their daily lives and instead they decided to meet on the beach every day to conduct their meetings. This group of self-help pioneers established what later became known as the therapeutic community (‘man helping man to help himself’), one of the major modalities applied in drug-free treatment and rehabilitation (Yablonsky 1965).
The self-help approach as applied to a diversity of groups and populations has gone through many changes (Table 1 -1). Like most therapies, mutual self-help groups appear to create emotional interest and stimulate feelings of hope in the individual members. However, it has been argued that in order to influence individual motivation people must believe in the task, or in this case, the therapeutic intervention (Kleinman 1980;Brown 1993). Moreover, they must believe that they have the power to change their relationships through interacting with others in contrast to being fearful and mistrusting of others. The mutual self-help group creates a safe environment for people to talk about the ‘family secret’.
Parents and parenting are personal issues to be discussed in relation to mutual self-help thinking and empowerment, particularly when it comes to drug dependency in the family. Most parents expect obedience and respect from their children which are strongly reinforced by their parenting skills and a moral code of behaviour. When the children violate these codes there is a consensus in the family concerning punishment and consequences that usually include the norms of parenting shared by that particular culture or village. In other words, there is a public consensus regarding ‘proper’ child rearing against which parents measure their own performance.
Since mothers are often viewed as responsible for raising the children the mother-child relationship comes into focus. This is particularly the case when something is wrong within the family, and the mother is generally suspect when something goes wrong with the child. Her vulnerability often causes her to feel anxious, guilty and, in some cases, suspicious of others and of authority in general and professionals in particular. She may be afraid of gossip in the neighbourhood that will lead to stigmatising the whole family, and if others should find out they will try to pry out the ‘family secret’, which everyone knows anyway, but no one talks about. It is a daunting task for two parents, not to mention women in single parent households, to seek support from the health services and develop an empathetic rapport with the health staff.
Parents have no other choice than to handle the crisis situations in the family with or without support. Along with implementing mutual the self-help message, the importance of educating parents (i.e. mothers) in areas, such as rehabilitation and drug treatment issues, the recovery process and building organisations will be instrumental in the long-term prevention of drug dependency. Self-help is a support initiative that should be offered to these parents in order to begin their process of healing through empowerment and personal responsibility. Parents can connect with each other and begin to speak about it and not be frightened.
The self-help group is an alternative for different kinds of people because it concerns the isolated value of personal responsibility relevant to individuals in all cultures and traditions. The fact that various self-help approaches are applied to different types of problems indicates that it is recognised as a constructive and cost-efficient attempt to problem-solving and, most importantly, as complementary to professional services within the field of mental health.
Whether practised by informed laypersons or specialists self-help is part of the therapeutic discourse. The essential experiences it addresses are how the individual nurtures his or her own inner strength in the group and the way these experiences are communicated to other group members in a caring way. Generalisation is difficult but many people involved in therapeutic solutions will often project their individual problems outward onto society. Both practitioners and laypersons alike must find a pragmatic and an altruistic way to assist others in this therapeutic predicament of blame, because it is often the case that they will tend to shift responsibility for resolving their problems onto someone else’s shoulder. The primary values of responsibility, caring for others and trust in the self-help group are considered ideal behaviours and only evolve over time (Table 1 - 2) with the help of group process.
PART II - Group Process and Structure
(Norwegian Self-help Forum)
What is a process? A process signifies movement and change over time (Brown 1998). Brown introduces the concept of process by saying that it does not give any ‘final’ answers, but rather communicates a diversity of viewpoints, feelings, experiences and different perspectives on a situation. Moreover, process gives the possibility for the person to find oneself on a certain journey with a set of goals. Group process appears to be formed by the member’s needs and the facilitator’s function and the group setting. These combine to create a situation where members’ feelings and expectations in the here and now are shared in the group and form the process.
In a mutual self-help approach to problem solving, process is primarily linked to relations within the group. This implies that relations will always be in a state of change and spontaneous in order to promote the emotional involvement of each member in the group in the here and now. The spontaneous process helps members uncover their own abilities and potentials within themselves and discover a fuller understanding of the inner person, or the ‘parent’ that is a good parent, which will ultimately empower the individual to lead a healthy lifestyle, governing his or her own life.
Evoking and provoking responses and feelings in the group sets the process in motion (Table 2-1). There is no stereotyping and each member should be treated as an individual. The person identifies himself or herself with the group by learning new boundaries and norms, subsequently, loosing the traditional ones and adapting to new norms. By sharing experiences and intuitions with others the individual debates and evaluates in the presence of others values that are central in his or her life. The person can concentrate on his or her relation to duties and the moral obligations of other social roles (e.g. a wife or a husband, a parent to the other children in the family, a brother, a sister, a cousin, a grandmother etc.). Process is thus felt by incremental changes in the perception of oneself and one’s problems.
The group process is both therapeutic and educational for the individual. And the most urgent rule in the process, particularly for the group facilitator/initiator, is to promote participation while safeguarding the psychological part of the individual in the group. The table below lists the tools of the group process, some of which are taken from George De Leon’s (2000) therapeutic community that can be adapted to mutual self-help groups. These elements are designed to encourage the development of self-responsibility in the individual, which begins when the member accepts responsibility for his or her actions, decisions and feelings in the group. They are divided in terms of intensity of expression: provocative tools provoke strong feelings and evocative tools evoke emotions that lead primarily to disclosure and more supportive gestures of participation. Most mutual self-help groups stress both a provocative and evocative stance that encourages support and participation that is facilitative.
Self- help and personal challenges - preparing oneself to make a choice
Most people believe in the power of reason to resolve problems. But it is usually not rational thinking that has created the problem in the first place, so according to this logic using the power of reason would not solve the problem. A good starting point for deciding on an intervention may be to look at the power of irrational thinking.
In order to motivate change in irrational thinking it is necessary to enlarge the perspective of the problem. The problem can either get ‘better or worse’, depending on the person’s perception of it. People can look at the problem as something that is ‘free’ to change, and as something that does not tie them down. When they try different interventions or solutions they are acting as free and active participants in the healing process. We are right to perceive the problem as a possibility for growth and healing and not as something that holds us back, but brings us closer to an enlightened understanding of it and consequently ourselves. On the other hand, if we experience the problem as something that takes away our responsibilities (i.e. as a citizen, a mother or father etc.) we become passive bystanders and not active participants. The process is a ‘perceptual’ challenge that is ultimately up to the individual to dare and take the risk.
A person can take the first step by:
· Acknowledging that he or she has a problem
· Getting to understand the problem by looking at it from different perspectives and at the different elements that constitute the overall problem. The person makes it manageable by not becoming overwhelmed by it, taking one aspect of the problem at a time.
· Dare and take the risk to share your thoughts, feelings and “family taboos” with those who have similar problems in a psychologically safe and confidential environment.
Generally, when we make choices the criteria we use to consider them is based on ideological, practical, pragmatic or intuitive reasoning? The kind of thinking or reasoning that we use depends largely on the culture and its socialisation practices. However, when confronted with a decision, most of us would like to encounter the practical use of both ideology and moral beliefs that give us meaning in everyday life. And if our goal as human beings is to find meaning through positive experiences then we must make a conscious effort to attain it through discovering our possibilities. And to discover the answer to “what gives meaning” to our everyday life, we must look to the social network of people whom we share goals with.
If the aim is to have positive experiences rather than painful ones, it is obvious that the criteria for making the choice to attend a group meeting would be rational. If the aim is to learn something new about the ‘inner’ person, it usually does not come without some conflict or discomfort. If the aim is to receive advice or discuss problems, there will be disappointment because a mutual self-help group is not a discussion group (Table 2-6). Instead, the group gives the psychological support in the decision that is taken, provided it is a healthy decision. Hence it is necessary to consider over time whether the group is useful in terms of resolving problems in everyday life. Indeed, what the person gets out of the group experience depends on what the person puts in to the group.
Before embarking on this journey, the critical aspect is that the person prepares for the group with a general awareness of the goals whether they are to increase self-confidence and self-esteem or to reduce anxiety, loneliness or withdrawal from social activities, experiences must be felt and communicated.
‘My changing influences your changing in a mutual self-help system.’
What constitutes a group? Considering similarities and common needs and problems are the first steps toward developing the group as an instrument for support for the individual. Yet individuals also experience group membership in the psychological sense, and not only because they are similar to one another (Brown 1998) but because they are dependent on one another for survival. Thus, a collection of passengers on a plane does not constitute a group because their interdependence is minimal. However, if the situation transformed from a ‘passenger’ to ‘hostage’ situation their fates are interconnected. This means that each person directly facilitates change in the other person because each one plays a meaningful role in the change process, which directly influences the other. Feelings of interdependence in the fate among group members are needed in order to create meaningful relationships within the group.
Through interdependence of fate, or ‘a situation’, members form caring relationships with each other which is the most important feature in the group process, whereas structure is secondary and power relations tertiary. Indeed, caring relationships require a time commitment and regular attendance by the long-standing members; however, a time commitment is also necessary from the new members in order to maintain the group process, continuity and stability. As we have mentioned, initially a common problem brings the group together, uniting them by the situation and similar needs. Because they have similar life situations, they frequently share similar feelings of shame, guilt, and embarrassment and even social rejection. Thus, caring relationships are more easily formed provided there are not too many disruptions caused by frequent member change.
