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Addiction or substance-use disorder (SUD) is a problem of near epidemic proportions in Canada, affecting an estimated 21% of the population (Statistics Canada, 2021). With Of that group, Youth, or 18-25 year-olds, make for the majority at 50-60%.

Smith et al. (2020) emphasize the dangerous impact SUD can have on adolescent brain development and the long lasting consequences of drug use. Smith et al. (2020) also acknowledges the great power of peer influence in their lives of adolescents and how this can be harnessed to foster change and growth in recovery. The importance of peer influence on youth with SUD is not only helpful in guiding them towards harm reduction or abstinence, but also for building healthy relationships with others which is a key to long-term success (Smith et al., 2020). Of course, within that group of youth with SUD is an ascendant recovery community. Harris et al. (2012) stress that peer support groups are some of the most beneficial resources for youth struggling with SUD. More than ever there is a need for what Kottler & Carlson (2020) describe as the magic of group work.

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The first need in any group setting of this kind is safety.  An emphasis on confidentiality, respectful sharing, committing to attendance, and all-in participation is necessary for this group work to achieve best results. Relapse prevention is a key part of the focus of these groups as well. Gonzales et al. (2012) identify the importance of relapse prevention when working with adolescents in recovery. It is also highlighted that gaining the perspective of youths and seeing them as the experts in their own needs and lives is not only useful but necessary in planning programs and strategies for youth when it comes to relapse prevention tools. Part of addressing this need in the program will be to have youth with lived experience inform the creation of the group.

Despite a focus on relapse prevention, treating youth substance-use disorder is challenging, relapse rates can still be expected within the first year to often surpass 60% (Wilkins, 2017). Studies also suggest that promoting fun, a sense of belonging and accountability are elements that are likely to help youth get over some feelings of ambivalence in recovery and get down to the hard emotional work of ‘recovering’ (Winters et al. 2011).

This kind of group has many strengths, as youth are oftentimes highly sociable, hard-working and intelligent. Each day sober very often correlates to a higher level of personal well-being, confidence, and general positivity (Smith et al., 2020).

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Adolescents in the group will be in a transitional stage of their life and quite vulnerable emotionally. It is important to consider these factors when deciding what kind of group to use.

An open group may not be the best option for this type of work because the group's success is thought to be connected to feelings of safety and familiarity with other groups members. Peer-led, self-help, or guided therapeutic groups are ideal for this demographic. Peer support groups are made up of people who are all directly affected by a particular issue, but can have a professional discussion leader or facilitator, and tend to work best in smaller group sizes. The smaller size (4-8) can add to the trust and intimacy of the group, as well as provide more opportunity for personal connections. The larger the group, the more tendency for sub-groups to form within because it's harder to relate equally to everyone, and there's more room to ‘hide’ or not share openly. Psychoeducational groups are more focused on sharing information or knowledge about a particular topic, which can be useful in this setting, especially in regards to relapse prevention. Guided therapeutic groups are typically led by a professional service provider, therapist, or facilitator with the goal of providing treatment and education.

Guidelines for group membership are set in the first meeting and then brought up as needed throughout the subsequent weeks. Also important to note is the possibility of ‘homework’, or out of group reading and study material relevant to the topic, being provided at the end of each session to assist the youth as they return home or to their prospective living spaces. Wholistic support both delivered within the safe space of a group setting, and continuing with them into their personal lives, should assist group members with motivation to continue their efforts towards wellness outside of the session.

A flexible yet structured and open therapeutic group has been selected as most appropriate.

Role of facilitator (s)

In groups with adolescents in recovery, the role of a facilitator is a necessary addition to assist the group in maintaining their guidelines, intervening if bullying and other disruptive behaviours take place, but also to encourage feedback between group members (Malekoff, 1994 & Kottler & Carlson, 2020).

Due to the rising levels of addiction rates among Indigenous youth in Canada, we also ask that both facilitators have knowledge of both the Western, seeking safety model as well as incorporate Indigenous ways of knowing into the group.(Government of Canada, 2021).

Life Persona (n.d.) stresses that inclusive groups can be fostered with a variety of activities in each phase of group development. It is important for facilitators to have an extensive repertoire of activities that are inclusive of all members' unique abilities, strengths, and challenges. Team work, writes Harris et al. (2012) is one of the ways adolescents can build upon their resiliency and rely on one another for support.

Issues of Power

To address the issue of power in this group and to create an extra layer of safety and trust between facilitator and group members, we recommend that group facilitators either be in recovery from addiction themselves or have an exceptional knowledge of addiction and evidence-based approaches to assisting individuals.

