terapia grupal alcoholismo

A Treatment Improvement

Protocol

Substance Abuse Treatment:Group Therapy

TIP41

GROUPTHERAPY

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatmentwww.samhsa.gov

This TIP, Substance Abuse Treatment: Group Therapy, presents anoverview of the role and efficacy of group therapy in substanceabuse treatment planning. This TIP offers research and clinical find-ings and distills them into practical guidelines for practitioners ofgroup therapy modalities in the field of substance abuse treatment.The TIP describes effective types of group therapy and offers a theo-retical basis for group therapys effectiveness in the treatment of sub-stance use disorders. This work also will be a useful guide to supervi-sors and trainers of beginning counselors, as well as to experiencedcounselors. Finally, the TIP is meant to provide researchers and clini-cians with a guide to sources of information and topics for furtherinquiry.


DHHS Publication No. (SMA) 05-3991Printed 2005

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Collateral ProductsBased on TIP 41

Quick Guide for Clinicians

GROUPTHERAPY

Sub

stance A

bu

se Treatmen

t: Gro

up

Therap

yTIP 41

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceSubstance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment

1 Choke Cherry RoadRockville, MD 20857


Philip J. Flores, Ph.D.Consensus Panel Chair

Jeffrey M. Georgi, M.Div., CGP, CSAC, LPC, CCSConsensus Panel Co-Chair

A Treatment Improvement

Protocol

TIP41

AcknowledgmentsNumerous people contributed to the develop-ment of this TIP (see pp. ix, xi, and appendicesF, G, and H). This publication was produced by The CDM Group, Inc. (CDM)under the Knowledge Application Program(KAP) contract number 270-99-7072 with theSubstance Abuse and Mental Health ServicesAdministration (SAMHSA), U.S. Departmentof Health and Human Services (DHHS). KarlD. White, Ed.D., and Andrea Kopstein,Ph.D., M.P.H., served as the Center forSubstance Abuse Treatment (CSAT) Govern-ment Project Officers. Christina Currierserved as the CSAT TIPs Task Leader. Rose M.Urban, M.S.W., J.D., LCSW, CCAC, CSAC,served as the CDM KAP Executive DeputyProject Director. Shel Weinberg, Ph.D., servedas the CDM KAP Senior Research/AppliedPsychologist. Other CDM KAP personnelincluded Raquel Witkin, M.S., Deputy ProjectManager; Susan Kimner, Managing Editor;James Girsch, Ph.D., Editor/Writer; MichelleMyers, Quality Assurance Editor; and SonjaEasley, Editorial Assistant. In addition, SandraClunies, M.S., I.C.A.D.C., served as ContentAdvisor. Jonathan Max Gilbert, M.A., SusanHills, Ph.D., and Mary Lou Rife, Ph.D., were writers.

DisclaimerThe opinions expressed herein are the views ofthe Consensus Panel members and do not nec-essarily reflect the official position of CSAT,SAMHSA, or DHHS. No official support of orendorsement by CSAT, SAMHSA, or DHHSfor these opinions or for particular instru-ments, software, or resources described in thisdocument are intended or should be inferred.The guidelines in this document should not beconsidered substitutes for individualized clientcare and treatment decisions.

Public Domain NoticeAll materials appearing in this volume exceptthose taken directly from copyrighted sourcesare in the public domain and may be repro-duced or copied without permission fromSAMHSA/CSAT or the authors. Do not repro-duce or distribute this publication for a feewithout specific, written authorization fromSAMHSAs Office of Communications.

Electronic Access and Copiesof PublicationCopies may be obtained free of charge fromSAMHSAs National Clearinghouse for Alcoholand Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearingimpaired), (800) 487-4889, or electronicallythrough the following Internet World WideWeb site: www.ncadi.samhsa.gov.

Recommended CitationCenter for Substance Abuse Treatment.Substance Abuse Treatment: Group Therapy.Treatment Improvement Protocol (TIP) Series41. DHHS Publication No. (SMA) 05-3991.Rockville, MD: Substance Abuse and MentalHealth Services Administration, 2005.

Originating OfficePractice Improvement Branch, Division ofServices Improvement, Center for SubstanceAbuse Treatment, Substance Abuse and MentalHealth Services Administration, 1 ChokeCherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 05-3991

Printed 2005

ii Acknowledgments

Contents

What Is a TIP?............................................................................................................vii

Consensus Panel ..........................................................................................................ix

KAP Expert Panel and Federal Government Participants ....................................................xi

Foreword ..................................................................................................................xiii

Executive Summary .....................................................................................................xv

Chapter 1Groups and Substance Abuse Treatment ...........................................................1

Overview......................................................................................................................1Introduction .................................................................................................................1Defining Therapeutic Groups in Substance Abuse Treatment ....................................................2Advantages of Group Treatment ........................................................................................3Modifying Group Therapy To Treat Substance Abuse .............................................................6Approach of This TIP .....................................................................................................8

Chapter 2Types of Groups Commonly Used in Substance Abuse Treatment ..........................9

Overview......................................................................................................................9Introduction .................................................................................................................9Five Group Models .......................................................................................................12Specialized Groups in Substance Abuse Treatment................................................................29

Chapter 3Criteria for the Placement of Clients in Groups................................................37

Overview ....................................................................................................................37Matching Clients With Groups .........................................................................................37Assessing Client Readiness for Group ................................................................................38Primary Placement Considerations ...................................................................................40Stages of Recovery ........................................................................................................43Placing Clients From Racial or Ethnic Minorities .................................................................44Diversity and Placement.................................................................................................52

Chapter 4Group Development and Phase-Specific Tasks .................................................59

Overview ....................................................................................................................59Fixed and Revolving Membership Groups ...........................................................................59Preparing for Client Participation in Groups.......................................................................61Phase-Specific Group Tasks ............................................................................................72

Chapter 5Stages of Treatment ....................................................................................79

Overview ....................................................................................................................79Adjustments To Make Treatment Appropriate .....................................................................79The Early Stage of Treatment ..........................................................................................80The Middle Stage of Treatment ........................................................................................85The Late Stage of Treatment............................................................................................88

iii

iv

Chapter 6Group Leadership, Concepts, and Techniques ..................................................91

Overview ....................................................................................................................91The Group Leader ........................................................................................................92Concepts, Techniques, and Considerations ........................................................................105

Chapter 7Training and Supervision............................................................................123

Overview...................................................................................................................123Training....................................................................................................................123Supervision................................................................................................................131

Appendix A: Bibliography ..........................................................................................137

Appendix B: Adult Patient Placement Criteria................................................................149

Appendix C: Sample Group Agreement .........................................................................151

Appendix D: Glossary ................................................................................................153

Appendix E: Association for Specialists in Group Work Best Practice Guidelines ..................159

Appendix F: Resource Panel .......................................................................................165

Appendix G: Cultural Competency and Diversity Network Participants ...............................167

Appendix H: Field Reviewers ......................................................................................169

Index ......................................................................................................................175

CSAT TIPs and Publications........................................................................................181

Contents

vFigures

1-1 Differences Between 12-Step Self-Help Groups and Interpersonal Process Groups ...................42-1 Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models .............112-2 Characteristics of Five Group Models Used in Substance Abuse Treatment ...........................132-3 Group Vignette: Joes Argument With His Roommate.......................................................262-4 Joes Case in an Individually Focused Group .................................................................272-5 Joes Case in an Interpersonally Focused Group.............................................................282-6 Joes Case in a Group-As-A-Whole Focused Group..........................................................292-7 The SageWind Model for Group Therapy......................................................................333-1 Eco-Map ...............................................................................................................383-2 Client Placement by Stage of Recovery .........................................................................433-3 Client Placement Based on Readiness for Change............................................................443-4 What Is Culture? ....................................................................................................453-5 Diversity Wheel ......................................................................................................463-6 When Group Norms and Cultural Values Conflict ...........................................................483-7 Three Resources on Culture and Ethnicity ....................................................................483-8 Guidelines for Clinicians on Evaluating Bias and Prejudice...............................................493-9 Self-Assessment Guide ..............................................................................................503-10 Preparing the Group for a New Member From a Racial/Ethnic Minority..............................543-11 Culture and the Perception of Conflict ........................................................................574-1 Characteristics of Fixed and Revolving Membership Groups..............................................62 4-2 The Family Care Program of the Duke Addictions Program ..............................................664-3 SageWind..............................................................................................................674-4 Examples of Agreements About Time and Attendance ......................................................694-5 Examples of Agreements About Group Participation........................................................714-6 Reminders for Each Group Session .............................................................................746-1 Shame ..................................................................................................................956-2 Confidentiality and 42 C.F.R., Part 2.........................................................................1106-3 Jodys Arm ..........................................................................................................1217-1 How Important Is It for a Substance Abuse Group Leader To Be in Recovery?.....................1267-2 Does Online Communication Impede Attachment? .........................................................1327-3 Group Experiential Training ....................................................................................133

Contents

What Is a TIP?

