Group counseling was known to be a beneficial method of treatment for substance abuse even prior to the 1935 founding of Alcoholics Anonymous, but it wasn’t until after World War II that group therapy became a widely accepted form of treatment. It was used in psychiatric hospitals, outpatient treatments, correctional centers, substance abuse treatment and other types of treatment. Group counseling lends itself to teaching clients and their families that they are not alone with their problems — that many of their anxieties and fears are shared by others. Today, group counseling is still one of the preferred methods of treatment, not only because of the need for clients to find connectedness but also because of the therapy’s powerful use of peer pressure.

Ethical considerations

One of the central ethical issues in group work is confidentiality. The group leader must not only keep the confidences of members but also convince the members to preserve one another’s confidences. Still, best practice emphasizes the importance of clearly communicating to all members of a group that even though the counselor is obligated to not reveal client information, the counselor cannot guarantee that group members will uphold confidentiality. For this reason, it is prudent to obtain a signed confidentiality form from all participants.

If a group technique is to be effective, it is of utmost importance for the group leaders to have proper training and to conform to the ethical standards of care. The counselors must also possess personal emotional regulation skills, healthy interpersonal functioning and effective group leadership skills. If the counselors do not have these skills, they could lose control of the group exercise. It is very beneficial for the group counselors to possess previous experience working as co-leaders, especially when they use the inner/outer group technique. They will have to rely on each other to observe the group that is not being processed and be able to convey a concern to the inner group leader through something as simple as a raised eyebrow. Group leaders should also understand the purpose of choosing this method, be able to work in partnership and know the group members (both clients and their families).

Conducting the inner/outer group

The inner/outer group technique is helpful in bringing out important issues, both for the clients and the counselors. In the safety of the group, clients’ family members can introduce important issues that help counselors to identify exaggerations, projections, conflicts and other types of miscommunications that can be valuable to discuss in a therapeutic environment.

The inner/outer group uses a co-leadership model that is processed by forming an inner circle made up of family members and an outer circle consisting of the clients. The family members and clients then trade circles and finally end in one large circle.

There are two primary goals for the inner/outer group. The first is to provide a safe environment for family members to voluntarily share how their loved one’s substance use has affected them. The second goal is to provide the clients with an opportunity to listen to the hurt of the families. This helps to reduce denial and minimization, especially as it pertains to
the family.

The success of the inner/outer group technique hinges on the ability of the counselors to screen group members for suitability. Therefore, it is essential for the group leaders to meet prior to conducting this technique to review the preliminary screening. It is preferable for the counselor who usually works with the substance use clients in group to again serve as the group leader in this exercise. The counselor who is familiar with the family members will work with the family.

It is the responsibility of the group leaders to not jeopardize anyone’s well-being and to follow all ethical guidelines. No member should be coerced into participating. Clients need to be informed of the importance of being open to honest feedback and allowing family members to be involved in the exercise.

On the other side, family members are more likely to feel safe and to participate in this technique if the counselor has established credibility and trust with them and if they feel that the counselor understands what they are going through. Most family members welcome the opportunity to share their feelings because, often, their loved one hasn’t wanted to hear or believe that the pain caused by his or her substance use has been that “bad.” Frequently, family members approach the inner/outer group exercise saying, “It’s finally my turn to be heard.”

The group leaders must agree that the technique will be canceled if anyone is reluctant about or unsuitable for the process. Because young children may not understand the process, it is recommended that all participants be at least 12 years old.

The total group size should not exceed 16. This allows ample time for everyone to share and feel like they are being heard. For instance, there may be six clients and 10 family members, or there may be nine clients and seven family members as, occasionally, there will be a client without any family present. But this too provides opportunities for learning because it is not unusual for a person to lose family support due to the inappropriate behaviors associated with the substance use. It may also be that a client’s family is unable to attend for other reasons. A small group of as few as five participants can be workable, mostly because the family members are eager to have “their chance.”

The important point is for the group to be kept manageable, both for the group leaders and the time allotted. The time will depend on the total number of clients, but experience has shown that the process works well if 45 minutes is allocated for each session of the inner, outer and then large group to debrief.

Keeping in mind the ethics of informed consent, it is imperative that each group leader meets with his or her respective members at least 10 minutes prior to the session to again check and clarify the process with everyone involved. Group leaders must concur that the technique will be canceled if anyone is disinclined to participate. It is a good idea for the group leaders to decide ahead of time on some discreet signal that the technique is a “no go” in order to protect confidentiality. In such cases, the clients and family members can be formed into a large group as the group leaders work on restabilizing the group. The process can be started by discussing the many reasons that it is difficult for participants to share and to trust again. The inner/outer group technique is less likely to be canceled when members are effectively screened beforehand.