One of the first things to be made very clear when structuring the initial guidelines of the group is that facilitators are not exempt from feedback and are expected to respond with open mindedness and humility if they are in the wrong, have made an incorrect judgment, or shown a lack of empathy. If a group member is uncomfortable with how the facilitators are behaving or speaking in any way, it is to be known from the first meeting that facilitators are not always in the right, that they too can make mistakes and say the wrong things. From anecdotal evidence, respect and trust is built between facilitators of therapeutic groups and their members if they are able to apologize when they do something unethical or unkind and that a strengthening of trust and the therapeutic alliance is strengthened from this kind of humility. Kottler & Carlson (2020) explain that humility is a strength when it comes to traits of group facilitators and can be used to build cohesion and trust.

Another way power dynamics can be addressed is the recommendation of having two individuals co-facilitate the groups in order to balance and distribute zooming in and out, biases, and strengths (Kottler & Carlson, 2020).

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Beginning and Middle Phases of Group Development, Planning, and Recruitment

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Beginning and Middle Phases of Group Development, Planning, and Recruitment

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Funding will be gathered through government grants and donations. We realize that structural issues such as stigma, lack of resources, and lack of collaboration at the organizational level are issues which is why providing education to the public is so important. Connections with youth social service agencies to spread the word and screen for adolescents that would benefit from this program will be a key recruitment tactic. Social media campaigning as a way to normalize seeking help for adolescents with SUD can be a great way to gather members and show our group is non-judgemental and relevant.

The group will be held preferably twice a week with between 4-8 members for 2-3 months. Trust and confidentiality is more easily maintained in smaller groups and can assist the members in developing and maintaining cohesive connections (Kottler & Carlson, 2022). Harris et al. (2012) also stress the importance of cohesion in maintaining the interest of adolescents with SUD and preventing them for dropping out of the program early. The setting should be the same each week to create safety and familiarity. Meeting rooms can be rented out in town halls, schools, and a variety of other locations.

Types of Activities:

Activity selection is an important aspect of this group for many reasons. Activities can help members in the forming stage get to know one another, assist with conflict in the storming phase, or provide a way to close and end groups with meaningful rituals (Schmid, 2022).

Activities that can help during the forming stage are ice breakers such as filling out a questionnaire about hopes, expectations, and fears about the group process and sharing answers with the group Schmid (2022). In the beginning stage you might notice group members falling into roles such as the quiet one or the monopolizer. Either taking up too much or too little space in the beginning stages is common as defences are up and trust is not yet built. Being patient and meeting youth with non-judgement is very important at this stage (Kottler & Carlson, 2020). Activities can help to shift up group dynamics and allow quiet members the opportunity to share and encourage louder members to listen. Pairing group members together and giving them five minutes each to share their story or whatever they like with their partner is another way to encourage listening and empathizing. After the five minutes is up, the group member who listened will then have 2 minutes to summarize and share with the group what they learned about their partner. This is not to put any group member on the spot but to encourage focused attention on others, empathy, and relationship building.

Community relations are critical as research tells us that adolescents are at high risk of dropping out of therapeutic groups early if they lack cohesion (Harris et al., 2012). Therefore, the types of activities and techniques involved in the development of cohesion is of great importance and a key focus for suggested activities.

Another incredible tool for cohesion building is called “Common things” where group members must find 10 things they have in common with other group members (Life Persona, n.d.). This can be adapted to writing a list of behaviours the adolescents want to change or have done due to their addiction. When they realize how much in common they have with their group members in this way it can battle feelings of shame and normalize their circumstances.

Activities outside of the group are also important. Mayadas & Glasser (1981) write that one way to keep group members focused on the goals of their group outside of sessions is to provide homework. This can spark next week’s conversation, build confidence and motivation in the group member’s personal goals for their recovery, and help them to understand things like self care and boundaries which are integral parts of life after active addiction.

Conflict:

Conflict emerges in groups for many reasons. Adolescents seeking help for their recovery can be emotionally raw as they have been numbing their feelings with substances. Having protocols in place such as group guidelines will be important to refer to if unkind words or gossip becomes an issue. Due to the sensitive nature of topics covered in group, confidentiality is something that should be discussed right away.

Conflict can also emerge when group members are flooded with emotion or are overwhelmed by a discussion topic. Allowing members the freedom to leave and take breaks if they are triggered or become overwhelmed is highly important. As a therapeutic group there are measures taken to ensure things don’t get as raw as in a one on one session with a therapist but sometimes feelings happen and that's ok. Encouraging members to take some time out or have some water can help them feel supported without putting the other members at risk. Screening for traumatic symptoms and other issues is also an important thing to note for recruitment as some youth will need one on one counselling first or in addition to group therapy.