Treatment Improvement Protocols (TIPs), developed by the Center forSubstance Abuse Treatment (CSAT), part of the Substance Abuse andMental Health Services Administration (SAMHSA) within the U.S.Department of Health and Human Services (DHHS), are best-practiceguidelines for the treatment of substance use disorders. CSAT draws onthe experience and knowledge of clinical, research, and administrativeexperts to produce the TIPs, which are distributed to a growing numberof facilities and individuals across the country. The audience for theTIPs is expanding beyond public and private treatment facilities as alco-hol and other drug disorders are increasingly recognized as a majorproblem.

CSATs Knowledge Application Program (KAP) Expert Panel, a distin-guished group of experts on substance use disorders and professionals insuch related fields as primary care, mental health, and social services,works with the State Alcohol and Drug Abuse Directors to generate top-ics for the TIPs. Topics are based on the fields current needs for infor-mation and guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agen-cies and national organizations to a Resource Panel that recommendsspecific areas of focus as well as resources that should be considered indeveloping the content for the TIP. Then recommendations are commu-nicated to a Consensus Panel composed of experts on the topic who havebeen nominated by their peers. This Panel participates in a series of dis-cussions; the information and recommendations on which they reachconsensus form the foundation of the TIP. The members of eachConsensus Panel represent substance abuse treatment programs, hospi-tals, community health centers, counseling programs, criminal justiceand child welfare agencies, and private practitioners. A Panel Chair (orCo-Chairs) ensures that the guidelines mirror the results of the groupscollaboration.

A large and diverse group of experts closely reviews the draft document.Once the changes recommended by these field reviewers have beenincorporated, the TIP is prepared for publication, in print and online.

vii

The TIPs can be accessed via the Internet atthe URL: www.kap.samhsa.gov. The move toelectronic media also means that the TIPs canbe updated more easily so that they continue toprovide the field with state-of-the-art informa-tion.

While each TIP strives to include an evidencebase for the practices it recommends, CSATrecognizes that the field of substance abusetreatment is evolving, and research frequentlylags behind the innovations pioneered in thefield. A major goal of each TIP is to conveyfront-line information quickly but responsi-bly. For this reason, recommendations prof-fered in the TIP are attributed to eitherPanelists clinical experience or the literature.If research supports a particular approach,citations are provided.

This TIP, Substance Abuse Treatment: GroupTherapy, presents an overview of the role andefficacy of group therapy in substance abusetreatment planning. The goal of this TIP is tooffer the latest research and clinical findingsand to distill them into practical guidelines forpractitioners of group therapy modalities in thefield of substance abuse treatment. The TIPdescribes effective types of group therapy andoffers a theoretical basis for group therapyseffectiveness in the treatment of substance usedisorders. This work also will be a useful guideto supervisors and trainers of beginning coun-selors, as well as to experienced counselors.Finally, the TIP is meant to provideresearchers and clinicians with a guide tosources of information and topics for furtherinquiry.

viii What Is a TIP?

ChairPhilip J. Flores, Ph.D., COP, FAGPAAdjunct Clinical SupervisorDepartment of PsychologyGeorgia State UniversityAtlanta, Georgia

Co-ChairJeffrey M. Georgi, M.Div., CGP, CSAC,

LPC, CCSClinical DirectorDepartment of Behavioral ScienceDuke School of Nursing and Duke University

Medical CenterSenior ClinicianDuke Addictions ProgramDuke University Medical CenterDurham, North Carolina

Workgroup LeadersDavid W. Brook, M.D., CGPDepartment of Community and Preventive

MedicineMount Sinai Medical CenterNew York, New York

Frederick Bruce Carruth, Ph.D., LCSWPrivate PracticeBoulder, Colorado

Sharon D. Chappelle, Ph.D., M.S.W., LCSWPresidentChief Executive Officer Chappelle Consulting and Training

Services, Inc.Middletown, Connecticut

David E. Cooper, Ph.D.Psychologist/PsychoanalystChestnut Lodge HospitalChevy Chase, Maryland

Charles Garvin, Ph.D.Professor of Social WorkSchool of Social WorkUniversity of MichiganAnn Arbor, Michigan

Panelists Marilyn Joan Freimuth, Ph.D.Psychologist/Faculty MemberThe Fielding InstituteBedford, New York

Barbara Hardin-Perez, Ph.D.DirectorStudent Health and Mental Health ServicesSt. Marys UniversitySan Antonio, Texas

Frankie D. Lemus, Jr., M.A.Clinical DirectorSageWind (Oikos, Inc.)Reno, Nevada

Marilynn Morrical, CCDN, NCACII(Deceased 2002)Alcohol, Tobacco, and Drug ConsultantMarilynn Morrical Consulting and

RehabilitationReno, Nevada

Tam K. Nguyen, M.D., LMSW, CCJS, DVC, MAC

President Employee & Family ResourcesPolk City, Iowa

Candace M. Shelton, M.S., CADACClinical DirectorNative American Connections, Inc.Tucson, Arizona

Darren C. Skinner, Ph.D., LSW, CACDirectorGaudenzia, Inc.Gaudenzia House West ChesterWest Chester, Pennsylvania

ix

Consensus Panel

Judith S. Tellerman, Ph.D., MAT, M.Ed.,CGPAssistant Clinical ProfessorCollege of MedicineUniversity of IllinoisChicago, Illinois

Marsha Lee Vannicelli, Ph.D., FAGPAAssociate Clinical ProfessorDepartment of PsychiatryHarvard Medical SchoolBelmont, Massachusetts

x Consensus Panel

Barry S. Brown, Ph.D.Adjunct ProfessorUniversity of North Carolina at WilmingtonCarolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC,CCDC III, CJSProfessor of Clinical PsychiatryCollege of MedicineUniversity of CincinnatiCincinnati, Ohio

Deion CashExecutive DirectorCommunity Treatment and Correction

Center, Inc.Canton, Ohio

Debra A. Claymore, M.Ed.Adm.Owner/Chief Executive OfficerWC Consulting, LLCLoveland, Colorado

Carlo C. DiClemente, Ph.D.ChairDepartment of PsychologyUniversity of Maryland Baltimore CountyBaltimore, Maryland

Catherine E. Dube, Ed.D.Independent ConsultantBrown UniversityProvidence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CACChief, ServicesDivision of Clinical and Services ResearchNational Institute on Drug AbuseBethesda, Maryland

Michael Galer, D.B.A., M.B.A., M.F.A.Independent ConsultantWestminster, Massachusetts

Renata J. Henry, M.Ed.DirectorDivision of Alcoholism, Drug Abuse,

and Mental HealthDelaware Department of Health and Social

ServicesNew Castle, Delaware

Joel Hochberg, M.A.PresidentAsher & PartnersLos Angeles, California

Jack Hollis, Ph.D.Associate DirectorCenter for Health ResearchKaiser PermanentePortland, Oregon

Mary Beth Johnson, M.S.W.DirectorAddiction Technology Transfer CenterUniversity of MissouriKansas CityKansas City, Missouri

Eduardo Lopez, B.S.Executive ProducerEVS CommunicationsWashington, DC

Holly A. Massett, Ph.D.Academy for Educational DevelopmentWashington, DC

Diane MillerChiefScientific Communications BranchNational Institute on Alcohol Abuse

and AlcoholismBethesda, Maryland

xi

KAP Expert Panel and FederalGovernment Participants

xii

Harry B. Montoya, M.A.President/Chief Executive OfficerHands Across CulturesEspanola, New Mexico

Richard K. Ries, M.D.Director/ProfessorOutpatient Mental Health ServicesDual Disorder ProgramsSeattle, Washington

Gloria M. Rodriguez, D.S.W.Research ScientistDivision of Addiction ServicesNJ Department of Health and Senior ServicesTrenton, New Jersey

Everett Rogers, Ph.D.Center for Communications ProgramsJohns Hopkins UniversityBaltimore, Maryland

Jean R. Slutsky, P.A., M.S.P.H.Senior Health Policy AnalystAgency for Healthcare Research & QualityRockville, Maryland

Nedra Klein Weinreich, M.S.PresidentWeinreich CommunicationsCanoga Park, California