This technique should be conducted only once per group. If it is an open group, care must be taken that no member has participated previously.

The inner/outer group process is less threatening and more relaxing when an atmosphere conducive to interaction and safety is created. This can be done in part by using lamps that are softer than overhead lights or by using lights with dimmers. There should be no distractions of any kind, including cell phones, smartphones or other electronic devices.

The inner group, which is composed of family members, should sit in a close but not tight circle. Always have a box of tissues handy, preferably on a small table in the center of the circle. Family members tend to feel more open to share when they do not make eye contact with their loved one, so it is important that each client sits almost directly behind his or her family member.

The outer circle is then formed with the clients. The outer co-leader should be positioned by sitting opposite the inner co-leader. This allows the outer co-leader to observe the reactions of the outside members for later processing. In this way, family members are protected from responding to the reactions of their loved ones because in this exercise, clients are expected to just listen.

The inner group

Once everyone is seated, the inner group co-leader should again review the group rules: use “I” statements, no blaming, share your own feelings without projecting. The inner group co-leader should start off by acknowledging that this technique can provoke a little anxiety and asking everyone to take a couple of deep breaths to help relax. The family members should then be reassured that the inner group co-leader is there to assist and support them.

The process should start with the person the group leader knows is most likely to share effectively, thereby modeling for the rest of the family members. Typically, this is someone who has been an active participant in the family sessions.

The process could go something like this: “I know that you have already shared what it’s been like for you to live with someone who has an addiction, but for the sake of the other members, would you please briefly share again?” This is also a good place to inquire about what the person’s hopes and fears may be as his or her loved one is in treatment.

With the newer family members, ask questions such as “What has it been like for you to be in this relationship?” and “What are your expectations now that your loved one is in treatment?” Another question might be, “Is there something you would like to say to your loved one at this time?” This can be a good closing question because it tends to be answered with expressions of love and hurt, yet also hope, and this often invokes tears.

Once everyone in the inner group has had a chance to share, the group leader should summarize and acknowledge the work that has been done by thanking the inner group and reminding everyone to maintain silence while trading places with the outer group.

The outer group

The process starts again with the outer group now becoming the inner group and the outer group co-leader becoming the inner group co-leader. This time, family members sit behind their loved one. The current inner group leader once again reviews the group rules and asks clients to share their reactions to what they heard from their family members. The group leader might also point out behaviors that he or she observed during the previous group. For example, “I noticed tears when your family member was talking about _______. Tell me what the tears were about.”

It is important that this part of the process focuses on reactions to what was previously said in order for the clients to let go of any minimizing or denials of the effects that their substance use has had on their family members. This also helps to validate the family members. Once again, the group leader could summarize and end the session similar to the way the first session was concluded.

The large group

All members are then asked to form a large group circle. While the large group is being formed (the chairs placed in one large circle), the lights are turned back up. This seems to help participants make the transition back from the intensity of the small group work. During this transition, families often hug each other and cry, which speaks to the power of the technique.

In the large group, with the co-leaders sitting opposite each other, debriefing starts by asking for reactions to the inner/outer group process. It is more effective to call on each member rather than waiting for someone to start the process so that everyone has a chance to debrief. Each group member is asked merely to respond to the technique. Otherwise, there is a tendency for members to want to comment on what was last said by their loved one.

Conclusion

It cannot be emphasized enough that the success of this technique depends on proper screening and reminding all the participants of confidentiality. Also be prepared that at the next group session, clients may want to reflect on how difficult it was to hear their family members’ comments and see their anguish. Because as long as they did not hear and feel this pain, they could continue to deny that their behaviors affected others or minimize its impact. It is also common for clients and family members to later share that their family has grown closer since the inner/outer group process.

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Estela M. Pledge is a licensed clinical professional counselor living in Macomb, Illinois. In addition to maintaining a private practice, she is a counselor and clinical supervisor at the Alcohol & Other Drugs Center at Western Illinois University. Contact her at em-pledge@wiu.edu.

Daniel J. Campbell is a master’s-level graduate student in the clinical community mental health program at Western Illinois University and a graduate assistant at the Alcohol & Other Drugs Center.

Letters to the editor: ct@counseling.org

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