Cultural Sensitivity and Awareness:

Addiction is a serious issue that can be potentially life-threatening, and the risks of use go up as the drugs being consumed contain ever more toxic ingredients. Because of this, there will be opportunities in every group for members to provide feedback to their peers and an open expression of thoughts and feelings is encouraged. Once safety and respect have been established in the group, the hope is that feedback will no long be the sole responsibility of the facilitators but each and every group member (Malekoff, 1994). The goal is to address issues of pleasing people, lack of participation, and respect for the voices of all group members by encouraging them to speak directly to one another (as long as they feel safe to do so). Part of anti-oppressive practice is to give opportunities to each person regardless of their status or perceived amount of power in the group (Harms & Connoly, 2020). Everyone should be treated equally.

Relapse is another extremely important thing to be aware of within these groups (Gonzales et al., 2012). There is much debate about what to do if a group member relapses because of needing to balance group member safety with support of the individual. Gonzales et al. (2012) reminds us to understand recovery as a process and not a one size fits all is important. If a group member has a relapse, referring them to other services or supporting them to re-enter the group safely without judgement is crucial (Winters et al., 2011).

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1. Building a sense of community with others going through similar situations is a great way to instill confidence in people working through hardship in their lives (Harms & Connolly, 2020). Many of the adolescents we hope to serve come from marginalized backgrounds. Normalizing their experiences by hearing other group members' stories is part of this community building process and lets them know they are not alone (Harms & Connolly, 2020).

2.
A safe space to share where adolescents, although dealing with life-threatening issues, are encouraged to focus on their strengths and internal resources has been proven impactful for recovery sustainability (Harris et al., 2012 & Winters et al., 2011). Focusing only on group members pathology and problems can be a detriment to instilling hope and motivation towards their goals (Harms & Connolly, 2020).

3.

Opportunities for growth and development through peer and facilitator feedback is a huge benefit. Receiving information and suggestions from peers can often be the strongest factor in youth recovering from SUD (Smith et al., 2020).

4.

Life Persona (n.d.) informs readers of the positive impact activities can have on group dynamics, a sense of belonging, and motivation for member participation. While it may not seem that important, for adolescents who have been using substances, they may be socially isolated and depressed to the point where happy feelings are fleeting and rare. Not every activity in our program will spark feelings of positivity, yet the connection provided from group activities is nearly the opposite of addiction which disconnects oneself from others.

5.

Evidence-based techniques for relapse prevention will be implemented in the homework given between sessions along with group discussion. Seeing the growth in others can spark motivation in adolescents when their strengths are acknowledged (Smith et al., 2020). Celebration of accomplishments and strengths when given and received from other group members builds confidence and increases group connections (Smith et al., 2020).

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Endings are said to be such sweet sorrow, and are often difficult for peer-support and therapeutic groups, as the bond becomes quite strong between both group members as well as facilitators. This can be mitigated and even worked with by ending groups with ‘closing traditions’ and group building exercises. Highs and Lows, and Feelings in a Bag, are 2 such activities. The first is a tradition that involves passing around a piece of paper for group members to write down hopes for or positive affirmations for each group member, as well as fears that they have overcome, which can allow them to carry something physical with them to take into a new chapter of their life (Kottler & Carlson, 2020). The second closing tradition, Feelings in a Bag, is a short activity wherein at the end of a group a small pouch containing a number of scraps of paper, each with a name of a feeling (such as joy, confusion, or fear, etc.) is passed around the group. Each member pulls out at random a feeling, and they relate it to themselves in a personal way in reference to their day. This helps youth both understand and recognize personal feelings, as well as build trust and vulnerability going into their personal life. Ending groups in this method of planned termination ensures it becomes one more piece of a functional set of group processes, in which worker and member participate in equitable, intentional exchanges (Mayadas & Glasser, 1981).

Preparing the group, even during the initial phases when they are less likely to be emotionally impacted is suggested (Mayadas & Glasser, 1981). Grief in endings - Some group members may feel relieved and excited to take what they have learned throughout the group process while others may feel significant loss and fears around what their life will be like without their weekly group support system. No members' feelings or reactions to endings should be judged. It is even common for some group members to ‘no show’ the last session because goodbyes provide added emotional challenges. Ongoing support for group members who do not feel ready should be offered (Mayadas & Glasser, 1981). Mayadas & Glasser (1981) also stress that if this happens, this group member’s goals may not have been achieved. To put that in ‘recovery’ terms, it can be a tell that the aforementioned group member may have harboured reservations about using substances, or perhaps does not have the confidence to trust they can be safe after leaving the group.