Clarissa WittenbergDirectorOffice of Communications and Public LiaisonNational Institute of Mental HealthKensington, Maryland

Consulting Membersof the KAP Expert PanelPaul Purnell, M.A.Vice PresidentSocial Solutions, L.L.C.Potomac, Maryland

Scott Ratzan, M.D., M.P.A., M.A.Academy for Educational DevelopmentWashington, DC

Thomas W. Valente, Ph.D.Director, Master of Public Health ProgramDepartment of Preventive MedicineSchool of MedicineUniversity of Southern CaliforniaAlhambra, California

Patricia A. Wright, Ed.D.Independent ConsultantBaltimore, Maryland

KAP Expert Panel and Federal Government Participants

Foreword

The Treatment Improvement Protocol (TIP) series fulfills SAMHSAsmission of building resilience and facilitating recovery for people with orat risk for mental or substance use disorders by providing best-practicesguidance to clinicians, program administrators, and payors to improvethe quality and effectiveness of service delivery, and, thereby promoterecovery. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience,and implementation requirements. A panel of non-Federal clinicalresearchers, clinicians, program administrators, and client advocatesdebates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panels work is then reviewed andcritiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewersbring to this highly participatory process have helped to bridge the gapbetween the promise of research and the needs of practicing cliniciansand administrators to serve, in the most scientifically sound and effectiveways, people who abuse substances. We are grateful to all who havejoined with us to contribute to advances in the substance abuse treat-ment field.

Charles G. Curie, M.A., A.C.S.W.AdministratorSubstance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAMDirectorCenter for Substance Abuse TreatmentSubstance Abuse and Mental Health Services Administration

xiii

Executive Summary

With the recognition of addiction as a major health problem in thiscountry, demand has increased for effective treatments of substance use disorders. Because of its effectiveness and economy of scale, grouptherapy has gained popularity, and the group approach has come to beregarded as a source of powerful curative forces that are not alwaysexperienced by the client in individual therapy. One reason groups workso well is that they engage therapeutic forceslike affiliation, support,and peer confrontationand these properties enable clients to bondwith a culture of recovery. Another advantage of group modalities istheir effectiveness in treating problems that accompany addiction, suchas depression, isolation, and shame.

Groups can support individual members in times of pain and trouble,and they can help people grow in ways that are healthy and creative.Formal therapy groups can be a compelling source of persuasion, stabilization, and support. In the hands of a skilled, well-trained groupleader, the potential healing powers inherent in a group can be har-nessed and directed to foster healthy attachments, provide positive peerreinforcement, act as a forum for self-expression, and teach new socialskills. In short, group therapy can provide a wide range of therapeuticservices, comparable in efficacy to those delivered in individual therapy.

Group therapy and addiction treatment are natural allies. One reason isthat people who abuse substances are often more likely to stay sober andcommitted to abstinence when treatment is provided in groups, appar-ently because of rewarding and therapeutic benefits like affiliation, con-frontation, support, gratification, and identification. This capacity ofgroup therapy to bond patients to treatment is an important assetbecause the greater the amount, quality, and duration of treatment, thebetter the clients prognosis (Leshner 1997; Project MATCH ResearchGroup 1997).

The primary audience for this TIP is substance abuse treatment coun-selors; however, the TIP should be of interest to anyone who wants to learn more about group therapy. The intent of the TIP is to assist

xv

counselors in enhancing their therapeutic skillsin regard to leading groups.

The consensus panel for this TIP drew on itsconsiderable experience in the group therapyfield. The panel was composed of representa-tives from all of the disciplines involved ingroup therapy and substance abuse treatment,including alcohol and drug counselors, grouptherapists, mental health providers, and Stategovernment representatives.

This TIP comprises seven chapters. Chapter 1defines therapeutic groups as those withtrained leaders and a primary intent to helppeople recover from substance abuse. It alsoexplains why groups work so well for treatingsubstance abuse.

Chapter 2 describes the purpose, main charac-teristics, leadership, and techniques of fivegroup therapy models, three specialty groups,and groups that focus on solving a single problem.

Chapter 3 discusses the many considerationsthat should be weighed before placing a clientin a particular group, especially keying thegroup to the clients stage of change and stageof recovery. This chapter also concentrates onissues that arise from client diversity.

Chapter 4 compares fixed and revolving typesof therapy groups and recommends ways toprepare clients for participation: pregroupinterviews, retention measures, and mostimportant, group agreements that specifyclients expectations of each other, the leader,and the group. Chapter 4 also specifies thetasks that need to be accomplished in the early,middle, and late phases of group development.

Chapter 5 turns to the stages of treatment. Inthe early, middle, and late stages of treatment,clients conditions will differ, requiring differ-ent therapeutic strategies and approaches toleadership.

Chapter 6 is the how-to segment of this TIP. Itexplains the characteristics, duties, and con-cepts important to promote effective groupleadership in treating substance abuse, includ-

ing how confidentiality regulations for alcoholand drug treatment apply to group therapy.

Chapter 7 highlights training opportunitiesavailable to substance abuse treatment profes-sionals. The chapter also recommends thesupervisory group as an added measure thatimproves group leadership and gives counselorsin the group insights about how clients mayexperience groups.

Throughout this TIP, the term substanceabuse has been used to refer to both sub-stance abuse and substance dependence (asdefined by the Diagnostic and StatisticalManual of Mental Disorders, 4th edition, TextRevision [DSM-IV-TR] [American PsychiatricAssociation 2000]). This term was chosen part-ly because substance abuse treatment profes-sionals commonly use the term substanceabuse to describe any excessive use of addic-tive substances. In this TIP, the term refers tothe use of alcohol as well as other substances ofabuse. Readers should attend to the context inwhich the term occurs in order to determinewhat possible range of meanings it covers; inmost cases, however, the term will refer to allvarieties of substance use disorders describedby DSM-IV.

The sections that follow summarize the contentin this TIP and are grouped by chapter.

Groups and SubstanceAbuse TreatmentBecause human beings by nature are socialbeings, group therapy is a powerful therapeutictool that is effective in treating substanceabuse. The therapeutic groups described in thisTIP are those groups that have trained leadersand a specific intent to treat substance abuse.This definition excludes self-help groups likeAlcoholics Anonymous and NarcoticsAnonymous.

Group therapy has advantages over othermodalities. These include positive peer sup-port; a reduction in clients sense of isolation;real-life examples of people in recovery; help

xvi Executive Summary

from peers in coping with substance abuse andother life problems; information and feedbackfrom peers; a substitute family that may behealthier than a clients family of origin; socialskills training and practice; peer confrontation;a way to help many clients at one time; struc-ture and discipline often absent in the lives ofpeople abusing substances; and finally, thehope, support, and encouragement necessaryto break free from substance abuse.

Groups CommonlyUsed in SubstanceAbuse TreatmentFive group models are common in substanceabuse treatment:

Psychoeducational groups, which educateclients about substance abuse

Skills development groups, which cultivatethe skills needed to attain and sustain absti-nence, such as those needed to manage angeror cope with urges to use substances

Cognitivebehavioral groups, which alterthoughts and actions that lead to substanceabuse

Support groups, which buoy members andprovide a forum to share pragmatic informa-tion about maintaining abstinence and man-aging day-to-day, chemical-free life

Interpersonal process groups, which delveinto major developmental issues that con-tribute to addiction or interfere with recovery

Three other specialized types of groups that donot fit neatly into the five-model classificationnonetheless are common in substance abusetreatment. They are designed specifically toprevent relapse, to bring a specific cultureshealing practices to bear on substance abuse,or to use some form of art to express thoughtsthat otherwise would be difficult to communi-cate. Groups also can be formed to help clientswho share a specific problem, such as anger orshyness, that contributes to their substanceabuse.

Criteria for thePlacement of Clientsin GroupsNot everyone is suited to every kind of group.Moreover, because recovery is a long, nonlin-ear process, the type of therapy chosen alwaysshould be subject to re-evaluation.

Appropriate placement begins with a thoroughassessment of the clients needs, desires, andability to participate. Evaluators rely on formsand interviews to determine the clients level ofinterpersonal functioning, motivation toabstain, stability, stage of recovery, and expec-tation of success in the group.

Most clients can function in a group that is het-erogeneous, that is, members may be mixed inage, gender, culture, and so on. What is essen-tial, however, is that all clients in a groupshould have similar needs. Some clients, suchas those with a severe personality disorder, willneed to be placed in homogeneous groups, inwhich members are alike in some way otherthan their dependence problem. Such groupsmay include people of a particular ethnicity, allwomen, or a particular age group.