Acquiring knowledge of the problem from each other’s experiences influences group process, but the process can be messy at times. For example, having a drug dependant family member or living with a drug user requires knowledge of experiences particular to this problem. Communicating these experiences gradually builds cohesion between the members where identified goals can be worked on through process and interaction, reaching some kind of consensus. Yet communicating the painful experiences of drug dependency, where no magic formula exists that would give ready-made answers that are ‘just right’ is messy, because mutual self-help is not an ‘impersonal’ technology that relies on consensus or agreement, but on group process. If the parent is searching for ready-made answers, he or she may become impatient. Each parent lives with the behaviours and attitudes associated with drug use lifestyles, such as domestic violence, criminality, accidents, or neglect of health and are emotionally affected by them. All the family members are trying to function in this environment. But self-defeating behaviours of the parent and the troubled family become evident over time, affecting their rational functioning. They may withdraw from their social network and activities or perform poorly at their job or at school. This is a ‘choice’ exercise that requires discussion, sharing and, most importantly, understanding and acceptance of oneself. Self-love is crucial for group members to experience and develop over time in the group.
This problem affects the whole family. Forming caring relationships in the self-help group based on personal sharing of similar experiences and trust provides opportunities for experiencing the feelings that are critical to individual change, and through social interaction sharpens the perception of reality. The importance of forming healthy relationships in the group is supportive and facilitates a multitude of responses such as empathy, compassion, understanding and trust. The parent’s new evaluation of the situation is also advantageous to facilitating a process of change within the family.
Looking at mutual self-help groups in this way allows for social comparisons of perceptual change between new members and old members. Newcomers in the group will often share experiences with the expectation of receiving advice and not to form relationships with the group members. However, when newcomers commit their time to the group they begin to experience ‘talking with others’ and what this does to affect the course of their thoughts and feelings.
Another final point to be emphasised with regards to this topic is that the ability to speak about the problem is also a function of the healing process. Thus if people are not able to speak about it, emotional or otherwise, they will not find the cure.
Along with trust, spontaneity of feelings and unpredictability in the here and now and forming caring relationships perhaps with people one does not know are essential components of the self-help group process. Group members may experience these dynamics as extremely messy communication. But there are constraints placed on the conditions of communication and interpretation by the group trainer/facilitator in co-operation with the group members. These are rules and norms that are linked closely with primary values. Therefore, it is critical to discuss rules regarding communication, which are set up to safeguard a healthy environment for group members.
Rules define the context and the definition of content that are important within that context to create a safe and secure environment for the individuals. Most newcomers are not ready to shift from one context (i.e. from the practical to symbolic activities). Nor are they ready to speak freely about their present condition or personal feelings. Before the meeting, some may even prepare what they will say by writing it down and then read it aloud to the group. In short, the newcomer is not ready to move from the pragmatic nature of problem solving to the symbolic activities and meanings in the group process. Group trainers and facilitators must acknowledge the importance of group process, it cannot be viewed as a mechanical device for development and change. Newcomers must make use of the opportunities in the group to articulate and communicate their stories.
Newcomers should be aware of the personal responsibility involved in problem solving. They take ownership of the problem and co-operate with others. The group does not own the problems of individual members, but facilitates the process of interaction so each member can activate his or her own solution and resources. When members begin to give advice, they assume ownership of each other’s problem and they stop using the group process (Table 2-6). Group trainers and facilitators as communicators need to be aware of these dynamics because they occur rather quickly in the self-help group setting.
Trainers and facilitators are aware of the different levels of communication that are operational in the group at different times (Table 2 - 2), giving attention to how individuals communicate experiences to each other. Group facilitators can foster situations through direct personal experience as opposed to trainers that generally cannot share the common problem with the group. Group trainers do not fully understand the collective meaning these experiences have on the individual’s social lives as a result of the problem: the disintegration of social networks and personal feelings of defeat and helplessness or loneliness appear to be prevalent, particularly for parents and families of drug dependants.
From the admissions of defeat and helplessness to empowerment, mutual self-help groups can help them tie these feelings to positive ones by emphasising, for example, a positive reframing of the problem. This term refers to a problem previously perceived as
negative and ‘relabelled’ as positive to foster experiential learning. Members confront the parent’s feelings with care and concern. Many parents have said that, “I thought I was protecting and caring for my child by attending to his needs and feelings. And then I realised that I was happy only when he was happy. If I was happy when he wasn’t, I felt guilty. I had no control over how “I” felt. My child had control over my feelings. “ The constant worrying about the child’s feelings and needs can be seen either as the mother being protective and supportive of the family, or as allowing her to continue with her admission of defeat, letting the child’s drug taking shirk her other individual, familial or marital responsibilities. In this example, the drug problem, the ‘family secret’, controls the entire family system.
Trying to influence perceptual change of the problem is essential for personal change and motivation. This indirectly and gradually encourages the newcomer to seek other ways of perceiving her experiences, using them as a positive resource towards change. Even though this way of thinking for the newcomer may radically depart from common sense solutions communication explicitly concerns the process of extending rather than narrowing the range of possibilities, choices and judgements regarding the problem.
Using such techniques in the self-help group goes counter to our traditional thinking because when someone is depressed our impulse is to try to cheer up the depressed person, or to give the person advice or solutions. However, when a person has shared something with the group that was very sensitive and difficult, it is acceptable after the group to give the person a hug to confirm that she has used the group and to show her feelings; an acknowledgement of identification. People must trust their own instincts and intuitions (Table 2-1). From the vantage point of reframing the problem, any direct attempts “to cheer someone up” is not considered using experiential knowledge or having an understanding of the mutual self-help process. The problem perceived as negative is viewed as part of the solution; members are the experts of their own situation and their experiential knowledge is seen as a positive resource for the group. It is up to the group trainer and facilitator to encourage the individual through the application of reframing or using different viewpoints. Thus, the negative interpretation of the problem is experienced as ‘free’ to change to a positive one (Seltzer1986).
Self-help is effective when training, rules and a structure for articulating experiences are communicated and can be replicated by others who want to start a self-help group. It concerns how group trainers or facilitators shape the group process derived from the active participation of members and apply cognitive learning experiences through role-playing and enactment of a situation in order for the trainers and facilitators to effectively expose the group’s thinking patterns. Trainers and facilitators must be good communicators and make themselves understood by others. These skills can be learned over time with continual support and guidance.
If process is associated with forming caring relationships, group structure gives the group stability and defines group norms and appropriate codes of behaviour as well as information about status and positions. Group norms are both implicit and explicit and tell the members how they should or should not behave. Status and positions occupied by individuals in the group are prominent aspects in self-help groups, which all members should be aware of. Status relationships in the group depend on the personalities of those involved and the complex nature of the task and intensity of the group. High status in the group implies the tendency to initiate ideas or generate solutions that others will follow. Any form of counselling or advice is generally not recommended because group members may feel pressured into taking the advice, though giving helpful information is sometimes necessary. Advice places a stronger emphasis on task-related activities in the self-help group and less emphasis on eliciting positive emotional behaviours. Sometimes the most influential person (high status) in the self-help group is not the most liked person in the group.
Before exploring in more detail the set-up and the structure of the self-help group, we have highlighted the group norms that create the basis for building a safe environment for the group members (Table 2 - 3).
Reinterpreting recent past experiences and linking them to the present situation can influence thinking patterns about a particular problem. The individual focuses on acquiring personal knowledge through experiential learning and remains focussed on feelings in the here and now. Through mutual self-help, the individual gains a wider perception of her or his possibilities and becomes less psychologically vulnerable or overwhelmed by the problem. The group acts as a training ground for everyday life because the changes some individuals may recognise in themselves are more often felt in the interactions of daily life rather than in the self-help group itself. One can say that individuals shape themselves to fit in with the group structure and the process will follow.
When dealing with self-help thinking and empowerment, a worldview is adopted shaped by process, emotion and rational decision-making. The empowerment process as experienced in self-help groups passes through different stages (Table 2 - 4) but they are not always recognisable to every member. Some members may recognise the group’s problem but not have a solution, and some may not recognise it at all. There are also obstacles to the process that groups or individuals may encounter from time to time in which they must find the correct solution for:
· Depression is one of the common problems in self-help groups, particularly for mothers with drug dependent children. Some mothers tend to disengage themselves from the group by recounting only unpleasant experiences along with the corresponding negative feelings. The mothers have very little individual motivation and belief in solutions because they have been exposed to many negative experiences.
· “Drowning in personal stories” – often the experiences or stories shared in the group are not positive and over time have a negative influence. This exchange should be confronted in order to prevent a negative feeling in the group. If no one confronts this situation then the facilitator takes the responsibility since it results in sustaining a communication that will cause people to leave the group.
· Fear of disclosure of personal experiences, stories or feelings. After several meetings the individual makes no attempt to share relevant feelings or experiences with the group.
· Conflicts within the group should be addressed before any newcomers are asked to join the group.
· Lack of external guidance for the facilitator can lead to the collapse of a group. For this reason, it is recommended that therapeutic support is available from experienced professionals with skills to provide emotional support on an ‘as needed basis’.
· Power tends to remain in the hands of one person. It is a mechanism of authority used to create a ‘social climate’ of maximum intervention by one person and members do not feel the freedom to express their opinions. The mutual self-help group should ideally be a ‘power-free’ zone.
Seim et al. (1998) has listed the most prominent features found in different kinds of self-help groups in Norway (Table 2 - 5). Though she does not examine the features in relation to group work methods or practice, each feature is interrelated and linked to the primary values and group norms to create a group dynamic that facilitates the process of experiential change. Group continuity and experiential learning, which were added by the authors, are generally found in psychological and group therapies.
Similarities and differences among members are vital for maintaining the group process and forming relationships; both attributes are complementary and provide the major resource for achieving the aims of the group. The idea of similarity does not primarily refer to social class, education or income, but to the fact that the members have a common problem, in this case, having to confront drug or alcohol dependency in the family on a daily basis. In this specific area, group members are the experts and ‘owners’ of the problem.
