This question-and-answer column appears regularly in NSGPeople and addresses complex dilemmas in group therapy. Featured are case vignettes presented by NSGP members, with responses by senior clinicians. If you have a question you would like considered for this column, please submit a case vignette of 400 words or less to Natasha Khoury, MA, M.ED. through the NSGP office, or via email to newsletter@nsgp.com. Please remember to preserve the confidentiality of any group members described.

Thank you to Nadia Khatchadourian, LICSW for editing this column for the past year.

Dear Analyze This,

I currently work at a clinic that specializes in treating addictions, where I run a Men’s Group that meets every week. The group consists of 20 men that suffer from opiate addiction who are required by the clinic’s policies to attend the group. Group members feel coerced to be there, which results in elevated amounts of aggression in each session. 

In order to address the dilemma I have been facing, you should know a little more about the demographic context of the group. I am a male that comes from a South American background, while all of the group members come from a Northeastern white suburban background. This distinction might seem unimportant, but in terms of the group process, the group’s aggression has found expression in racial themes and slurs. In light of recent global events like the Iran bombings and the coronavirus, most insults have been directed towards Persian and Chinese individuals that most members encounter in their day-to-day lives. 

Some examples of these slurs include expressions such as: “I swear I have a terrorist cell living across my street. I see all these little girls with their hoods on playing on the monkey bars. It bothers me to see them together; they ́re probably training to blow up,” and “Asians are disgusting. It’s because of the shit they eat that we are getting the coronavirus; it wouldn’t bother me if they were all dead.” Other comments involve drug-trafficking and cartels associated with my ethnic group. In summary, the group attacks Asians, Middle Easterners, and sometimes me. I assume this is a transference communication – something about me is unsettling – but how can I deal with this clinically? 

Although I have explored and addressed the group’s outspoken racism in session, I always wonder what is the limit between the opportunity to work therapeutically with the group’s aggression and the bonding that is being created among members through their shared hate to other ethnic groups. Although bonding is a need for these patients in light of the effects addiction and isolation have brought to their lives, should it come at the expense of endangering other individuals? Some may argue that this does not mean that they will necessarily act on their thoughts, but it does not mean they won’t, either. How do we understand the social responsibility of clinical practice? 

Sincerely,

The @#!%& Foreigner 

 

Dear @#!%& Foreigner,

I applaud the insight and courage it takes to name and explore racism while staying emotionally available! As a systemically disempowered cultural minority, you seem to grapple with finding the best therapeutic use of power given to you by your role. Addiction can be understood as disempowerment and loss of control, while racism as power and control through dominance. From this perspective, the racial slurs of your group members are attempts to regain power while being disempowered by their addiction, losses it brings, and “coercion” into treatment. Therapeutic work with racism, therefore, will involve exploring relationship to power.

My responses to your vignette are informed by my background and training. As a woman, I experience the reference to “little girls” as an expression of male dominance. Often perceived as Asian, I wonder if you feel physically safe in your group as I might not. Being trained in feminist theories of counseling, I am curious about to whom and why the cultural background “might seem unimportant,” and the impact such culture blindness might have on the therapeutic process. As a holistic trauma-informed counselor, I see aggression as an expression of trauma and want to understand how it feels (emotionally, physically, and spiritually) to sit with your group’s fear and hatred. Practicing from the cultural humility, not competency, perspective (Tervalon & Murray-Garcia, 1998), I am eager to learn with your group how cultural beliefs expand and limit relationships. 

With the above in mind, I might pursue the following lines of inquiry with your group:

Intrapersonal level (self-reflection): In response to the comment about “little girls”: “It sounds like you are afraid of those little girls. What do you do when afraid? How does it play into your addiction? How do you experience fear in your body?” In response to comments about Asians: “What else makes you feel disgusted? It does not bother you if all Asians die – what DOES bother you? How does it impact your recovery?” Internally, I will connect to my own fear and disgust for “others” to inform me about possible internal states of my group members.