Some clients probably are not suitable for certain groups, or group therapy in general,including

People who refuse to participate People who cannot honor group agreements,

including preserving privacy and confiden-tiality of group members in accordance withthe Federal regulations (42 C.F.R., Part 2)

People who make the therapist very uncom-fortable

People who are prone to dropping out or whocontinually violate group norms

People in the throes of a life crisisPeople who cannot control impulsesPeople who experience severe internal

discomfort in groups

Professional judgment is also essential andshould consider characteristics such as sub-

xviiExecutive Summary

stances abused, duration of use, treatment setting, and the clients stage of recovery. Forexample, a client in a maintenance stage mayneed to acquire social skills for interacting innew ways, address emotional difficulties, orbecome reintegrated into a community or culture of origin.

Ethnicity and culture can have a profoundeffect on treatment. The greater the mix of ethnicities in a group, the more likely it is thatbiases will emerge and require mediation.Special attention may be warranted, too, ifclients do not speak English fluently becausethey may be unable to follow a fast-flowing discussion. Programs should ensure that groupmembers are fluent in the language for theirspecific demographic area, which may or maynot be English. Further, while it might be desir-able to match the group leader and all groupmembers ethnically, the reality is that it is sel-dom feasible. Thus, it is crucial for the groupleader to understand how ethnicity affects substance abuse and group participation.

Group Developmentand Phase-SpecificTasksGroup membership may be fixed, with a stableand relatively small number of clients.Alternatively, membership may revolve, withnew members entering a group when they areready for the service it provides. Either typecan run indefinitely or for a set time.

The preparation of clients for group participa-tion commences when the group leader meetsindividually with each prospective group mem-ber to begin to form a therapeutic alliance,reach consensus on what is to be accomplishedin therapy, educate the client about group ther-apy, allay anxiety related to joining a group,and explain the group agreement. In these pre-group interviews, it is important to be sensitiveto people who differ significantly from the restof the group whether by age, ethnicity, gender,disorder, and so on. It is important to assureclients that a difference is not a deficit and canbe a source of vitality for the group.

Selection of group members is based on theclients fit with a specific group modality.Considerations include the clients

Level of interpersonal functioning, includingimpulse control

Motivation to abstain from drug or alcoholabuse

StabilityStage of recoveryExpectation of success

Throughout the initial group therapy sessions,clients are particularly vulnerable to relapseand discontinuation of treatment. The firstmonth appears to be especially critical(Margolis and Zweben 1998). Retention rates in a group are enhanced by client preparation,maximum client involvement, feedback,prompts to encourage attendance, and the pro-vision of wraparound services (such as childcare and transportation). The timing and duration of groups also affect retention.

While group leaders have many responsibilitiesin preparing clients for participation in groups,clients have obligations, too. A group agree-ment establishes the expectations that groupmembers have of each other, the leader, andthe group itself. It specifies the circumstancesunder which clients may be barred from groupand explains policies regarding confidentiality,physical contact, substance use, contact outsidethe group, group participation, financialresponsibility, and termination. A group mem-bers acceptance of the contract prior to enter-ing a group has been described as the singlemost important factor contributing to the suc-cess of outpatient therapy groups.

The tasks in the beginning phase of a groupinclude introductions, review of the groupagreement, establishment of an emotionallysafe environment and positive group norms,and focusing the group toward its work. In themiddle phase, clients interact, rethink theirbehaviors, and move toward productivechange. The end phase concentrates on reach-ing closure.

xviii Executive Summary

Stages of TreatmentAs clients move through different stages ofrecovery, treatment must move with them. Thatis, therapeutic strategies and leadership roleswill change with the condition of the clients.

In the early phase of treatment clients tend tobe ambivalent about ending substance use,rigid in their thinking, and limited in their abil-ity to solve problems. Resistance is a challengefor the group leader at this time.

The art of treating addiction in the early phaseis in the defeat of denial and resistance. Groupsare especially effective at this time since peoplewith dependencies often have had adversarialrelationships with people in authority. Thus,information from peers in a group is more easily accepted than that from a lone therapist.

People with addictions remain vulnerable during the middle phase of treatment. Thoughcognitive capacity usually begins to return tonormal, the mind can still play tricks. Clientsmay remember distinctly the comfort of theirpast use of substances, yet forget just how badthe rest of their lives were. Consequently, thetemptation to relapse remains a concern.Because people with dependencies usually areisolated from healthy social groups, the grouphelps to acculturate clients into a culture ofrecovery. The leader draws attention to posi-tive developments, points out how far clientshave traveled, and affirms the possibility ofincreased connection and new sources of satisfaction.

In the late phase of treatment clients are stableenough to face situations that involve conflictor deep emotion. A process-oriented group maybecome appropriate for some clients who final-ly are able to confront painful realities, such asbeing an abused child or an abusive parent.Other clients may need groups to help thembuild a healthier marriage, communicate moreeffectively, or become a better parent. Somemay want to develop new job skills to increaseemployability.

Group Leadership,Concepts, andTechniquesEffective group leadership requires a constellation of specific personal qualities andprofessional practices. The personal qualitiesnecessary are constancy, active listening, firmidentity, confidence, spontaneity, integrity,trust, humor, and empathy.

Leaders should be able to

Adjust their professional styles to the particular needs of different groups

Model group-appropriate behaviorsResolve issues within ethical dimensionsManage emotional contagionWork only within modalities for which they

are trainedPrevent the development of rigid roles in the

groupAvoid acting in different roles inside and out-

side the groupMotivate clients in substance abuse treatmentEnsure emotional safety in the group Maintain a safe therapeutic setting (which

involves deflecting defensive behavior with-out shaming the offender, recognizing andcountering the resumption of substance use,and protecting physical boundaries accordingto group agreements)

Curtail emotion when it becomes too intensefor group members to tolerate

Stimulate communication among group members

Key concepts and techniques used in grouptherapy for substance abuse follow.

Interventions are any action by a leader tointentionally affect the processes of the group.Interventions may be used, for example, toclarify understanding, redirect energy, or stopa damaging sequence of interactions. Effectiveleaders do not overdo intervention. To do sowould result in a leader-centered group, which

xixExecutive Summary

is undesirable because in therapy groups, thehealing comes from the connections forgedbetween group members. One type of interven-tion, confrontation, deftly points out inconsis-tencies in clients thinking.

Confidentiality restricts the information thatproviders can reveal about clients and thatclients may reveal about each other. Groupleaders and clients should understand the exactprovisions of this important boundary.

Diversity plays a highly important role ingroup therapy, for it may affect critical aspectsof the process, such as what clients expect ofthe leader and how clients may interpret otherclients behavior. Clinicians should be open tolearning about other belief systems, should notassume that every person from a specific groupshares the same characteristics, and shouldavoid appearing as if they are trying to persuadeclients to renounce their cultural characteristics.

Many people in treatment for substance abusehave other complex problems, such as co-occurring mental disorders, homelessness, orinvolvement with the criminal justice system.For many clients, group therapy may be oneelement in a larger plan that also marshalsbiopsychosocial and spiritual interventions toaddress important life issues and restore faithor belief in some force beyond the self.

Integrated care from diverse sources requirescooperation with other healthcare providers.For example, it is critical that all providersworking with clients with multiple disordersknow what medications they are taking and why.

Two aspects of group management relate toconflict and subgroups. Properly managed,conflict can promote learning about respect fordifferent viewpoints, managing emotions, andnegotiation. Part of the therapists job as aconflict manager is to reveal covert conflictsand expose repetitive and predictable argu-ments. The therapist also reveals covert sub-groups and intervenes to reconfigure negativesubgroups that threaten the groups progress.

Various types of disruptive behavior mayrequire the group leaders attention. Suchproblems include clients who talk nonstop,interrupt, flee a session, arrive late or skip ses-sions, decline to participate, or speak only tothe problems of others. The leader also shouldhave skills to handle people with psychologicalemergencies or people who are anxious aboutdisclosing personal information.

Training andSupervisionNational professional organizations are a richsource of training. Through conferences orregional chapters, national associations providetrainingboth experiential and direct instruc-tiongeared to the needs of a wide range ofpersons, from graduate students to highly expe-rienced therapists. More training options areusually available in large urban areas. It islikely, however, that online training will makesome types of professional development accessi-ble to a greater number of counselors in remoteareas.

Clinical supervision as it pertains to grouptherapy often is best carried out within the con-text of group supervision. Group dynamics andgroup process facilitate learning by setting up amicrocosm of a larger social environment. Eachgroup members style of interaction willinevitably show up in the group transactions.As this process unfolds, group members, guid-ed by the supervisor, learn to model effectivebehavior in an accepting group context.