However, differences refer to how individuals experience feelings. They are valuable to the development and sustainability of the group. An acceptance of differences within the group gives the group a dynamic and strengthens it so it does not remain static. A pragmatic approach to mutual self-help acknowledges that even though the experiences shared are similar and that the members are bonded by a common problem, experiences are recognised as having very different meanings for different individuals.
As the group develops and strengthens, they adapt to new norms. Though similarities still exist within the group, each member will grow and change at different rates and, consequently, the emotional responses towards his or her experiences will be different. Each member must show mutual respect for this aspect of self-help. Thus, sharing a common problem with others who have similar social and psychological needs is one characteristic for starting self-help activities, and making sure that the communication among the group does not occur in a language of medical problems or diagnosis, but in interaction with others; sharing experiences.
Reciprocity is an important dimension in the change process and is interrelated to group continuity. Once members have located the common problem by sharing experiences, integration and identification with the group takes place. Through this process, experiential changes in one group member can reciprocally produce experiential changes in others (De Leon 2000). When members gradually become more secure with the operations of the group, the common problem, or ‘stigma’, fades into the background, becoming more or less unimportant and the emotional features become more important.
When the group is in conflict, or having a ‘family quarrel’, reciprocity is not operational. Hence, power and control issues should be sorted out as soon as they occur, particularly before the group takes in any newcomers. If competition or power struggles occur over a long period of time the group will not move in a positive direction. The members must allow time for these issues to be resolved and be patient. For example, it is inescapable that some members will make social comparisons in terms of who is suffering the most, however, members usually confronted the situation rationally and with care and concern. As we all know, it is difficult to evaluate another’s misery and suffering because it is a subjective experience. This is interrelated to accepting differences in others. Psychological comparisons tend to be a common occurrence in open groups comprised of newcomers before they have learned how to communicate and interpret their own subjective experiences. Social comparisons on the other hand can also act as a positive frame of reference for the long-standing members in terms of registering their own personal change against the newcomers (see section on open and closed groups).
Group norms and values represent continuity in the group. Therefore continuity develops in the group when norms and values are safeguarded and passed from generation to generation directly between long standing members (Bailus et al.1978).
When discussing continuity in relation to mutual self-help groups, there are some influential factors that can disrupt the group:
· firstly, that people focus on the historical past and not the ‘here and now’
· secondly, that people’s beliefs and concepts are not always coherent
· thirdly, rapid turnover of newcomers can disrupt group ‘traditions’, i.e. continuity
Though conforming and compliance to group norms and new values are pivotal to the group’s development, it can make some people uncomfortable, particularly those with alcohol or drug dependency problems in the family. While in the first stage of starting a group, group trainers and facilitators will be the main focus of the members shared feelings. They also regard them as symbols of the community and displace their feelings of resentment and community disapproval on to the group trainers or facilitators. Since these feelings have originated from community disapproval and the some of the group members, it is in line for the group trainers and facilitators, with support from others, to question the reality of their attitude.
Autonomy from any outside or external authority or control is a factor to consider especially if the group is receiving funds from either the state or the municipality. There could be compromises or changes that the group must consider, but nevertheless the group should maintain autonomy in relation to the content, structure and activities. Autonomy is linked to the personal value of freedom, which is deeply rooted in Western liberal culture. From this perspective, a sense of individual sovereignty is a prerequisite for personal change, therefore the group members must feel a certain measure of freedom.
Experiential learning deals with the conscious part of the self that lies on the surface, in contrast to the historical past; the psychoanalytical model of the self that lies deep within the self. Experiences recounted in the group are connected to everyday life and grounded in the individual’s immediate social context. Knowledge is acquired, produced and reproduced in the here and now, through the act of sharing and exchanging experiences in the moment. The person learns to process the new information, using experiences as resources and the group as a training ground for learning how to manage new and perhaps unfamiliar experiences and feelings. Group members learn through action, experience and practice.
Unquestionably, there are multiple approaches and styles found in different self-help groups and activities, but these are the cornerstones of the mutual self-help method found in many NGOs that practice self-help. Even in self-help groups with leadership styles that are more directive or confrontative, proposing concrete solutions and answers for the individual, it is ultimately up to the individual to activate the solution and not up to the ‘group leader’ or the specialist. Group members must trust themselves. Self-help groups offer mutual support to its members, thus encouraging them in the process to accept responsibility for what has previously been denied, particularly for those who have addiction problems in the family. Many family members’ lives are controlled by the drug dependency, and sympathy for the drug dependent person blinds them to (drug user’s) manipulations. Mutual self-help groups build confidence provided members share these experiences with their peers. Consequently, their well-being and the well-being of other family members will not be dominated totally by the drug dependent person. De Leon (2000) describes their behaviour as “deft at manipulating people, procedures, and systems in the service of their immediate wants.” (pg.61)
The group circle
Usually, when members enter the meeting room they sit in a circle, the best format for the group meeting. However, the group can decide among themselves whether they wish to sit either in a circle, a horseshoe or around a table. The meaning of the circle in the group has long been associated with ‘symbolic’ activities much like those related to ritual and magic. From the earliest times, the circle has carried religious meanings and interpretations, hence the magic circle. The formation of Stonehenge in England, the Viking burial cites are constructed in ring formations, the Buddhist and Brahman cycles, and in Byzantine and Orthodox weddings, the groom and bridegroom circle the altar several times during the marriage ceremony. Moreover, the wedding ring signifies ‘till death do us part’. Such acts have been associated with magic or supernatural forces in earlier times and with religious meanings in later times, and for the individual it answers to spiritual needs or to powers of the unseen world.
When making the circle, there is also an ethical code of rules that the formation of the circle binds and integrates its members and determines their behaviour towards each other and towards the things they believe. When observing others in the circle, we may feel that we share a destiny, an identity with each member and an interdependence of fate. The trainer, or the group facilitator, in the circle should be perceived as the one who has sympathy and empathy with its members and with whom one feels they can communicate.
Similarities are important when planning a group regardless of the special problem or population it is designed to help. However, it is also of paramount importance that the group not only shares similar psychological needs or problems, but similar goals, for example, to reduce stress in daily life by learning healthy coping strategies. Because simply coming together with each other in a self-help group without identifying goals will not help hold the group together. Therefore in order to ensure success, the group trainer or facilitator must assist the group in defining the goals and consequently, group structures and ethics will fall into place. Through this kind of social participation comes the development of trust in each other. This discussion will be important in relation to open groups, since there is a rapid turnover of members in a short period of time that can compromise the primary value of trust.
The use of the formal closed group model used to teach group work methods in social work has also been used to understand the open group model (Henry 1988), as is standard practice in AA as well as with other populations in order to meet the needs of different groups. Open groups do not fit into prescribed models of traditional therapeutic group work, which is commonly based on closed groups. The open group model gives information and an understanding of the advantages and disadvantages of groups based on certain criteria and the needs of the target group or users.
The terms open and closed refer to groups which do or do not add members once the group has convened in its initial session. The definition of open groups is based on membership change and time. ‘Open-ended’ refers to a group in which the membership is continually changing: open in terms of membership whereby members enter and leave the group at their own pace of growth and change.
There have been studies claiming that when long-term members constantly accept newcomers into the group, group continuity (i. e. integration and identification) will be difficult. However, other studies have claimed that with each formation of a new group, integration can take place at an even higher level than occurred in the previous group (Bailus et al. 1978 and Hill and Gruner 1973). If long-standing members make group norms intelligible and rational, and practise the active ’use of group process’ minimal group disruption will be felt when newcomers arrive.
Group trainers and facilitators practice the group process with an emphasis on sharing personal stories and experiences that members have in common. They must try to implement the key principles of group work at all times (Heap 1988):
· ‘Using the group’,
· ‘Active use of oneself’
· ‘Use of the group process’
This may be particularly relevant to groups that practice ‘open’ membership if a rapid turnover effects group structure, but not necessarily group process or continuity. For example, self-help groups such as AA and in drug treatment and recovery programs have a ‘pass through system’, in its structure, meaning that even if the group takes in new members there still remains the core group who represent cohesion. Open groups are often designed to help clients in transition and crisis. Therefore, maintaining a core group membership in open groups helps to establish norms and values that represent continuity and, most importantly, makes them intelligible to newcomers.
There are different ways of practising mutual self-help groups. Some groups are small and closed, running for a certain period of time (e.g.12 sessions) and after 12 sessions new members are accepted. While others are open and run indefinitely, where members enter and exit the groups at their own pace of personal growth and change on an ‘as needed’ basis.
· ’Closed groups’ (e. g. commitment, inflexible, predictable group membership and time boundaries)
· ‘Open groups’ (fluid, members come and go depending on their individual needs, or after a set period of attendance, reflects the needs of the users of the group.
· Requires cohesion between members, and a developmental stage which identified goals can be worked on through group process and interaction and agreement.
· Open groups are characterised by the intention to take in new membership while the group is in progress.
· Core membership represents continuity and group functioning, despite disruptions caused by member change.
· Continuity, stability as represented by the core group and facilitator reduces the need to re-negotiate rules on which the group operates.
· In order for the open group to achieve individual change, it must reach a level of maturity (Table 2-4).
1. ‘Drop-in’ (drop out’) model - ‘user controlled’
User controlled models are different by the ability of users to decide whether they fit entry criteria and exactly how often and when they wish to attend the group, and for how long (e. g. AA, field of drug abuse)
2. Replacement model – ‘worker controlled’
Fluctuations in membership will be seen as ‘absent’ members, who may not always be present, similar to a closed group. When one member leaves, there is a ‘vacancy’ for a new member. Group size is important and must be compatible with the group’s purpose.
3. Re-formed model – ‘worker controlled’
Members contract for a set period of time (i.e. 6 sessions) in which no new members are added to the group, but members can drop out.