Interpersonal level (relationships): I will use members’ comments and responses to explore relationships. For example, “Jack and Sam nodded when Bill made his comment about Asians. Jack, Sam, what did you try to convey to Bill through your nod? Bill, how does it make you feel?” “John, when you made this comment about cartels, how do you think it made me feel? Did you want me to feel this way, and why? How is it for you to have a South American therapist?” Internally, I will consider ethnocultural transference/countertransference (Comas-Diaz & Jacobsen, 1991, 1995) for therapeutic use.   

Group-as-a-whole level (scapegoating): I interpret scapegoating of “@#!%& foreigners” as a group-as-a-whole defense, and I will explore what the group defends itself from through expression of racism. For example, I will ask what about recovery the group does not discuss as it talks about disgusting and threatening others, or what members find disgusting and threatening about themselves or the group. While racial slurs make the group appear tough, I will explore the other side of aggression, which is vulnerability. I will point out that bonding “through shared hatred to other ethnic groups” is as fallible as bonding through drug use and encourage the group to explore other ways of creating meaningful relationships. Internally, I will connect to places of fear and disgust for my group to use my insights therapeutically.

Large Group level (society): I will normalize the group’s anxieties brought up by global crises. I will point out that blaming others and using substances are just some of the ways of dealing with such anxieties and will encourage exploring other alternatives. Brown (2001), rejecting the psychoanalytic construct of transference/countertransference, talks about a “symbolic relationship” (p. 1006) in which personal and cultural histories of the therapist and clients intertwine into a “continuous, interactive loop between internal and external realities” (p. 1006). Viewing “disgusting Asians,” terrorist “little girls,” and “drug trafficking” Latinos as social constructs, I will explore what they symbolically represent to my group and how it relates to their struggle with addiction. I will state my anti-racism stance on the matter and will emphasize that despite our differing views, I am there to aid my group members’ recovery.  

Basically, I would approach racial slurs as an opportunity to explore the relationship to power in a way that supports connection, agency, and resilience. Like racism, addiction induces hopelessness. Whatever you choose as a clinical intervention, I would encourage you to act from the place of hope – for yourself in your ability to help and for your group members in their potential to transform with your help, despite your fears, differences, and disagreements.

Sincerely,

A @#!%& foreigner myself, 

Alexandra (Sasha) Watkins, LMHC

References

Brown, L. S. (2001). Feelings in context: Countertransference and the real world in feminist therapy. Journal of clinical psychology, 57(8), 1005-1012.

Comas-Diaz, L. & Jacobsen, F.M. (1991). Ethnocultural transference and countertransference in the therapeutic dyad. American Journal of Orthopsychiatry, 61(3), July, 392-401.

Comas-Diaz, L. & Jacobsen, F.M. (1995). The therapist of color and the white patient dyad: Contradictions and recognitions. Cultural Diversity and Mental Health, 1(2), 93-106. 

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.

 

Dear The @#!%& Foreigner,

Thank you for your submission and question. From your careful description, I can vividly picture your group in my mind. Here are my thoughts, which are divided into practical/pragmatic, interpersonal, and psychodynamic. I end with my personal thoughts.

Practical/pragmatic: Despite the mandatory nature of your group, each patient’s care at your clinic is voluntary. Therefore, implicit agreement exists for attendance to your group. Patients have the opportunity to obtain care at other clinics with a different approach to treatment. Addictions programs are notoriously understaffed. While the purpose or duration of the group was not specified (i.e. skills, Suboxone, process group, etc.), it would be a challenge to independently manage a group of that size. There are some areas of group psychotherapy which are meant to work in a moderate to large group setting; for example, systems-centered group therapy uses functional subgrouping to explore difference. A simple solution would be to reduce the size of the group to change dynamics of aggression or add a therapist to bring in additional support to you. The synergy of a smaller group and an additional therapist (preferably white) could help with affect regulation in the group. Any specific intervention within the group will depend on the purpose of the group. Process groups may require exploration of these expressions of aggression – including their racial overtones. Alternatively, a skills-based group may require corrective response toward behavior that detracts from the task at hand. However, the safety of the therapist and the other group members is paramount.