Supervisory groups reduce, rather than esca-late, the level of threat that can accompanysupervision. In place of isolation and alien-ation, group participation gives counselors asense of community. They find that othersshare their worries, fears, frustrations, tempta-tions, and ambivalence. This reassurance is ofparticular benefit to novice group counselors.

xx Executive Summary

11 Groups and SubstanceAbuse Treatment

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In ThisChapter

Introduction

DefiningTherapeuticGroups in

Substance AbuseTreatment

Advantages ofGroup Treatment

Modifying GroupTherapy To TreatSubstance Abuse

Approach of This TIP

OverviewThe natural propensity of human beings to congregate makes group therapy a powerful therapeutic tool for treating substance abuse, onethat is as helpful as individual therapy, and sometimes more successful.One reason for this efficacy is that groups intrinsically have manyrewarding benefitssuch as reducing isolation and enabling members to witness the recovery of othersand these qualities draw clients into a culture of recovery. Another reason groups work so well is that theyare suitable especially for treating problems that commonly accompanysubstance abuse, such as depression, isolation, and shame.

Although many groups can have therapeutic effects, this TIP concen-trates only on groups that have trained leaders and that are designed topromote recovery from substance abuse. Great emphasis is placed oninterpersonal process groups, which help clients resolve problems inrelating to other people, problems from which they have attempted toflee by means of addictive substances. While this TIP is not intended as a training manual for individuals training to be group therapists, itprovides substance abuse counselors with insights and information thatcan improve their ability to manage the groups they currently lead.

IntroductionThe lives of individuals are shaped, for better or worse, by their experi-ences in groups. People are born into groups. Throughout life, they joingroups. They will influence and be influenced by family, religious, social,and cultural groups that constantly shape behavior, self-image, and bothphysical and mental health.

Groups can support individual members in times of pain and trouble,and they can help people grow in ways that are healthy and creative.However, groups also can support deviant behavior or influence an individual to act in ways that are unhealthy or destructive.

Because our need for human contact is biologi-cally determined, we are, from the start, socialcreatures. This propensity to congregate is apowerful therapeutic tool. Formal therapygroups can be a compelling source of persua-sion, stabilization, and support. Groups orga-nized around therapeutic goals can enrichmembers with insight and guidance; and duringtimes of crisis, groups can comfort and guidepeople who otherwise might be unhappy orlost. In the hands of a skilled, well-trainedgroup leader, the potential curative forcesinherent in a group can be harnessed anddirected to foster healthy attachments, provide

positive peer rein-forcement, act as aforum for self-expression, andteach new socialskills. In short,group therapy canprovide a wide rangeof therapeutic ser-vices, comparable in efficacy to thosedelivered in individ-ual therapy. In somecases, group therapycan be more benefi-cial than individualtherapy (Scheidlinger2000; Toseland andSiporin 1986).

Group therapy and addiction treatment arenatural allies. One reason is that people whoabuse substances often are more likely toremain abstinent and committed to recoverywhen treatment is provided in groups, appar-ently because of rewarding and therapeuticforces such as affiliation, confrontation, sup-port, gratification, and identification. Thiscapacity of group therapy to bond patients totreatment is an important asset because thegreater the amount, quality, and duration oftreatment, the better the clients prognosis(Leshner 1997; Project MATCH ResearchGroup 1997).

The effectiveness of group therapy in the treat-ment of substance abuse also can be attributedto the nature of addiction and several factorsassociated with it, including (but not limited to)depression, anxiety, isolation, denial, shame,temporary cognitive impairment, and charac-ter pathology (personality disorder, structuraldeficits, or an uncohesive sense of self).Whether a person abuses substances or not,these problems often respond better to grouptreatment than to individual therapy (Kanas1982; Kanas and Barr 1983). Group therapy isalso effective because people are fundamentallyrelational creatures.

Defining TherapeuticGroups in SubstanceAbuse TreatmentAll groups can be therapeutic. Anytime some-one becomes emotionally attached to othergroup members, a group leader, or the groupas a whole, the relationship has the potential toinfluence and change that person. Identifying agroup as therapy does not imply that othergroups are not therapeutic. In preparing thisTIP, the consensus panel debated at lengthwhat constitutes group therapy and what distinguishes therapy groups from other typesof groups.

Although many types of groups can have thera-peutic elements and effects, the group typesincluded in this TIP are based on the goals andintentions of the groups, as well as the intendedaudience of the TIP (especially substance abusetreatment counselors and other substanceabuse treatment professionals). Thus, this TIPis limited to groups that (1) have trained lead-ers and (2) intend to produce some type ofhealing or recovery from substance abuse. ThisTIP describes (in chapter 2) five models ofgroup therapy currently used in substanceabuse treatment:

Psychoeducational groups, which teach aboutsubstance abuse.

2

Groups provide

positive peer

support and

pressure to abstain

from substances

of abuse.

Groups and Substance Abuse Treatment

Skills development groups, which hone theskills necessary to break free of addictions.

Cognitivebehavioral groups, which rear-range patterns of thinking and action thatlead to addiction.

Support groups, which comprise a forumwhere members can debunk each othersexcuses and support constructive change.

Interpersonal process group psychotherapy(referred to hereafter as interpersonal pro-cess groups or therapy groups), whichenable clients to recreate their pasts in thehere-and-now of group and rethink the rela-tional and other life problems that they havepreviously fled by means of addictive sub-stances.

Treatment providers routinely use the first fourmodels and various combinations of them. Thelast is not as widely used, chiefly because of theextensive training required to lead such groupsand the long duration of the groups, whichdemands a high degree of commitment fromboth providers and clients. All the same, manypeople enter substance abuse treatment with along history of failed relationships exacerbatedby substance use. In these cases, an extendedperiod of therapy is warranted to resolve theclients problems with relationships. The reali-ty that extended treatment is not always feasi-ble does not negate its desirability.

This TIP does not discuss multifamily and mul-ticouple groups, which are discussed in TIP 39,Substance Abuse Treatment and FamilyTherapy (Center for Substance AbuseTreatment 2004). Even though multifamily andmulticouple groups typically are made up ofunrelated groups of families, they focus onfamily relations as they affect and are affectedby a member with a substance use disorder.This TIP concentrates on therapy groups,which have a distinctively different focus.

Also outside the scope of this TIP is the use ofpeer-led self-help groups such as AlcoholicsAnonymous (AA) or group activities like socialevents, religious services, sports, and games.Any or all may have one or more therapeutic

effects, but are not specifically designed toachieve that purpose. Figure 1-1 (see p. 4)shows other differences between self-helpgroups and interpersonal process groups. Inmost aspects, the comparison would apply tothe other four group models as well.

Advantages of GroupTreatmentTreating adult clients in groups has manyadvantages, as well as some risks. Any treat-ment modalitygroup therapy, individualtherapy, family therapy, and medicationcanyield poor results if applied indiscriminately oradministered by an unskilled or improperlytrained therapist. The potential drawbacks ofgroup therapy, however, are no greater thanfor any other form of treatment.

Some of the numerous advantages to usinggroups in substance abuse treatment aredescribed below (Brown and Yalom 1977;Flores 1997; Garvin unpublished manuscript;Vannicelli 1992).

Groups provide positive peer support andpressure to abstain from substances of abuse.Unlike AA, and, to some degree, substanceabuse treatment program participation,group therapy, from the very beginning, elic-its a commitment by all the group members toattend and to recognize that failure to attend,to be on time, and to treat group time as spe-cial disappoints the group and reduces itseffectiveness. Therefore, both peer supportand pressure for abstinence are strong.

Groups reduce the sense of isolation thatmost people who have substance abuse disor-ders experience. At the same time, groupscan enable participants to identify with oth-ers who are struggling with the same issues.Although AA and treatment groups of alltypes provide these opportunities for sharing,for some people the more formal and deliber-ate nature of participation in process grouptherapy increases their feelings of securityand enhances their ability to share openly.