Worker controlled models will tend to place demands on entry/exit requirements, criteria and attendance (e. g. family therapy for cancer patients, ‘short-term’ transition groups).
· ‘Limited time’ to reach goal, goals do not change, can resemble closed group approach for example, 12 sessions.
· ‘Unlimited time’ - drop-in group, membership changes each session, goals are changed or replicated.
Conceptually, open groups are a series of single sessions whereas closed groups are worker controlled and run for a period of 12 sessions or 6-9 months depending on whether long term members decide to stay on for the next session.
Family therapy groups for cancer victims and their families on an ‘as needed’ basis. Families attend for anything from one session up to the entire 12 months of the group’s existence.
· AA groups for recovering alcoholics. Individuals after treatment join AA to stay sober or at least prolong period of sobriety. Some attend meetings 7 days a week, or on an ‘as needed’ basis.
· Short-term transition’ groups in which ten or twelve people meet twice weekly for a set period of time. At the end of this time, a reorganisation produces a new group consisting of some remaining members plus new ones.
· Parent groups for purposes of mutual support and learning management skills (e. g. parents of autistic children, handicapped children, children with drug abuse problems and groups for prevention of child abuse and neglect).
Advantages and disadvantages of open-ended groups
· Serves a variety of users and their needs
· Therapeutic benefits: newcomers see that change is possible by looking at the successful core group members. The more long-standing members can help newcomers through their ‘denial’ of the problem, and get further gratification from sharing their experience.
· Little demand for the newcomer’s acceptance of responsibility for the group.
· Can strengthen each member’s capacity for responding to external stress, transitions and crises.
· Open groups have multiple purposes, and the dominant purpose is helping members cope with transitions and crises.
· Group flexibility: maintains ability to accept newcomers.
· Assimilation of newcomers: introduction and structure
· Therapeutic benefits of open groups as opposed to closed groups are fewer.
· More difficult to ‘develop’ group cohesion, i.e. ‘to develop group emotions towards each other’ as new members enter and old ones leave.
· ‘No commitment, use it if you wish’ approach which avoids a sense of obligation.
· Core members, ‘central person’ must carry tradition and continuity (i. e. group norms and values, purpose, its history)
· A rapid turnover of new members
· Unpredictability of group size
· Unclear boundaries of entry and exit needed to sustain cohesion
· Frame of reference
A wide variety of people enter the group, which increases the potential for a long standing member to comparing oneself against others “experiential changes”. Generally, it has core group members who maintain group stability and represent continuity in the group.
· Time perspective
The present dominates, ‘here and now’, practical suggestions or problem-solving depending on the problem
Open groups develop procedures to minimise the disruption of change or ‘disequilibrium’.
Ability of the newcomers to disrupt the group by early departure
· Membership change
Power relationships within the group change based on the group’s perceived need for newcomers. This affects group structure more than group process.
Why are groups ‘open’?
· Rapid turnover of users of larger systems at unpredictable times, e. g. institutions, hospitals
· Open groups take into account individual abilities to change and grow at different rates
· User’s needs for urgent and temporary help, i. e. crisis situation, or transitions
· Group services often require flexible structures
· Responsive to stability and instability
Unlike the symbolic meanings of the magic circle, techniques and activities in the self-help group are accessible and can be learned by group trainers and facilitators. There are six questions that should be asked by group trainers/facilitators when planning a a new self-help group (Heap 2002).
1. Who are members of the group? (common needs)
2. Where are we going? (purpose/identified goals)
3. Why are we doing it this way? (choosing self-help methods, e.g. groupwork, experiential learning and change)
4. What is the size of the group? (goals and intensity)
5. How will you empower the group? (motivation, contracts, open/closed groups, rules and values)
6. What will the group be like? (group expectations, possibilities)
It is important that members identify with one another in the group and are socially committed. Conditions for group membership should be clear. Their problems and needs should be similar. However, there must be a balance in the group between sameness and the freedom to express differences and make comparisons in their situations (i.e. not everyone’s subjective experience of the situation is the same, and not everyone has the same resources or capabilities for solving the problem). Sociodemographic features are also important for sustaining the mutual self-help group process: (e. g. social class, age, gender, cultural background and family members).
Where are we going?
To answer where we must examine the purpose of the group that could be:
· to satisfy social needs
· to develop close relationships that are sustainable over time
· to break the social isolation (parents are alone with the problem)
· to understand problems
· to increase individual’s awareness and knowledge of the problem.
There should not be a great variation in these ideas within the group. This is to say that attitudes should not vary to a large extent from person to person and from group norms and values as it may raise the anxiety level for the newcomer. If the group trainer or facilitator lessens the person’s resistance to new ideas, there is a better chance of reducing the anxiety in order to begin the mutual self-help process. If there is a high frequency of disagreements in the group, suggesting few similarities between the members, the group is not ready to take in new members.
Group trainers and facilitators ask what attitudes and feelings are important for holding the core group together and recruiting newcomers. The purpose of the group is to influence change and to address or reach common goals along the way.
Why mutual self-help? We choose mutual self-help because the group itself is a form of support. Group support is crucial for experiential learning. The newcomer’s fear of connecting experiences to the problem through exposure perhaps evokes feelings of incompetence and her incapacity for decision making. The group facilitator and the member must also take into careful consideration the individual’s abilities to process this information.
At the same time, core group members find different ways of getting the newcomer to experiment with new attitudes in a non-defensive way. Resistance to experiencing new attitudes and feelings is common in all groups. Members address the issue of resistance when it emerges in the group. It must be shared and talked about since it can increase anxiety and an unsafe environment in the group. Even though resistance is perhaps more common to newcomers, it also occurs in healthy groups where the facilitator has a good relationship with the members. There is very little evidence that people’s behaviour is consistent in every situation (Brown 1993). However, if there are more negative than positive feelings in the group, the group trainer must ‘use the group process’ and invite other members to participate, asking if they recognise these feelings from their own experiences. This is supportive to the group atmosphere and reduces the anxiety of the individual, while creating the balance in the group necessary for individual support and group stability.
Group size must be compatible with the purpose, the goal and the intensity of the process in terms of interaction, disclosure and sharing experiences. A mutual self-help group as we have described usually consists of 4-7 persons. “Drop in” or user controlled groups are considerably larger, such as AA meetings which are concerned with understanding the issues of staying sober and using the group for maintaining sobriety and not necessarily with self-disclosure. The larger the group the less equal participation there will be from every member. Generally, those with strong personalities or high status, will participate the most. Then there are the ‘social loafers’ without motivation and do not make any contributions to the group, letting the group do the hard work while they share equally in the rewards.
How will you empower the group? (motivation, contracts)
Motivational process is fostered when the group understands and communicates to the member’s feelings of anxiety, disagreement or confusion. Connecting one’s experiences to the present situation in the group builds motivation and competence. Each member in the group has resources that give mutual support and strength to others. Experiential changes in one person can reciprocally produce changes in others. For example, when understanding and acceptance are communicated through words, actions or gestures, individuals experience being understood and accepted. With mutual support the newcomer, for example, can confront her own painful situation together with others, borrowing the “I” strength from the group and increasing rational thinking and decision making (Heap 2000).
Confidentiality contract is a symbolic agreement and builds trust, which creates a psychologically safe environment (Annexe 1). Another aspect when considering contracts is the group profile. Look at the rules and group norms. Will it be an open or closed group? Single sessions on an ‘as needed basis’ or closed group sessions (12 sessions over a period of 4 months). Will members contract for a set period of time? What are the common goals and purpose that link each member together?
What will the group be like? (expectations, possibilities)
Group members usually wish to place the group initiator or facilitator in some kind of leader position. The person is seen as having the skills, competence and knowledge relevant to the group’s needs. Facilitators and trainers are representative of certain values and forms of behaviour (e. g. norms) that the members aspire. A degree of dependence upon the ‘leader’ develops, while the members explore and discover its meaning for them. This is an initial dependence of the members on the trainer or facilitator partly because they have taken the initiative to start the group and partly because members have feelings of hope which they bring with them into the group. This is a very sensitive stage of group work so it is important for the facilitators and trainers to respond to this initial stage, and failure to respond to their responsibility of bringing the group together could cause resentment and disappointment in the members.
First steps towards group membership
The purpose of the exercise is to involve members in the first step
toward developing group membership. In order to come to a conclusion
that certain criteria are important for group membership, they must share experiences, compare ideas, thoughts, feelings and solutions. Themes for discussions:
1. Who? What are the common needs, problems and interests in this group?
2. What is the purpose of this group?
3. What are the criteria for group membership?
4. How many?
5. How will we empower the group?
6. What will the group be like?
Strategies for maintaining group integrity
Follow-up is important to create a sense of continuity in the group. Therefore the group facilitator (or any group member) should open up the meeting by asking for feedback (responses) related to the previous group. What were the themes discussed last time? And has anyone thought about these issues? Does any member have further thoughts or comments or experiences?
General guidelines for practice
In table 2-7, facilitators/trainers will find some guidelines to follow regarding do’s and don’ts. They should not be viewed as independent of the situation or the special problems encountered; they should be referred to according to the behaviour that emerges in the situation. Hence, ‘use the right guideline at the right time’. Moreover, as guidelines, they are not to be followed meticulously. It is important to separate the rules and norms of the self-help group from the do’s and don’ts. The latter are recommendations in order to maintain a healthy and safe environment in the group with a certain degree of dependence on the group setting. The guidelines have emerged from the situation.
By group trainers we mean professionals or specialists who have a competent understanding of the concepts and practices of the mutual self-help system and the capacity to initiate the group process through the training and counselling of self-help group facilitators. Group trainers are those who will train facilitators to initiate self-help groups and capable of taking care of the social and emotional aspects of the group. The responsibility of the group trainer is to launch a group and to train other group leaders or facilitators and to provide supervision if needed through observation and assessment, but not to participate in the actual meeting. Facilitators are equal members of the group in that they share the common problem.
