Don't shut out contact outside of the group.

In the March/April issue I offered an overview of boundaries in group psychotherapy. Examining some of these boundary issues in more detail, this column takes a look at the various boundaries that have been applied to contact outside of the group, both between members and between member and therapist.

Classical psychodynamic group therapists often have advocated a very tight boundary concerning contact outside of the group. In theory, this position helps to maintain members' focus on examining all their relationships to one another in the presence of all group members and the therapist. When group members come from different social and professional realms, this boundary is workable, as long as the group meets in a relatively large metropolitan area and the therapist is vigilant about checking members' social and professional networks before they arrive in the group. When the inevitable situation arises where members of a group do have a common tie outside of the group, the therapist who uses this kind of tight boundary removes one of the individuals with the common tie.

For most of us working with recovering addicts, such a tight boundary is neither easy to practice nor necessarily the most useful tool in our work. Groups that are conducted in residential treatment centers that draw from a large geographical area may have group members who have never met one another prior to treatment. However, in this setting, any attempt to restrict members' contact outside of the group is clearly futile; members will be eating meals together and will have many opportunities during the day to engage in other therapeutic activities. In such groups, a common guideline is for members to bring into the group any significant contact outside of the group--particularly contact that has generated conflict or intense feelings.

Productive aspects

If we view relationships in the group as a mirror for how group members relate in the world outside, then bringing outside contact into the group can be used to enhance the group's appreciation of the consistency of each member's role inside and outside of the group. Particularly in working with recovering addicts, contact outside of the group may be much more likely than with group members who are not attending 12-Step meetings in addition to group therapy. With the possible exceptions of the largest metropolitan areas, the recovering community is still small enough that maintaining even one degree of separation between group members may pose a significant challenge.

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In addition, the isolation that characterizes most of our group members is not ameliorated through attempts to limit access to one another outside of group time. Indeed, some of the most useful work we can accomplish in the group involves examining the group's resistance to bonding more effectively.

One argument traditionally raised against contact outside of the group is that without the therapist present, dysfunctional dynamics between members may threaten their emotional and even physical safety. This argument assumes a somewhat paternalistic role for the therapist. It reinforces the illusion that the therapist is somehow powerful enough to protect the group from feeling hurt--or even that protecting the group from such feelings is useful. The alternative approach is to welcome these opportunities to examine how group members have sabotaged relationships by shaming and blaming others or by withholding direct expression of feelings when they feel hurt. In this model, conflicts between group members, either inside or outside of the group, serve as vehicles for learning how to create healthy boundaries and how to express feelings directly.

Therapist's outside role

Particularly if the group therapist is also recovering from addiction or codependence, his/her contact with members outside of the group becomes a distinct possibility. Some group therapists have adopted a boundary of not attending any 12-Step meetings with any of their patients. While this boundary may be viable in a community with abundant meetings, even the largest community may not hold many meetings of some of the smaller 12-Step or codependency fellowships. These therapists then may be restricting their own recovery by not attending meetings of the smaller fellowships, or may be reluctant to recommend these meetings to patients for fear of seeing their group members at a meeting.

One alternative to this restrictive boundary parallels the suggestion for member-to-member interaction. If any contact between group member and therapist is brought into the group, then whatever thoughts, feelings, or fantasies arose in the course of the contact can be fruitfully examined and understood. Some sophisticated group members may attempt to undermine such examination by invoking the therapist's anonymity (with the common understanding in 12-Step meetings being that "what is said here stays here"). I suggest that from the therapist's point of view, the therapist has no anonymity in the context of the therapy group. Any of the therapist's behavior, including attendance at a 12-Step meeting or what the therapist says at a meeting, must be open for examination. Naturally, this radical openness on the therapist's part may be quite challenging, which may explain why many therapists take the road of avoiding being in meetings with their patients.

My personal boundary in this area is rather pragmatic. If I am at a meeting with any of my patients, I understand that everything I say and do is grist for the mill. I need to get the help and support that the meeting offers, so I behave in whatever manner I need to in order to receive that help. Since my motive in being at the meeting is entirely selfish, my concern about having group members present is simply that if too high a proportion of my patients are in attendance, I may not get the help I need because of the risk of hearing my own disease recycled through those whom I am treating. I believe that my recovery depends on my being exposed to recovering people over whom I have no position of authority.

Jeffrey D. Roth, MD, is an addictions psychiatrist and group psychotherapist. He is a Fellow of the American Group Psychotherapy Association and the American Society of Addiction Medicine (ASAM), and is a member of ASAM's Family and Generational Issues Work Group. He is the author of Group Psychotherapy and Recovery from Addiction: Carrying the Message (published by The Haworth Press and reviewed in the September 2004 issue of Addiction Professional). Dr. Roth welcomes comments from readers on their experiences with contact outside of the group, either between members or between member and therapist. His e-mail address [e-mail].

by Jeffrey D. Roth, MD