3Groups and Substance Abuse Treatment

4 Groups and Substance Abuse Treatment

Figure 1-1

Differences Between 12-Step Self-Help Groups and Interpersonal Process Groups

Self-Help Group Interpersonal Process GroupSize Unlimited (often large) Small (815 members)

Leadership

Peer leader or individual in recovery Leadership is earned over time Implicit hierarchical leadership

structure

Trained professional Appointed leader Formal hierarchical leadership

structureParticipation Voluntary Voluntary and involuntary

GroupGovernment Self-governing Leader governed

Content

Environmental factors, no examination of group interaction

Emphasis on similarities among members

Here-and-now focus

Examination of intragroup behaviorand extragroup factors

Emphasis on differences and similarities among members

Here-and-now focus plus historical focus

ScreeningInterview None Always

GroupProcesses

Universality, empathy, affective sharing,self-disclosure (public statement of problem), mutual affirmation, moralebuilding, catharsis, immediate positivefeedback, high degree of persuasiveness

Cohesion, mutual identification, education, catharsis, use of group pressure to encourage abstinence and retention of group membership, outside socialization (depending on the group contract or agreement)

GroupGoals

Positive goal setting, behaviorally oriented

Focus on the group as a whole and the similarities among members

Ambitious goals: immediate problemplus individual personality issues

Individual as well as group focus

LeaderActivity

Educator/role model, catalyst for learning

Less member-to-leader distance

Responsible for directing therapeutic group experience

More member-to-leader distance

Use ofPsycho-dynamicTechniques

No Yes

Confiden-tiality Anonymity preserved

Anonymity strongly emphasized andincludes everything that occurs in thegroup, not just the identity of groupmembers

Groups enable people who abuse substancesto witness the recovery of others. From thisinspiration, people who are addicted to substances gain hope that they, too, canmaintain abstinence. Furthermore, an inter-personal process group, which is of longduration, allows a magnified witnessing ofboth the changes related to recovery as wellas group members intra- and interpersonalchanges.

Groups help members learn to cope withtheir substance abuse and other problems byallowing them to see how others deal withsimilar problems. Groups can accentuate thisprocess and extend it to include changes inhow group members relate to bosses, par-ents, spouses, siblings, children, and peoplein general.

Groups can provide useful information toclients who are new to recovery. For exam-ple, clients can learn how to avoid certaintriggers for use, the importance of abstinenceas a priority, and how to self-identify as aperson recovering from substance abuse.Group experiences can help deepen theseinsights. For example, self-identifying as a

person recovering from substance abuse canbe a complex process that changes signifi-cantly during different stages of treatmentand recovery and often reveals the set oftraits that makes the system of a persons selfas altogether unique.

Groups provide feedback concerning the values and abilities of other group members.This information helps members improvetheir conceptions of self or modify faulty, distorted conceptions. In terms of processgroups in particular, as specific themesemerge in a clients group experience, repeti-tive feedback from multiple group membersand the therapist can chip away at thosefaulty or distorted conceptions in slightly different ways until they not only are correctable, but also the very process of correction and change is revealed throughthe examination of the group processes.

Groups offer family-like experiences. Groupscan provide the support and nurturance thatmay have been lacking in group membersfamilies of origin. The group also gives mem-bers the opportunity to practice healthy waysof interacting with their families.


Self-Help Group Interpersonal Process GroupSponsorshipProgram Yes (usually same sex) None

Determina-tion of Timein Group

Members may leave group at their ownchoosing

Members may avoid self-disclosure ordiscussion of any subject

Predetermined minimal term of groupmembership

Avoidance of discussion seen as possible resistance

Involvementin OtherTherapies

Yes Yeseclectic models Nopsychodynamic models

TimeFactors

Unlimited group participation possibleover years Often time-limited group experiences

Frequencyof Meetings

Active encouragement of daily participation

Meets less frequently (often once ortwice weekly)

Source: Adapted from Spitz 2001. Used with permission.

Groups encourage, coach, support, and reinforce as members undertake difficult oranxiety-provoking tasks.

Groups offer members the opportunity tolearn or relearn the social skills they need tocope with everyday life instead of resortingto substance abuse. Group members canlearn by observing others, being coached byothers, and practicing skills in a safe andsupportive environment.

Groups can effectively confront individualmembers about substance abuse and otherharmful behaviors. Such encounters are possible because groups speak with the com-bined authority of people who have sharedcommon experiences and common problems.Confrontation often plays a part of substanceabuse treatment groups because group members tend to deny their problems.Participating in the confrontation of onegroup member can help others recognize anddefeat their own denial.

Groups allow a single treatment professionalto help a number of clients at the same time.In addition, as a group develops, each groupmember eventually becomes acculturated togroup norms and can act as a quasi-therapisthimself, thereby ratifying and extending thetreatment influence of the group leader.

Groups can add needed structure and disci-pline to the lives of people with substance usedisorders, who often enter treatment withtheir lives in chaos. Therapy groups canestablish limitations and consequences, whichcan help members learn to clarify what istheir responsibility and what is not.

Groups instill hope, a sense that If he canmake it, so can I. Process groups canexpand this hope to dealing with the fullrange of what people encounter in life, overcome, or cope with.

Groups often support and provide encour-agement to one another outside the groupsetting. For interpersonal process groups,though, outside contacts may or may not bedisallowed, depending on the particulargroup contract or agreements.

Modifying GroupTherapy To TreatSubstance AbuseModifying group therapy to make it applicableto and effective with clients who abuse sub-stances requires three improvements. One isspecific training and education for therapists sothat they fully understand therapeutic groupwork and the special characteristics of clientswith substance use disorders. The importanceof understanding the curative process thatoccurs in groups cannot be underestimated.

Most substance abuse counselors have respond-ed by adapting skills used in individual therapy.Counselors have also sought direction, clinicaltraining, and practical suggestions. Despiteindividual efforts, however, group therapy oftenis conducted as individual therapy in a group.

Individual therapy is not equivalent to grouptherapy. Some principles that work well withindividuals are inappropriate for group therapy.Using the wrong approach may lead to severalundesirable results. First, the rich potential ofgroupsself-understanding, psychologicalgrowth, emotional healing, and true intimacy will be left unfulfilled. Second, group leaderswho are unfamiliar with and insensitive toissues that manifest themselves in group thera-py may find themselves in a difficult situation.Third, therapists who think they are doinggroup therapy when they actually are not mayobserve the poor results and conclude thatgroup therapy is ineffective. Compounding allthese difficulties is the fact that group therapyis so ubiquitous. Thus, poorly conceivedapproaches are being used frequently.

Group therapy also is not equivalent to 12-Stepprogram practices. Many therapists who lackfull qualifications for group work have adaptedpractices from AA and other 12-Step programsfor use in therapeutic groups. To say that thisborrowing is inadvisable is not to say that theprinciples of AA are inadequate. On the con-trary, many people seem to be unable to recov-er from dependency without AA or a program


similar to it. For this reason, most effectivetreatment programs make attendance at AA oranother 12-Step program a mandatory part ofthe treatment process. By the same token, AAand other 12-Step programs are not grouptherapy. Rather, they are complementary com-ponents to the recovery process. Twelve-Stepprograms can help keep the individual whoabuses substances abstinent while group thera-py provides opportunities for these individualsto understand and explore the emotional andinterpersonal conflicts that can contribute tosubstance abuse.

Progress toward optimal group therapy hasalso been hindered by the misconception thatgroup therapy with clients who have addictionsdoes not require specially qualified leaders.This notion is false. Therapy groups cannotjust take care of themselves. Group therapy,properly conducted, is difficult. One reasonthat it is challenging has to do with the natureof the clients; an addicted population posesunique problems for the group therapy leader.A second reason is the complexity of grouptherapy; the leader requires a vast amount ofspecialized knowledge and skills, including aclear understanding of group process and thestages of development of group dynamics. Suchmastery only comes with extended training andexperience leading groups.

Many groups led by untrained or poorlytrained leaders have not fulfilled their potentialand may even have had negative effects on aclients recovery. It matters little whether theinadequately trained group therapist is a per-son who once abused substances or someonewho developed knowledge in a traditionalcourse of academically based training. Whereproblems exist, they usually relate to one of twodeficiencies: a lack of effective group therapytraining or use of a group therapy model that isinadequate for clients who are chemicallydependent. Additional training and educationis needed to produce therapists who are wellqualified to lead therapy groups composed pri-marily of individuals who are chemicallydependent.

A second major improvement needed if peoplewho have addictions are to benefit from grouptherapy is a clear answer to the question,Why is group therapy so effective for peoplewith addictions? We already have part of theanswer, and it lies in the individual with addic-tion, a person whose character style ofteninvolves a defensive posture commonly referredto as denial. Addiction is, in fact, frequentlyreferred to as a disease of denial.

The individual who ischemically dependentusually comes intotreatment with anuncommonly complexset of defenses andcharacter pathology.Any group leader whointends to help peoplewho have addictionsbenefit from treat-ment should have aclear understandingof each group mem-bers defensive pro-cess and characterdynamics. More than20 years ago, John Wallace (1978) wrote aboutthis important issue in an informative essay onthe defensive style of the individual who isaddicted to alcohol. He referred to these char-acter-related defensive features as the pre-ferred defense system of the individual addict-ed to alcohol.