Roles and functions in perspective
We have described group trainers/initiators as professionals without a personal history of the problem shared by group members. But in order for group trainers to understand and empathise, they too must examine perhaps any psychological or physical problems they have experienced that have required them to undergo profound changes in personal growth. It is beneficial if the group trainers have had personal growth experiences that resemble those of the group’s. Thus they would be considered more equal as would people who have been involved in personal change and emotional adjustment. However, it is up to the individual group trainer to choose whether to share personal experiences or not.
Even though some roles and functions of the group trainer overlap with those described for the group facilitator, trainers and facilitators have different impacts on group members. Facilitators can challenge group norms since they have similar personal histories that are readily understood and accepted by group members. They have built up ‘credit’ with the rest of the group and have experiences that have come from an intimate and first-hand knowledge of the problem. They are defined explicitly as equal to the others, as people involved in personal change through experiential learning. Yet for both trainers and facilitators, it is important to focus on what each member has achieved thereby creating positive and hopeful attitudes towards change.
In order for group trainers to avoid some common pitfalls and errors of the beginner, they should have an extensive understanding of the mutual self-help approach. It is understood that the group trainer introduces the facilitators to the main content of Part I and II during the initial training sessions.
The primary aim is to teach facilitators how group members, such as parents, can be their own helpers, “parents helping parents to help themselves”. Group facilitators lead the group ‘by not actively leading the group’, but taking responsibility. From this perspective, group trainers should focus on general topics such as:
· Group members are the ‘experts’ of their own situation, not group trainers.
· Basic principles and norms and rules of the mutual self-help approach
· Self-help group features: reciprocity, a supportive and safe environment, and the freedom to express oneself without reproach or moral judgements, empathy, and integration into a social network with meaningful group identity.
· Mutual self-help groups provide support for people in crisis situations, problem-solving, alleviating tension or conflict in the ‘here and now’, seeking acceptance and safety from a dangerous world, and guiding individuals towards experiencing positive resources within themselves.
The task of the group trainer/initiator is primarily to establish and start groups, not to continue in the group process but gradually hand the group to the facilitator. The roles and functions of group trainers/initiators in the mutual self-help approach are similar in some ways with that of mental health workers in the group work setting. The task of the group trainer is to stimulate and to mobilise the resources inherent in the group process. Since the group is the context and the means used by the individual to dare and take the personal risks of sharing meaningful experiences, it is necessary for trainers to actively engage each member in this experience. Without this essential therapeutic element, putting group process into practice will be difficult.
Group trainers tend to impose their own aims and evaluations on group members by giving opinions, directions or engaging in counselling activities. Why does this occur? Professional evaluations and assessments of group trainers and group theory have indicated that most group leaders actively use their personalities, i.e. themselves, in the group more than they use the process. This in turn leads the trainer to assert authority, which results in less attention paid to group members’ views and feelings. This is described and well documented in professional literature (Heap 1988; 2002; Brown 1988).
Some essential skills that a group trainer should develop with the group are:
· Group trainer prepares the group beforehand
· Builds confidence and trust with the group
· Understands and empathises with group members’ circumstances
· The group trainer adheres to group norms and achieves the position in the group, as opposed to being appointed or elected. When the position of trust, confidence and legitimacy is achieved new ideas and views will be accepted and tolerated
· Group trainer facilitates changes by being flexible; a gradual process can begin; to suggest radical departure from old thinking to new routines
· The group trainer is able to alter the prevailing norms (i.e. negative views and feelings about the self)
· The group trainer is able to help the group adopt new norms (i.e. positive views and feelings)
· The group trainer remains responsive to the group’s views and feelings
· The group trainer enhances the alliance between individual and the group in order to foster the mutual self-help process
· Group trainer understands that he/she can make mistakes
Unlike the group trainer/initiator, the group facilitator is a permanent member of the group sharing the common problem and interests of the other group members. The group facilitator is a guide who assists others on a path that they have also travelled. They have encountered difficult experiences related to crisis situations. They do not define their needs and feelings in terms of other’s personal crises. Through direct personal experience, they understand the learning experiences and situations needed in the group in order for change to occur.
Some selected skills and criteria a group facilitator should develop:
· facilitators possesses knowledge, experience and skills relevant to the group’s needs
· facilitator has passed through crisis stage and has demonstrated commitment to the group
· shares personal experiences with the group to produce the perceptual change needed in the mutual self-help system
· provide security for newcomers
· challenges ‘age old’ myths (old norms) about themselves that are negative
· facilitator can reach out to others who are confused and unable to relate to other member in the group
· appears in more control than the other members do
· facilitator must be willing to co-operate and work together with group trainer/initiator or other professional teams
· facilitator makes possible their activity as a group
· follows through with responsibility
· should have access to reading materials on mutual self-help groups and group process, or other relevant reading materials within the field of drug dependency and prevention
The previous political system has left little room for private initiatives, especially in the field of health services. Thus the concept and methods of mutual self-help are not yet familiar in Russia, neither among professionals nor lay people. So, in order to launch training in the area of self-help, professionals and parents alike will need an introduction to the concept and why such initiatives can be helpful for both facilitators and professionals.
Parents often blame specialists, who represent the authorities or the community, for their frustrations. If the professional applies the self-help method, she/he does not take responsibility for the parent’s situation or should be made to feel guilty. In self-help, it is the parent’s responsibility to own the problem. Parents often believe that professionals, like the authorities, do not like them and don’t care about them and moreover, they mistrust them. Yet at the same time the parents want leadership or someone to help them lift the problem off their shoulders. They expect professionals to have knowledge of the problem and the skills and competence which they ‘believe’ they don’t have. These beliefs are very powerful and deeply embedded in their perceptions of the problem and of who they are, which place boundaries on their possibilities for change. This is the traditional “helper-client perspective who see themselves as passive recipients of help. In mutual self-help, each member is considered to have knowledge of the problem and the competence and skills to come up with solutions together. The process and responsibility of involvement is placed on each participant in such a way that he or she takes ownership of the problem – and does not rely on the professional to provide solutions.
Many parents with drug dependency in the family have expectations for their children that have been thwarted by social and health services. Usually, the parents feel deprived and ignored in some way. In other words, they feel worse off than other groups in the wider society, which often leads to strong feelings of discontent. It is difficult for the parents to get at the true source of their ‘frustrations’, impulses or emotional energy, without conducting rational ‘talk’ sessions, which help them find their own voice and language of communication. Some parents may seek parenting or advice from others in the self-help group, while others may be impulsive and act out by expressing conflict in the group in a socially undesirable way or in a manner that alienates others. These among other elements should be focused upon in the training.
Parents in general are sceptical towards professionals since they usually represent public services that, in the eyes of most, have taken little responsibility for finding solutions for the rapid increase in drug taking. This reflects a general attitude rooted in times when the community was one of surveillance and control. This aspect must be taken into account when the idea is presented to the parents in order to prepare the ground for increased trust between public services and marginalised groups.
Professionals are often chosen as scapegoats for this ‘emotional energy’ because they are trying to help and in this context considered less threatening. It is important to be aware of the displaced feelings that have been aroused by the more threatening objects in their world, such as community disapproval and social exclusion. This mechanism is experienced in many families, for example, the man who has been frustrated by his boss yells at his wife or child. In order to discuss how professionals are incorporated into this reality and build trust and confidence without becoming the focus of resentment and anger, the group trainers as professionals must remind parents that we are working together to reduce drug problems in the community.
The most distinguishing feature of the self-help approach is that self-help mainly focuses on the present situation of the individual – the ‘here and now’. This is in contrast to the traditional therapeutic emphasis that deals with the past, the unconscious or subconscious part of the individual. The challenge for the facilitator is to maintain the parent’s focus on her feelings and behaviour in the present situation, in contrast to her focus on the needs and feelings of the child and the child’s behaviour. The parent must eventually learn to perceive the problem as ‘free’ to change. When the parent defines the problem as bound (unfree) or as something that voluntarily nothing can be done about, either now or in the future, is not the responsibility of the facilitator. He or she merely facilitates the process of change so the parent takes the responsibility to alter the perception to a ‘perceived freedom’ (Seltzer 1986).
It is important for specialists who are involved in preparing parents and significant others as facilitators of mutual self-help groups to be aware of the parents’ expectations when they come to the group. For example, that the group will have advice for her about how to set boundaries for the child and she wants to know what is the right thing to do. Even though it is easy for facilitators to take on the role of advisor or counsellor, it is important that this responsibility is avoided. Instead the facilitator directs the question to the group, allowing the response to the parent’s feelings come from each or some of the group members. This is what we have referred to in other sections as ‘using the group process’ and reflecting and mirroring feelings and experiences (Table 2-5).
Establishing an alliance with the group
The facilitators lead the members into learning opportunities by encouraging direct personal experiences and remind the group that they must take some personal risks by expressing how they feel. The group facilitator tries to remove hindrances and obstacles that may get in the way of the individual from attending the self-help group. For example, a newcomer is experimenting with new attitudes, a different way of thinking about her situation and may have many excuses for not coming to the group, referred to as ‘resistance’.
In order to motivate the group members and strengthen co-operation and friendliness, their frustrations and problems should be discussed. Group trainers and facilitators can use a group management style, encouraging everyone’s contribution. In discussing this point, questions would focus on what are the feelings and driving forces behind the desire to create self-help networks for this particular group? Why bother to create self-help groups? And what are the possibilities for the future? Members should generate ideas that would help the group situation by promoting participation. Themes that should be addressed are:
· Discussing norms and values members would want in a self-help group
· Listing each individual frustration
· Defining common objectives and interests of the group: each individual frustration should be translated into a collective aim- e.g. stigmatisation, negative attitudes, and promoting anti taboo work in the community
· Making lists representing members’ concerns, interests or reasons for self-help groups that are guided by rationality rather than by frustrations
· Role-play exercises on themes such as: recruitment, crisis management, acceptance of newcomers etc.