Interpersonal: The phase of the group and stage of recovery from substance use (early, middle, late) are important to consider. From your description, the repeated references to foreigners may suggest general distrust in life. Using their own language and applied to the lives of substance users: 

“I swear I have a crack house across my street. I see all these crackheads with their hoods on hanging out on the street. It bothers me to see them together; they ́re probably waiting to rob me,” and “Dope fiends are disgusting. It’s because of the shit they shoot in their veins that we are getting more HIV and hepatitis C; it wouldn’t bother me if they were all dead.”

I wonder how the group would be able to relate to these expressions in which they are seen as dangerous, worthless, and responsible for creating misery in the lives of others. Refocusing the group on their felt sense of being “disdained outsiders” may create more space for trust and real cohesion to energize change.

Psychodynamic: It is exceedingly rare that any group be completely in agreement about any subject. I wonder about the silence of members in the group whose ideology differs from hatred toward ethnic groups. If there were members in the group who held different views, explore how the group is complicit in ensuring the silence of those members. A comment like, “I wonder if the members who do not share or agree with the expressed feeling would be treated in a group like this. Would they be able to speak or would they be attacked?” This question is not asking anyone to speak against the aggression but rather a way to understand the created norms of “we are right and they are wrong.” The silent “minority” would crave protection from being consumed or scapegoated by the group. Rather than creating cohesion, this may be an expression of distrust within the group which is projected onto an outside other – Middle Eastern children, Chinese, and South Americans.

Being from a South American background can mean multiple things; for simplicity, I will focus on the concrete. While you did not describe your appearance or speech (i.e. with or without accent), the interpretation of the group’s comments would suggest a different meaning if you were seen to be “one of us” or “not like us.” Was the group making racialized statements because “no one was watching” and thus could create more cohesion with you and the members? Or was the group trying to evoke in you the sense of fear, helplessness, and hopelessness which is a manifestation of the circumstances of their addicted minds? Or are they unapologetic xenophobes?   

Personal thoughts:  We are in an unprecedented time in the world. There has been massive civil unrest created by the murder of African Americans by law enforcement, in the context of social isolation and hundreds of thousands losing their lives to COVID-19. Yet, it is interesting that this case was given to me to consider – an African American provider. I wondered, why was this case not given to a white provider? A white therapist could unravel the mysteries of a Northeastern American white suburban man, as any one of these men could easily be their neighbor. Reading the vignette, my first thought was, “The question is, how do I manage these white people?” And this seems to be the question faced by this nation. The answer will never be provided by Black, Indigenous, People of Color, or immigrants. The underlying structures have their bedrock in white supremacy. I define white supremacy as the belief that white thought, ideas, bodies, and culture are the standards by which all of humanity will be measured. Social advocacy in clinical practice would work to dismantle the institutions and structures that breed ideology that divides. Social justice is rarely achieved by changing one person at a time, but rather by rehauling overlapping systems (medical, legal, educational, etc.) which continue to enshrine white supremacy. And in this, we also need white people. They built it and need to be responsible for dismantling it.

Sincerely,

Shunda McGahee, MD, CGP

References

Bartoli, E & Pyati, A (2009). Addressing Clients’ Racism and Racial Prejudice in Individual Psychotherapy: Treatment Considerations. Psychotherapy Theory, Research, Practice, Training 46(2), 145-57.

Black, A.E. (2017). On Attacking and Being Attacked in Group Psychotherapy, International Journal of Group Psychotherapy. 67(3), 291-313.

Flores, P.J. (2004). Addiction as an Attachment Disorder. Maryland: Rowman & Littlefield Publishing Group.

Kleinburg, J.L. (ed). (2012). The Wiley Blackwell Handbook of Group Psychotherapy. United Kingdom: John Wiley & Sons, Ltd.