A third major modification needed is the adap-tation of the group therapy model to the treat-ment of substance abuse. The principles ofgroup therapy need to be tailored to meet therealities of treating clients with substance usedisorders.

For the most part, group therapy has beenbased on a model derived from outpatient ther-apy for clients whose problems may or may notinclude substance abuse. The theoreticalunderpinnings and practical applications ofgeneral group therapy are not always applica-ble to individuals who abuse substances.


Groups instill

hope, a sense that

If he can make it,

so can I.

Substance abuse treatment sometimes is imple-mented as a grab bag of strategies, approaches,and techniques that were not tailored for peo-ple with substance use disorders. Further, thecommon characteristics and typical dynamicsseen in this population have not always beenevaluated adequately, and this lapse has inhib-ited the development of effective methods oftreatment for these clients.

This model suitability problem is further com-plicated by the fact that clients with substanceuse disorders, and even staff members, oftenbecome confused about the different types ofgroup treatment modalities. For instance, inthe course of their treatment, clients mayengage in AA, Narcotics Anonymous, other 12-Step groups, discussion groups, educationalgroups, continuing care groups, and supportgroups. Given this mix, clients often become

confused about thepurpose of grouptherapy, and thetreatment staff some-times underestimatesthe impact thatgroup therapy canmake on an individ-uals recovery.

The upshot of theseproblems has beenpartial or completefailure; that is, thetechniques andstrategies that usual-ly work with the gen-eral psychiatric pop-ulation often do notwork with peopleabusing substances.

A further negative result is that the clients whohave addictions may be unfairly viewed as poortreatment riskspeople resistant to treatmentand unmotivated to change.

Time also is an important factor in a personsrecovery. What a group leader does in grouptherapy with clients in an inpatient setting in ahospital during the first few days or weeks ofrecovery will differ dramatically from whatthat same group therapist will do with the samerecovering person in a continuing care group 6months into abstinence with the expectationthat the person will remain in the group at leastanother 6 to 12 months.

Approach of This TIPWhile this TIP does not provide the trainingneeded to become an interpersonal processgroup therapist, the point of view, attitudes,and considerations of these group therapistsinfuse the discussions throughout this TIP. Thepanel hopes that this TIP will help counselorsexpand their awareness and comprehension of dynamics that might be going on in their current substance abuse treatment groups.These insights will help counselors become bet-ter prepared to manage their groups and theirindividual members, inform group membersindividual therapists of possible issues thatneed resolution, record dynamics and issuesfor use in treatment during later stages ofrecovery, and improve retention by appropri-ately acknowledging issues that are outside thescope of the group. The TIP will achieve itspurpose to the extent that it assists counselorsas they juggle immediate client needs, interac-tions in groups, tasks leading to recovery, andsheer human complexity.


This TIP will help

counselors expand

their awareness

and comprehen-

sion of dynamics

occurring in their

treatment groups.

92 Types of GroupsCommonly Used inSubstance AbuseTreatment

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OverviewThis chapter presents five models of groups used in substance abusetreatment, followed by three representative types of groups that do notfit neatly into categories, but that, nonetheless, have special significancein substance abuse treatment. Finally, groups that vary according to specific types of problems are considered. The purpose of the group, its principal characteristics, necessary leadership skills and styles, andtypical techniques for these groups are described.

IntroductionSubstance abuse treatment professionals employ a variety of grouptreatment models to meet client needs during the multiphase process ofrecovery. A combination of group goals and methodology is the primaryway to define the types of groups used. This TIP describes five grouptherapy models that are effective for substance abuse treatment:

Psychoeducational groups Skills development groups Cognitivebehavioral/problemsolving groups Support groups Interpersonal process groups

Each of the models has something unique to offer to certain populations;and in the hands of a skilled leader, each can provide powerful thera-peutic experiences for group members. A model, however, has to bematched with the needs of the particular population being treated; thegoals of a particular groups treatment also are an important determi-nant of the model that is chosen.

This chapter describes the groups purpose, principal characteristics,leadership requisites, and appropriate techniques for each type ofgroup. Also discussed are three specialized types of groups that do not fit

In ThisChapterFive Group ModelsPsychoeducational Groups

Skills Development Groups

CognitiveBehavioralGroups

Support Groups

Interpersonal ProcessGroup Psychotherapy

Specialized Groupsin Substance Abuse

TreatmentRelapse Prevention

Communal andCulturally Specific Groups

Expressive Groups

Groups Focused onSpecific Problems

into the five model categories, but that functionas unique entities in the substance abuse treat-ment field:

Relapse prevention treatment groupsCommunal and culturally specific treatment

groups Expressive groups (including art therapy,

dance, psychodrama)

Figure 2-1 lists some groups commonly used insubstance abuse treatment and classifies theminto the five-model framework used in this TIP.This list of groups is by no means exhaustive,but it demonstrates the variety of groups foundin substance abuse treatment settings.

Occasionally, discussions in this TIP refer tothe stages of change delineated by Prochaskaand DiClemente (1984). They examined 18 psy-chological and behavioral theories of howchange occurs, including the components of abiopsychosocial framework for understandingsubstance abuse. Their result was a continuumof six categories for understanding client moti-vation for changing substance abuse behavior.The six stages are:

Precontemplation. Clients are not thinkingabout changing substance abuse behaviorand may not consider their substance abuseto be a problem.

Contemplation. Clients still use substances,but they begin to think about cutting back orquitting substance use.

Preparation. Clients still use substances, butintend to stop since they have recognized theadvantages of quitting and the undesirableconsequences of continued use. Planning forchange begins.

Action. Clients choose a strategy for discon-tinuing substance use and begin to make thechanges needed to carry out their plan. Thisperiod generally lasts 36 months.

Maintenance. Clients work to sustain abstinence and evade relapse. From thisstage, some clients may exit substance usepermanently.

Recurrence. Many clients will relapse andreturn to an earlier stage, but they may movequickly through the stages of change and mayhave gained new insights into problems thatdefeated their former attempts to quit sub-stance abuse (such as unrealistic goals or frequenting places that trigger relapse).

For a detailed description of the stages ofchange, see TIP 35, Enhancing Motivation forChange in Substance Abuse Treatment (Centerfor Substance Abuse Treatment [CSAT] 1999b).

The clients stage of change will dictate whichgroup models and methods are appropriate ata particular time. If the group is composed ofmembers in the action stage who have clearlyidentified themselves as substance dependent,the group will be conducted far differentlyfrom one composed of people who are in theprecontemplative stage. Priorities change withtime and experience, too. For example, a groupof people with substance use disorders on theirsecond day of abstinence is very different froma group with 1 or 2 years of sobriety.

Theoretical orientations also have a strongimpact on the tasks the group is trying toaccomplish, what the group leader observesand responds to in a group, and the types ofinterventions that the group leader will initiate.Before a group model is applied in treatment,the group leader and the treating institutionshould decide on the theoretical frameworks tobe used, because each group model requiresdifferent actions on the part of the group lead-er. Since most treatment programs offer a vari-ety of groups for substance abuse treatment, itis important that these models be consistentwith clearly defined theoretical approaches.

In practice, however, groups can, and usuallydo, use more than one model, as shown inFigure 2-1. For example, a therapy group in anintensive early recovery treatment setting mightcombine elements of psychoeducation (to showhow drugs have ravaged the individuals life),skills development (to help the client maintainabstinence), and support (to teach individualshow to relate to other group members in anhonest and open fashion). Therefore, the

10 Types of Groups Commonly Used in Substance Abuse Treatment

11

Group Types

Figure 2-1

Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models

Group Model or Combination of Models

Source: Consensus Panel. *See Specialized Groups in Substance Abuse Treatment on p. 29.

SkillsDevelop-

ment

CognitiveBehavioralTherapy

Inter-personalProcess

Support SpecializedGroup*

Psycho-educa-tional

Anger/feelings management Co-occurring disorders Skills-building Conflict resolution Relapse prevention 12-Step psychoeducational Psychoeducational Trauma (abuse, violence) Early recovery Substance abuse education Spirituality-based Cultural Psychodynamic Ceremonial healing practices Support Family roles (psychoeducational) Expressive therapy Relaxation training Meditation Multiple-family Gender specific Life skills training Health and wellness Cognitivebehavioral Psychodrama Adventure-based Marathon Humanistic/existential

Types of Groups Commonly Used in Substance Abuse Treatment

descriptions of the groups in this chapter are ofideal, pure forms that rarely stand alone inpractice. It must be acknowledged, too, thatthe terms used to describe groups are not alto-gether clear-cut and consistent. In differenttreatment settings, programs, and regions ofthe country, a term like support group maybe used to refer to different types of treatmentgroups, including a relapse prevention group.