· Group facilitator must understand that he/she can make mistakes
Some common group dynamics others may react to in the group:
· Projection: A member confronts his or her own problem by confronting someone else. This is a defense mechanism that protects the individual from pain or anxiety.
· Identification: A member identifies with another person’s story.
· Empathy: Emotional involvement is a pre-condition for empathy
· Emotional Blocking: A person emotionally dissociates or disengages from what is happening and remains silent.
· Transference and Counter Transference: Emotions felt from situations and/or persons from the past are transferred to group members, group trainers/facilitators
As noted earlier, identification and empathy are positive tools for the group process in that they are supportive and caring gestures. Whereas projection, emotional blocking and transference, are mechanisms that should be contained by the group.
Professional support for group facilitators
The fact that group facilitators are struggling with similar problems as the other group members makes them psychologically vulnerable during the times of personal or family crises and, in some cases, they do not come to the group. It is therefore suggested to organise a permanent “support team” consisting of two experienced professionals with an understanding of the perspective and goals who can provide the additional emotional support needed for the group facilitator. Together, they can discuss and analyse current problems within the group focusing on how to activate further resources and the capabilities of the group members.
This has proven to be a motivational source for group facilitators, and particularly supportive during those times when the facilitators themselves are going through difficulties in their own families. Furthermore, it increases trust and co-operation between health officials and the marginal and, often invisible, parents of drug dependants. However, it is very important that professionals from the health field, pedagogues or other professionals working within this field do not become over-involved to the point where they take over facilitator’s individual responsibilities or tasks. Responsibilities for continuing the group process always lies with the participants.
The main reasons for establishing support teams for group facilitators are twofold:
1 The support team serves as advisor for facilitators of self-help groups when problems occur and they have special needs for emotional support.
2 By providing professional knowledge and factual information, the facilitator will feel active support and hence feel more secure in his or her role as facilitator.
3 The support team will, through their involvement, be able to pass on new knowledge about the mutual self-help approach to other professionals within the fields of health and social services, as well as to drug policy planners.
PART IV - ORGANISING SELF-HELP WORK
In 1969, Ms. Gunhild Bakke established the first organisation for parents of drug dependants in Norway, which could be seen as creating a further expansion of civil society in a country that already had an established social service system with strong democratic structures and an organised labour force in place. Ms. Bakke saw how parents of drug dependants were suffering greatly from neglect and wanted to do something about it. She identified with a cause and quickly began to personify the parent’s situation of helplessness. She played to her strengths: business and networking. Her story illustrates how grassroots organisations can make a direct contribution to the expansion of people’s possibilities and social opportunities, to the quality of life and to other relevant social arrangements for families and parents of drug dependants.
On a winter day in 1969, Ms. Bakke was called to the police station because her daughter had been arrested for the first time for drug use. Shocked, worried and feeling helpless, she placed her frustrations and despairs on the well experienced and understanding police doctor, Mr. Bauge, and finally burst out, “tell me what to do!” The doctor calmly responded that he did not have the answer, but asked if she had ever thought of talking to other people in the same situation as herself, such as other parents, siblings, aunts, uncles, or significant others who were experiencing similar problems. His advice was taken favourably (“Surely, together you may find solutions”, he told her). She immediately began to hunt for other parents who were experiencing this problem in the family. This idea urged Ms. Bakke to talk to young drug users in the city centre, to ask them their parent’s names and contact them. To stand any chance of influencing the parents, she also had to find other contacts in the general public. She collected names from sources, mainly from institutions that might be able to help i.e. politicians and professionals alike who were accountable for drug policies and rehabilitation. She then called the first meeting for family members of drug users. She appealed to them to help her establish what turned out to be one of the first European organisations of its kind for parents of drug dependants.
There are a number interesting issues of practice in this simple example. But what we want to emphasise here is that at that time neither administrators nor professionals recognised family members as part of the solution to rehabilitation but rather they were part of the problem. Today, however, praise for success is given to Ms. Bakke and other pioneers in this field. They have shed light on the question of the importance of family organisations as an informational base for drug policy makers and ethical issues alike. The organisation has not merely had an impact of the significance of voluntary work in civil society, but in the belief of the people’s productive abilities to influence and change politics and policies in their own society.
Parent organisations act as an informational base for evaluation of the drug problem for administrators and professionals. They listen to the parents because they have much to offer each other and society in general through the way in which they practise self-help.
Self-help is a support-led process, however its success depends on the growth process being wide-based and expansive. This is to say that if self-help groups expand, becoming more inclusive and organised by devising strategies for further action, they will have a broader impact; hence an organisation must be built. Currently, parents’ organisations play an advisory role to policy planners and professionals alike in the field of drug demand reduction in many countries.
The importance of visibility and anti-taboo work
Drug dependency whether it concerns misuse of alcohol, illegal drugs or other volatile substances is indeed known to be subject to stigmatisation in the community and drug dependants and their families are likened to special taboos of shame and social rejection. Statistics on alcohol and drug abuse around the world shows that it is ongoing in so many families and thousands of children in school constantly carry with them the “family secret” in their thoughts and their hearts.
The present day situation calls for anti-taboo work within the local community by increasing social engagement and by practising empathy, particularly when it comes to social exclusion and discrimination; anti-taboo work, and taboo-related problems, leads to loneliness and isolation, stigma, grief and anxiety. People often have no language to express these feelings in a way that they feel can be understood by others. Taboos are non-communicable. Traumas are one thing, but when the trauma at the same time is a taboo you know you are in deep trouble and the damages it causes are severe, but since "the invisible" is never observed it is difficult to come to grips with the situation.
Psychiatry has taught us that feelings and thoughts individuals deny in daily life in the end will cause problems. It is experienced beneath the surface, what is referred to as the “preconscious or subconscious”, and those issues are often very hard to handle. One has difficulties putting these feeling into words since they are not openly discussed. And when they cannot be talked about, it makes one easily vulnerable. Nevertheless, everyone who has had difficulties or problems needs to be seen and, for this purpose, mutual self-help groups have proven useful. Such groups make it possible to exercise these matters in a very simple way – to grow confidence and self-esteem.
Most commonly the main target groups for international drug demand reduction programmes are policy planners and professionals in the health field. In addition, drug prevention activities in the educational system have also been prioritised. The mutual self-help approach takes an opposite point of departure and takes in the situation of individuals and their families on the local level affected by drug addiction and the use and misuse of drugs.
Parents in Partnership take into consideration two contrasting and well-known paradigms in social development theory: top-down blueprint and bottom-up learning process to community and institutional structures. By paradigm, we mean a perspective that includes an understandable pattern of concepts, values, methods and behaviour applicable to a variety of different groups.
Top-down blueprints are concerned with the issues such as standardisation, measurements and calculations which go along with professionalism and high-status and are essential for building societies. The bottom-up approaches are concerned with the paradigm of people with lower status who are concerned with the learning process, judgement and diversity. The top-down blueprints have usually dominated development projects. Though trying to combine a top-down blueprint with the bottom-up learning approach is the challenge for most project formulations.
If the government, representing the formal sector, cannot yet provide institutional structures for drug treatment and rehabilitation then something else must be done to begin the process of healing for these families until the government formulates a policy on rehabilitation and treatment. One area that must be worked out is to primarily look at who should and who does participate in policy formulations. Keeping the boundaries of communication open on the different levels of society is important.
How can the informal sector be included in the current planning of public drug prevention initiatives? In order to answer this question, it is necessary to design a project whereby the current thinking includes the family’s priorities and concerns relating to self-help initiatives for families.
The involvement of three levels is essential in designing such programmes. This relates to an analysis of processes related to who should participate and who does participate in decision-making, activities, different perceptions and participation:
· The ministerial level represented by policy planners to better understand grassroots concerns and local needs
· Practitioners and professionals to support parents who are to become facilitators of self-help groups
· The core group of parents/families wanting to receive training to become facilitators of self-help groups.
Acceptance and inclusion of new members will always be a challenge when building an organisation. It is easy for those who are already members of a group to be content and comfortable in the self-help group in such a way that the organisation stagnates in its development and its purpose. The ‘support-led’ process of self-help on the one hand does not wait for dramatic increases in membership; it works through priority being given to the social and emotional welfare of the individual. On the other hand, the sustainability of the organisation depends on recruitment, which in turn is dependent on growth that implies, to a large extent, on the energy of its members directed toward recruitment activity and on funds received from other public sources. To prevent stagnation, the growth of the organisation and the support-led process of self-help are necessary elements in order to sustain continual development.
All organisations are dependent on various recruitment activities to survive and prosper, no matter what the purpose or circumstances may be. A family organisation against drugs is no exception and therefore a strategy must be developed to reach this objective. This requires maintaining correspondence with people, institutions, influential political parties, civic groups or editors of newspapers. In the following, are some important issues related to the recruitment process.
· Encourage other parents/family members to sign up as members.
· Address other families in the same situation and explain that they can get support through the organisation and at the same time contribute to actions for improved services for drug dependent persons.
· Formulate letters addressing some of the local drug problems that families see as most important for the local authorities to deal with and send it to local businesses, requesting them to support the work of the organisation.
· Distribute flyers and brochures at public places, drug clinics, doctors’ offices, local churches etc., and informing others about the organisation and how to become a member.
· Address the public through local media.