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Group therapy is an integral part of helping individuals to bring about a change for themselves, enhance their social functions, or better cope with the many challenges of life. However, providing group work interventions for Youth in Recovery can be a particularly challenging field of practice, as SUD itself is often a symptom of other emotional or mental distress. Additionally, on this journey toward recovery, relapse is a probability. Group therapy in all of its forms aims to bring about a reduction of negative symptoms such as ambivalent behavior and poor motivation, as well improvement in social and emotional health and functioning, better personal relationships, and even freedom from substance-use disorder. Because the numerical balance of this kind of group social work method favours the service user and not the service provider, it can be argued that it has the potential to be less oppressive than other methods (Lindsay & Orton, 2014). Moreover, this anti-oppressive dynamic can be further enhanced as long as the balance of power and knowledge in the group can be shared (Lindsay & Orton, 2014).

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                                     References

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                                     References

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Gonzales, R., Anglin, D., Beattie, R., Ong, C. A., & Glik, C.      (2012). Understanding recovery barriers: Youth perceptions about substance use relapse. American Journal of Health Behavior, 36(5), 602-614. https://doi.org/10.5993/AJHB.36.5.3

Government of Canada. (2021). Tobacco, alcohol and marijuana use among Indigenous youth attending off-reserve schools in Canada: Cross-sectional results from the Canadian Student Tobacco, Alcohol and Drugs Survey. Canada.ca. Retrieved November 25, 2022, from https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-39-no-6-7-2019/tobacco-alcohol-marijuana-use-indigenous-youth-off-reserve-schools.html

Harris, N., Brazeau, J., Clarkson, A., Brownlee, K. & Rawana, E. (2012). Adolescents’ perspectives on strengths-based group work and group cohesion in residential treatment for substance abuse. Journal of Social Work Practice in the Addictions, 12 (4), 333-347.  https://doi.org/10.1080/1533256X.2012.728485

Harm, L. & Connolly, M. (2019). Social work: From theory to practice [eBook edition 3]. Cambridge University Press. https://viu.vitalsource.com/reader/books/9781108678674/pageid/5

Kottler, J. A., & Englar-Carlson, M. (2020). Learning group leadership: An experiential approach. Cognella Academic Publishing.

Life Persona. (n.d.). 27 Group Dynamics for Youth and Adolescents. Life Persona. Retrieved October 7, 2022, from https://www.lifepersona.com/27-group-dynamics-for-youth-and-adolescents

Lindsay, T. & Orton, S. (2014). Groupwork practice in social work, Chpt 6, Programming and Activities (p. 99-107),3rd ed. Thousand Oaks, CA: Sage Publications.

Malekoff, A. (1994). A Guideline for Group Work with Adolescents. Social Work With Groups, 1I(1-2), 5-19. https://doi.org/10.1300/J009v17n01_02

Mayadas, N.S , & Glasser, P. (1981). Termination. Social Work With Groups, 4(1-2), 193-204, DOI:10.1300/J009v04n01_17

Pelech, W., Basso, R. , Lee, C.D. &  Gandarilla, M. (2016). Inclusive group work. Chapter 10, Leadership and Co-leadership (p. 127-142). New York, N.Y.: Oxford University Press.

Schmid, J. (2022). Week 10 middle phase facilitator skills: The use of activities in therapeutic groups  [Lecture Post]. https://learn.viu.ca/d2l/le/content/206195/viewContent/2593644/View

Smith, N. Z., Vasquez, P. J., Emelogu, N. A., Hayes, A. E., Engebretson, J., & Nash, A. J. (2020). The good, the bad, and recovery: Adolescents describe the advantages and disadvantages of alternative peer groups. Substance Abuse Research and Treatment 14, 1-9. https://doi.org/10.1177/1178221820909354

Statistics Canada. (2021, December 20). The Daily — Alcohol and drug use in Canada, 2019. Retrieved November 25, 2022, from https://www150.statcan.gc.ca/n1/daily-quotidien/211220/dq211220c-eng.htm

Winters, K., Bozdet, A., & Fahnhorst, T. (2011). Advances in adolescent substance abuse treatment. Current Psychiatry Rep, 13(5), 416-421. doi: 10.1007/s11920-011-0214-2