Despite such discrepancies between neat theoryand untidy practice, little difficulty will arise ifthe group leader exercises sound clinical judg-ment regarding models and interventions to beused. One exception to this assurance, however,should be noted. Close adherence to the theorythat dictates the way an interpersonal processgroup should be conducted has crucial implica-tions for its success.

Five Group ModelsFigure 2-2 summarizes the characteristics offive therapeutic group models used in sub-stance abuse treatment. Variable factorsinclude the focus of group attention, specificityof the group agenda, heterogeneity or homo-geneity of group members, open-ended ordeterminate duration of treatment, level offacilitator or leader activity, training requiredfor the group leader, length of sessions, andpreferred arrangement of the room.

Psychoeducational GroupsPsychoeducational groups are designed to edu-cate clients about substance abuse, and relatedbehaviors and consequences. This type of grouppresents structured, group-specific content,often taught using videotapes, audiocassette, orlectures. Frequently, an experienced groupleader will facilitate discussions of the material(Galanter et al. 1998). Psychoeducationalgroups provide information designed to have adirect application to clients livesto instillself-awareness, suggest options for growth andchange, identify community resources that canassist clients in recovery, develop an under-standing of the process of recovery, and

prompt people using substances to take actionon their own behalf, such as entering a treat-ment program. While psychoeducationalgroups may inform clients about psychologicalissues, they do not aim at intrapsychic change,though such individual changes in thinking andfeeling often do occur.

Purpose. The major purpose of psychoeduca-tional groups is expansion of awareness aboutthe behavioral, medical, and psychological con-sequences of substance abuse. Another primegoal is to motivate the client to enter the recov-ery-ready stage (Martin et al. 1996; Pfeiffer etal. 1991). Psychoeducational groups are pro-vided to help clients incorporate informationthat will help them establish and maintainabstinence and guide them to more productivechoices in their lives.

These groups also can be used to counteractclients denial about their substance abuse,increase their sense of commitment to contin-ued treatment, effect changes in maladaptivebehaviors (such as associating with people whoactively use drugs), and supporting behaviorsconducive to recovery. Additionally, they areuseful in helping families understand substanceabuse, its treatment, and resources availablefor the recovery process of family members.

Some of the contexts in which psychoeducation-al groups may be most useful are

Helping clients in the precontemplative orcontemplative level of change to reframe theimpact of drug use on their lives, develop aninternal need to seek help, and discoveravenues for change.

Helping clients in early recovery learn moreabout their disorders, recognize roadblocksto recovery, and deepen understanding of thepath they will follow toward recovery.

Helping families understand the behavior of a person with substance use disorder in away that allows them to support the individu-al in recovery and learn about their ownneeds for change.

Helping clients learn about other resourcesthat can be helpful in recovery, such as


meditation, relaxation training, anger management, spiritual development, andnutrition.

Principal characteristics. Psychoeducationalgroups generally teach clients that they need tolearn to identify, avoid, and eventually masterthe specific internal states and external circum-stances associated with substance abuse. The

coping skills (such as anger management or theuse of I statements) normally taught in askills development group often accompany thislearning.

Psychoeducational groups are considered a useful and necessary, but not sufficient, com-ponent of most treatment programs. Forinstance, psychoeducation might move clients

13Types of Groups Commonly Used in Substance Abuse Treatment

Figure 2-2

Characteristics of Five Group Models Used in Substance Abuse Treatment

Group model Group/leader focusSpecificity of the

group agendaHeterogeneous

or homogeneousOpen-ended/determinate

Level of facili-tator activity

Psycho-educational

Leader focused

Specific Either Either High

Skills development

Leaderfocused

Specific Either Either(dependingon topic)

High

Cognitivebehavioral

Mixed/balanced

Either Either Either High

Support Group focus Nonspecific Either Open Low to moderate

Interpersonalprocess

Group focus Nonspecific Heterogeneous Open Low to moderate

Group model

Level of facili-tator activity

Duration oftreatment

Length of session

Space andarrangement

Leader training

Psycho-educational

High Limited by program requirements

15 to 90 minutes

Horseshoe or circle

Basic

Skills development

High Variable 45 to 90 minutes

Horseshoe or circle

Basic withsome special-ized training

Cognitivebehavioral

High Variable andopen-ended

60 to 90 minutes

Circle Specializedtraining

Support Low to moderate

Open-ended 45 to 90 minutes

Circle Specializedtraining with process-oriented skills

InterpersonalProcess

Low to moderate

Open-ended 1 to 2 hours Circle Specializedtraining ininterpersonalprocess groups

in a precontemplative or perhaps contempla-tive stage to commit to treatment, includingother forms of group therapy. For clients whoenter treatment through a psychoeducationalgroup, programs should have clear guidelinesabout when members of the group are readyfor other types of group treatment.

Often, a psychoedu-cational group inte-grates skills devel-opment into its pro-gram. As part of alarger program,psychoeducationalgroups have beenused to help clientsreflect on their ownbehavior, learn newways to confrontproblems, andincrease their self-esteem (La Salvia1993).

Psychoeducationalgroups should workactively to engage

participants in the group discussion andprompt them to relate what they are learning totheir own substance abuse. To ignore groupprocess issues will reduce the effectiveness ofthe psychoeducational component.

Psychoeducational groups are highly struc-tured and often follow a manual or a pre-planned curriculum. Group sessions generallyare limited to set times, but need not be strictlylimited. The instructor usually takes a veryactive role when leading the discussion. Eventhough psychoeducational groups have a for-mat different from that of many of the othertypes of groups, they nevertheless should meetin a quiet and private place and take intoaccount the same structural issues (forinstance, seating arrangements) that matter inother groups.

As with any type of group, accommodationsmay need to be made for certain populations.Clients with cognitive disabilities, for example,

may need special considerations. Psycho-educational groups also have been shown to beeffective with clients with co-occurring mentaldisorders, including clients with schizophrenia(Addington and el-Guebaly 1998; Levy 1997;Pollack and Stuebben 1998). For more infor-mation on making accommodations for clientswith disabilities, see TIP 29, Substance UseDisorder Treatment for People With Physicaland Cognitive Disabilities (CSAT 1998b).

Leadership skills and styles. Leaders in psy-choeducational groups primarily assume theroles of educator and facilitator. Still, theyneed to have the same core characteristics asother group therapy leaders: caring, warmth,genuineness, and positive regard for others.

Leaders also should possess knowledge andskills in three primary areas. First, they shouldunderstand basic group processhow peopleinteract within a group. Subsets of this knowl-edge include how groups form and develop,how group dynamics influence an individualsbehavior in group, and how a leader affectsgroup functioning. Second, leaders shouldunderstand interpersonal relationship dynam-ics, including how people relate to one anotherin group settings, how one individual can influ-ence the behavior of others in group and somebasic understanding of how to handle problem-atic behaviors in group (such as being with-drawn). Finally, psychoeducational group lead-ers need to have basic teaching skills. Suchskills include organizing the content to betaught, planning for participant involvement inthe learning process, and delivering informationin a culturally relevant and meaningful way.

To help clients get the most out of psychoeduca-tional sessions, leaders need basic counselingskills (such as active listening, clarifying, sup-porting, reflecting, attending) and a fewadvanced ones (such as confronting and termi-nating) (Brown 1998). It also helps to haveleadership skills, such as helping the group get started in a session, managing (though notnecessarily eliminating) conflict between groupmembers, encouraging withdrawn group mem-bers to be more active, and making sure that


Psychoeducational

groups are highly

structured and

often follow a

manual or a

preplanned

curriculum.

all group members have a chance to participate.As the group unfolds, it is important that groupleaders are nondogmatic in their dealings withgroup members. Finally, the group leadershould have a firm grasp of material beingcommunicated in the psychoeducational group.

During a session, the group leader should bemindful both of the groups need and the spe-cific needs of each member. The group leaderwill need to understand group member rolesand how to manage problem clients. Except inunusual circumstances, efforts should be madeto increase members comfort and to reduceanxiety in the group. Leaders will use a varietyof resources to impart knowledge to the group,so each session also requires preparation andfamiliarization with the content to be delivered.

Group leaders should have ongoing trainingand formal supervision. Supervision benefitsall group leaders of all levels of skill and train-ing, as it helps to assure them that people inpositions of authority are interested in theirdevelopment and in their work. If direct super-vision is not possible (as may be the case inremote, rural ar

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