It can be helpful to discuss certain common procedures for the initial contacts with new parents/family members. There is no right or wrong way to do this, and much will depend on the context (you get a telephone, personal contact, referral through others where you are asked to contact someone etc.). However, it is important that the person feel that you can listen without being judgmental, that you know the problem and shows understanding. Be careful not to scare people away. A positive feeling about the outcome of the initial contact can make an important difference and create hope and perhaps even a turning point in the life of the other person!
After a brief telephone contact suggest a meeting. Bring another parent along to the meeting. Such preliminary contacts can be repeated a couple of times to create trust. The meeting can take place on the premises of the organisation, at a public place (cafe etc.) or in a home. Make sure the newcomer is given ample time to talk. Do not take sides or judge the other person’s story or feelings. You should also briefly share some of your own experiences to create a common ground - "we are in the same boat".
New members are very often experiencing a crisis. In such a situation, it is very important to have someone to talk to who understands the crisis and who has the compassion and patience to listen and, finally, someone who is familiar with the problem. The initial phase of the crisis experienced by a parent after s/he has discovered drug use by a family member or a child is one of disbelief and shock, which is followed by strong feelings of guilt and anger. It is very important that there is the possibility to talk with someone about these reactions, especially to make life bearable in adverse situations. Without this opportunity, it will be difficult for the parent to move on and not to allow the problem destroy the entire family.
This is often the situation you are faced with by a new member. Let us therefore focus upon a few issues of major importance in the process of approaching a new member.
· Make an appointment to meet with the newcomer and another member of your group.
· Understand and be open. Listen, do not “burden” the new person with your own story at this initial stage in the process.
· First contact – let the new person talk – it is good to be listened to! Present the brochure and mission statement of the organisation. Make the newcomer feel that you understand her/him.
· Invite the new person to your group. If s/he is hesitant and afraid of disclosure make a second appointment to talk more and to build her confidence in the group. Explain precisely what a self-help group is and how one can benefit from taking part. Explain that it is not a group to solve the child’s problem, it concerns acquiring a better quality of life for oneself in order to manage the stressful situation better.
· Leave a brochure with information about the self-help groups including time and address for meetings and, if possible, a number where you can be reached. If other material about the drugs, their impact, help services etc. is available make sure this is distributed as well.
· Suggest a second appointment to continue building trust and motivating for participation in your organisation and the self-help groups. If possible offer to meet the person before the meeting so you can arrive together. That makes it easier for the newcomer.
Some parents' organisations are systematically appointing a "big sister/big brother" to newcomers. This may ease the initiating process and create trust and hope. To make sure this task and responsibility is evenly spread among the group members one should only be "big sister" for one new member at the time. Remember - all participants are usually still struggling with drug issues in their own families so no one should take on too many responsibilities. A period of about four to six months, depending on the speed of the process of getting into the organisation is usually sufficient to guide and support a newcomer into the organisation.
The main task of a "big sister" is to be a special contact person and support the new member in the initial phase of the membership. Make sure that the newcomer has read and understood the information available about the organisation and the self-help activities. One on one contact for talks in addition to the group meetings should be offered if the newcomer desires. Be clear about the purpose of "a big sister" and be careful not to take on responsibilities and challenges that it is not supposed that a "big sister" should fulfil. In the group make sure attention and time is paid to the newcomer, and that s/he is being heard and that no one interrupts or judges her opinions etc. There are not any “right” or “wrong” feelings because we experience things differently.
If suitable and depending on the person’s interests (e.g. cinema, concerts, outings, home visits etc.), spend time with the newcomer outside the context of the organisation / group meeting.
When there is a new member at the group meeting, special attention should be paid to her/him. Do not forget your own feelings at your first group meeting; it can be a little bit scary and the group may seem too closed and private simply because of the fact that you are sharing private and sensitive information and emotions.
Also explain the purpose of the self-help group, and how they can be helpful as a support system. Make sure confidentiality is explained and underlined, giving out the declaration of confidentiality to be signed by the new member. Also provide the newcomer with the statutes of the organisation if such an organisation exists.
All members give a brief presentation, briefly explaining why they have joined the group and for how long they have been involved in the organisation. After the presentation, ask the new member if s/he would like to say something about her own situation. However, do not expect that the newcomer to listen to long stories from other members so be brief. You may also let the newcomer remain silent. Some people need time before they open up. Do not place any pressure on the person. Try to recall your own feelings at your first group meeting.
It is always very helpful for the process to include the ‘older’ members so that they share their stories and some of the things they have experienced. In relation to the shock and disbelief they too had felt when they first found out about the drug problem in their family, the denial, the anger, and the guilt and shame can still be remembered as if it had just happened.
Facilitating a meeting and taking care of each other
4-7 members is a suitable size for a group, Ideally, there should be two facilitators in each group. This will secure and maintain continuity. When a group grows to 8-10 members it is time to split into two groups and identify new leaders and co-leaders (facilitators). A mutual self-help group should run for about 1 ½ - 2 hours.
Organise theme meetings regularly in addition to self-help groups. Theme meetings can either be closed for members only or they may be organised as open meetings for the local area with invited speakers to give information on themes relevant to the members needs before the actual self-help group.
The group facilitator opens the meeting, welcoming the members and reminding the group about why they are here, “we are together to share our feelings and thoughts” related to the present situation that each member experiences at that moment. Common themes are feelings, personal goals, family, and strategies on how to protect each other from being overwhelmed by the problems caused by drugs.
· Prepare a fixed meeting schedule (i.e. same day and, if possible, the same place)
· Also remember that coffee/tea and snacks should be served either before or after the group and not during the group because it tends to distract the member’s concentration and focus.
· Establish a structure in the group (i.e. formalities and taking care of practical issues first)
· Do not interrupt while another member is speaking.
· Do not disqualify another member’s feelings or statements by being judgmental or moralistic. Another person’s feelings are not “right” or “wrong”, and it is meaningless to make comparisons regarding people’s feelings. Nothing positive is ever accomplished by making comparisons because the person experiences it as a personal criticism.
· Listen and learn.
· Let everyone take part in his or her capacity and form for expression, provided they remain within the group’s rules, norms and structure.
· Be aware that members can be "too open", and as a result when they come home they regret something that was said. Therefore be careful, especially with new group members, making them aware that there is no need for intimate confessions in order to be a "good student". Being in the group should be safe and not provoke anxiety or regrets.
· Don’t aim at taking away pain and distress
· Make sure the ‘word’ is passed around; everyone gets a chance to speak. Remember that all members should be included and invited to comment on each other’s statements and ideas, but not to give authoritative advice.
· Do not forget to close the group properly. Many groups have a little poem or “philosophy” they say before they part.
· Set a date for the next meeting
All successful social institutions, non-governmental organisations and businesses depend on mutual trust and group norms both explicit and implicit. Though unlike business partnerships, a barrier we are concerned with is that the building of mutual trust is implicit and dependent on a non-binding agreement between individual members of the organisation that must be cultivated through interpersonal relationships. Without the fundamental respect for a person’s desire for confidentiality and discretion, no institutions, private or public, would exist for very long. Any breach of confidentiality is seen and felt as a personal violation on the individual.
This is a concern that is an imperative in order to create trust and openness between members in any organisation or business. Especially, since the use of non-prescriptive drugs is an illegal activity in most countries the importance of guarantees of confidentiality has a direct influence on membership size, which of course becomes a deciding factor in terms of receiving funds. The importance of mutual trust in non- governmental organisations strengthens loyalty and commitment among the members. In order to emphasise the seriousness of this issue and to prevent disaster, all such organisations should provide a declaration of confidentiality signed by each member agreeing to this ethical principle (Annexe 1).
Establishing a formal organisation
Forming a parent organisation is not easy. One practical reason is that many parents of drug users are unwilling to step forward and be visible in the context of such an organisation. However, experience tells us that family members of drug dependants are the only group who really have the first hand experience in living with the problem and therefore they are in a unique position to help other families suffering from a similar situation. That being said, the shared experience of addiction in the family is a bond that ties them together, creating a common ground for action and the development of self-help groups. To set up such activities, one cannot simply depend on public drug services or professionals. At best, professionals can be initiators in the ‘support-led’ process, but they can never replace the genuine grassroots initiative organised by families themselves.
Preparing the annual work plan
A major issue on the agenda of the annual meeting of the organisation is the adoption of the annual work plan. A proposal should be distributed to all members, along with the other documents as settled by the statutes of the organisation in advance of the meeting.
In addition to the core activity, (e.g. to secure continuity in the running of self-help groups) most organisations are also involved in additional activities. Such as income generating activities, drug prevention in the local communities/municipality and involvement in drug policy matters, campaigning for better services, making the organisation and its activities known, organising open meetings about drug issues and becoming involved in local administrations relevant to drug issues etc.
To make an impact in some of these different areas, it is important to take stock of the human assets and talent of the members of the organisation. Usually, everyone can contribute something in one or more areas of activities. To map out your assets in relation to the work program - or may be even better - to map out the work program based on the assets of the organisation - you can set goals that are attainable based on the actual resources at a given period; no organisation can do everything. So focus on areas and tasks where you can make a difference! Based on this let people sign up around the main issues you have identified as relevant to your organisation.
Special working groups
The annual work plan should carefully consider its human resources, the interests of the members and to fully exploit the potential of the organisation in addition to the core activity, namely offering participation in mutual self-help groups.
A parent organisation consists of people with different talents, interests and preferences. Therefore it is helpful, in addition to the self-help groups, to split activities into a few major areas for action and form working groups accordingly.
In the following, you will find an overview of important areas where special working groups can contribute directly to the organisation so it can flourish. Groups responsible for organising open meetings/theme groups, fund-raising groups, networking group, drug policies group, drug prevention group, and the media group are areas to develop.
In addition to the regular weekly or biweekly self-help groups, open meetings should be organised from time to time to address drug issues relevant to the local community. Professionals, policy planners and others with special knowledge relevant to the organisation and its purpose should be invited to give presentations (e.g. doctors, psychologists, lawyers and politicians etc.). Such open meetings are useful for raising awareness, yet they may also assist in recruiting new members. Such theme groups can also be organised as an initial part of a self-help group meeting. For example, to have a discussion prior to the actual meeting of the self-help groups. It also serves as an important source for new knowledge for the group members.
The group should establish good relations and contacts with other organisations in the field of drug and alcohol dependency. These organisation have many goals in common such as public awareness raising, increase understanding of the problems related to drug dependency issues in families and improving social and public services etc.
Drug policies group
Local and national drug policies should be discussed in the organisation, and then later be explored and made visible to the general public. A working group could have this as a special area and be responsible for:
· Seek co-operation with professionals that are supporting the organisation. They
can give lectures/information to the organisation in their area of expertise e.g. drugs detox, rehabilitation and research etc.
· Seek contact with influential politicians and let them know about your
organisation and its goals and priorities.
· Share information with professionals and politicians about the problems facing
families with drug dependent members.
· Organise open meetings to let people know more about the local drug problems (ask professionals, teachers or politicians to give presentations and facts for debates)
· Address other relevant organisations in the field of drug and alcohol to
co-operate and create stronger networking in the third sector to strengthen the voice of grass roots organisations.
Drug prevention group
Many parents are involved in drug prevention activities in their municipality and local communities. This work should, however, be clearly separated from the self-help group. The main objective is to inform the public, as well as other professionals and politicians.
Co-operation with professionals and other organisations could be helpful and increase the possible impact. A working group on drug prevention should gather information about principles and methods of modern drug prevention and offer to give presentations at schools and other relevant arenas in the municipality.
Members all have different assets and talents. To work on financial issues and fund rising - one should not only know a little bit about how businesses build a positive profile by showing a social concern and responsibility, but one must also be well prepared and able to take rejections. Most of the time one may get a negative response. In any case, it is necessary that you are able to describe in short and to the point the purpose and aims of your organisation. You must also have this information in writing (maximum one page) to give to the person(s) you are in touch with.
References to authorities that support your work are helpful. Transparency in all financial matters is self evident and it should be made very clear to any possible sponsor that all accounting is for all to see.
The organisation must address relevant funding agencies on the state and municipal levels of government as well as private businesses to receive or apply for financial support and funding for materials, such as office equipment (e.g. phone, copy machine and computer), and furniture for the meeting room as well as the printing of information leaflets etc.
In some cases, there are public funds provided by the state, region or municipalities for voluntary, and non-profit organisations, not only in the area of culture, but also in the field of social affairs and drug prevention in the local community etc. In some countries, there are also some private foundations providing such support. Support can be provided in many different ways: cash, stipends and grants and project support, or as material support (e.g. equipment, free ads in local papers, materials etc.).
Most organisations will also create their own income generating activities such as lotteries (cakes, crafts etc.), second-hand markets, small craft productions all depending on the local situation and available resources.
Contacts with media
All organisations should develop a strategy for media contacts (e.g. press, radio and the TV). Try to develop good and reliable contacts with a few selected persons that have sympathy and understanding for the cause.
Currently, the real issue that must be addressed for organising and mobilising parents and families of drug dependants involve finding a solution to the material needs such an organisation would require to get started. The intensity of economic support needed can enhance rather than detract from the social tasks that lie ahead for the people. This is a discussion that depends on open debates and discussions of public funds and resources for the organisation. In this respect, people need to think and choose what they want to do and use the opportunities democracy has opened up and seize them positively in order to achieve the desired effect. Democracy has to be seen as creating opportunities for its citizens and these opportunities have to be exercised
Granting economic support to grassroots organisations supports democracy and its structures and strengthens the third sector and the process of development. It gives the marginal groups the opportunity to draw attention to the general needs of this population and to demand appropriate public action. The emergence of new values in society can only be achieved through a process of social dialogue and discussion, which in turn generate informed and reflected choices. These processes are crucial to the formation of values and norms concerning social rehabilitation and prevention issues facing the country. Therefore change in the system cannot take place unless the people have an arena where these discussions can occur.
In many western countries, those who see themselves as social liberals are not sceptical about human development and its overall impact. They believe that public resources should go towards increasing the quality of life for marginal groups. Those who are more sceptical sometimes express conservative views about which groups should receive funding. Regardless of the political or ideological platform, in most countries there is a lack of resources allocated to socially marginal groups. The lack of funding threatens all sectors of society: the schoolteacher, the nurse, the social worker and the civil society, which call for a better analysis and communication and participation of the role of voluntary organisations or NGOs. At the same time, it is important for the parents’ organisations to draw the public’s attention and compassion to the suffering, not only of parents and other family members, but to the children as well.
It is a fact that the transition period we have witnessed throughout the previous Soviet Union has given rise to serious financial problems. The transition from communism and a state economy to liberalisation and a free market economy, which is particularly the case in the countries that have recently joined the European Union, is extremely challenging for less affluent countries. Some of these countries are among the poorest in Europe. In this situation it is understandable that priorities are very strict, leaving many groups to fend for themselves. Many governments have therefore given the social tasks to voluntary organisations.
The achievements of democracy depend not only on the rules and procedures that are adopted and safeguarded, but also on the way citizens seize the opportunities. In this situation, it is extremely important that the state understands and accepts the need for growth in the third sector. Voluntary organisations can alleviate many of the current needs in the social sector if given the opportunity, moral support and minuscule economic support. The state must realise that this is a healthy investment.
Governments should see the benefit of expanding civil society by allocating funds and public resources to build grassroots organisations. Members represent the voice of a minority who see themselves as helpless in terms of receiving adequate psychological help for their children and the family. They cannot make informed choices. For example, parents’ organisations can create social opportunities for other parents to help them manage and adjust to the daily situation of emotional deprivation caused by drug abuse. They can offer a social remedy and explain to others in the same situation what can be done. Without hope there can be no solution to any problem we are confronted with either in the larger world or in the family. Furthermore, there is considerable evidence that improved health care for marginal groups make the workforce more productive (Sen 1999).
There is considerable controversy concerning the debate whether deprived groups really care about exercising democratic rights or freedom of expression when they have so many economic needs. Parents in Partnership has demonstrated that parents care as long as they are offered an incentive. Public debates and open dialogues concerning priorities and interests of socially excluded groups play an important role in democracies.
In terms of building social support systems, especially for socially excluded or less privileged groups, the role of the third sector has proven its contribution to both developed and developing democracies. The time has come for the authorities to acknowledge enlarge its perspective and recognise that public services and voluntary organisations go hand-in-hand with the social sector, speeding up the process of social development and creating healthy living, especially for those with special needs.
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Declaration of confidentiality
This letter, signed by the participants, states the shared objectives and responsibilities of the self-help initiative.
The two main objectives are:
a) To support and strengthen the parents skills and knowledge in order for them to become confident in their role as group members and facilitators.
b) To invite new parents into the network and multiply the number of self-help groups in the region.
Responsibilities of the participants:
To become involved in the training of group leader, learning skills by actively taking part in the PIP workshops and participating in the local self-help groups in between the workshops following the recommendations from the trainer(s).
Group member (sign)
Group facilitator: (sign)
Three common scenarios suitable for group role-play in self-help groups. When group trainers or facilitators are re-enacting types of situations, remember to give instructions concerning the activity or exercise, observe and then go to TIME OUT in order to examine and discus what is happening in the group. Give instructions separately to the group members and group facilitator(s). Two group members are given the task of being observers and are placed outside the group circle. The observers will explore areas such as, the do’s and don’ts and if the rules are being practised and experienced by group members. Observe the presentations.
Start the group and run it for about 10 – 15 minutes depending on the group dynamics and tempo. Then take TIME OUT for feedback from the observers.
Possible situations for observers to focus on:
· How was the presentation? What happened? Who starts the presentation?
· Everyone shared experiences and feelings – what did we learn?
· What are the qualities of being a good group trainer of facilitator?
· Are they using the ‘here and now’?
· Are all members encouraged to participate?
· Is attention given to the individual or to his family member?
· Did limits need to be set by the group facilitator?
· Is the ‘group’ or trainer/facilitator taking care of each member’s needs?
· Where there any difficult situations that occurred in the group
To the group: The group welcomes a new parent
To the observers: Observe what happens in the group
Look at motivation, to dare to ask for help, to set limits for yourself and others if needed, talking in the here and now, mutual respect, trust and acceptance of a newcomer etc.)?
Feedback to the group:
What happened? How was the individual taken care of?
Did the individual receive enough attention from the group?
To the group: You are having an ordinary group meeting. Choose a theme
or an exercise for the group meeting and start talking to
To the observers: Look at the themes people are focusing on. Which themes were presented in the activity or by a group member? Does the group accept that members are talking about events irrelevant to personal feelings/experiences, common goals, are they focusing on feelings in the ‘here and now’ or feelings in the ‘then and there’, are they giving facts about events?
Feedback to the group:
What happened? Tell the group if you think it managed to lead the discussion from “external” to “internal”?
To the leader(s): You are having an ordinary group meeting. Choose a theme
for the group meeting and give the floor to the group.
To the observers: Observe if the leader (or someone else in the group) makes sure everyone is getting involved. Are persons who demand too much attention prevented from receiving it by the group facilitator? Observe if the facilitator has asked each member if they would like to share something with the group? Has facilitator allowed a member to remain silent? How did the facilitator handle the silence?
Feedback to the group:
Tell how you think the group leader(s) made sure all members got involved through the “mirror method”