What follows is the executive summary of the guideline; for more detailed information on the recommendations, please see the original guideline document.
Groups and Substance Abuse Treatment
Because human beings by nature are social beings, group therapy is a powerful therapeutic tool that is effective in treating substance abuse. The therapeutic groups described in this Treatment Improvement Protocol (TIP) are those groups that have trained leaders and a specific intent to treat substance abuse. This definition excludes self-help groups like Alcoholics Anonymous and Narcotics Anonymous.
Group therapy has advantages over other modalities. These include positive peer support; a reduction in clients' sense of isolation; real-life examples of people in recovery; help from peers in coping with substance abuse and other life problems; information and feedback from peers; a substitute family that may be healthier than a client's family of origin; social skills training and practice; peer confrontation; a way to help many clients at one time; structure and discipline often absent in the lives of people abusing substances; and finally, the hope, support, and encouragement necessary to break free from substance abuse.
Groups Commonly Used in Substance Abuse Treatment
Five group models are common in substance abuse treatment:
- Psychoeducational groups, which educate clients about substance abuse
- Skills development groups, which cultivate the skills needed to attain and sustain abstinence, such as those needed to manage anger or cope with urges to use substances
- Cognitive-behavioral groups, which alter thoughts and actions that lead to substance abuse
- Support groups, which buoy members and provide a forum to share pragmatic information about maintaining abstinence and managing day-to-day, chemical-free life
- Interpersonal process groups, which delve into major developmental issues that contribute to addiction or interfere with recovery
Three other specialized types of groups that do not fit neatly into the five-model classification nonetheless are common in substance abuse treatment. They are designed specifically to prevent relapse, to bring a specific culture's healing practices to bear on substance abuse, or to use some form of art to express thoughts that otherwise would be difficult to communicate. Groups also can be formed to help clients who share a specific problem, such as anger or shyness, that contributes to their substance abuse.
Criteria for the Placement of Clients in Groups
Not everyone is suited to every kind of group. Moreover, because recovery is a long, nonlinear process, the type of therapy chosen always should be subject to re-evaluation.
Appropriate placement begins with a thorough assessment of the client's needs, desires, and ability to participate. Evaluators rely on forms and interviews to determine the client's level of interpersonal functioning, motivation to abstain, stability, stage of recovery, and expectation of success in the group.
Most clients can function in a group that is heterogeneous, that is, members may be mixed in age, gender, culture, and so on. What is essential, however, is that all clients in a group should have similar needs. Some clients, such as those with a severe personality disorder, will need to be placed in homogeneous groups, in which members are alike in some way other than their dependence problem. Such groups may include people of a particular ethnicity, all women, 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 confidentiality of group members in accordance with the federal regulations
- People who make the therapist very uncomfortable
- People who are prone to dropping out or who continually violate group norms
- People in the throes of a life crisis
- People who cannot control impulses
- People who experience severe internal discomfort in groups
Professional judgment is also essential and should consider characteristics such as substances abused, duration of use, treatment setting, and the client's stage of recovery. For example, a client in a maintenance stage may need to acquire social skills for interacting in new ways, address emotional difficulties, or become reintegrated into a community or culture of origin.
Ethnicity and culture can have a profound effect on treatment. The greater the mix of ethnicities in a group, the more likely it is that biases will emerge and require mediation. Special attention may be warranted, too, if clients do not speak English fluently because they may be unable to follow a fast-flowing discussion. Programs should ensure that group members are fluent in the language for their specific demographic area, which may or may not be English. Further, while it might be desirable to match the group leader and all group members ethnically, the reality is that it is seldom feasible. Thus, it is crucial for the group leader to understand how ethnicity affects substance abuse and group participation.
Group Development and Phase-Specific Tasks
Group membership may be fixed, with a stable and relatively small number of clients. Alternatively, membership may revolve, with new members entering a group when they are ready for the service it provides. Either type can run indefinitely or for a set time.
The preparation of clients for group participation commences when the group leader meets individually with each prospective group member to begin to form a therapeutic alliance, reach consensus on what is to be accomplished in therapy, educate the client about group therapy, allay anxiety related to joining a group, and explain the group agreement. In these pregroup interviews, it is important to be sensitive to people who differ significantly from the rest of the group whether by age, ethnicity, gender, disorder, and so on. It is important to assure clients that a difference is not a deficit and can be a source of vitality for the group.
Selection of group members is based on the client's fit with a specific group modality. Considerations include the client's
- Level of interpersonal functioning, including impulse control
- Motivation to abstain from drug or alcohol abuse
- Stability
- Stage of recovery
- Expectation of success
Throughout the initial group therapy sessions, clients are particularly vulnerable to relapse and discontinuation of treatment. The first month appears to be especially critical. Retention rates in a group are enhanced by client preparation, maximum client involvement, feedback, prompts to encourage attendance, and the provision of wraparound services (such as child care and transportation). The timing and duration of groups also affect retention.
While group leaders have many responsibilities in preparing clients for participation in groups, clients have obligations, too. A group agreement establishes the expectations that group members have of each other, the leader, and the group itself. It specifies the circumstances under which clients may be barred from group and explains policies regarding confidentiality, physical contact, substance use, contact outside the group, group participation, financial responsibility, and termination. A group member's acceptance of the contract prior to entering a group has been described as the single most important factor contributing to the success of outpatient therapy groups.
The tasks in the beginning phase of a group include introductions, review of the group agreement, establishment of an emotionally safe environment and positive group norms, and focusing the group toward its work. In the middle phase, clients interact, rethink their behaviors, and move toward productive change. The end phase concentrates on reaching closure.
Stages of Treatment
As clients move through different stages of recovery, treatment must move with them. That is, therapeutic strategies and leadership roles will change with the condition of the clients.
In the early phase of treatment clients tend to be ambivalent about ending substance use, rigid in their thinking, and limited in their ability to solve problems. Resistance is a challenge for the group leader at this time.
The art of treating addiction in the early phase is in the defeat of denial and resistance. Groups are especially effective at this time since people with dependencies often have had adversarial relationships 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. Though cognitive capacity usually begins to return to normal, the mind can still play tricks. Clients may remember distinctly the comfort of their past use of substances, yet forget just how bad the rest of their lives were. Consequently, the temptation to relapse remains a concern. Because people with dependencies usually are isolated from healthy social groups, the group helps to acculturate clients into a culture of recovery. The leader draws attention to positive developments, points out how far clients have traveled, and affirms the possibility of increased connection and new sources of satisfaction.
In the late phase of treatment clients are stable enough to face situations that involve conflict or deep emotion. A process-oriented group may become appropriate for some clients who finally are able to confront painful realities, such as being an abused child or an abusive parent. Other clients may need groups to help them build a healthier marriage, communicate more effectively, or become a better parent. Some may want to develop new job skills to increase employability.
Group Leadership, Concepts, and Techniques
Effective group leadership requires a constellation of specific personal qualities and professional practices. The personal qualities necessary are constancy, active listening, firm identity, 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 behaviors
- Resolve issues within ethical dimensions
- Manage emotional contagion
- Work only within modalities for which they are trained
- Prevent the development of rigid roles in the group
- Avoid acting in different roles inside and outside the group
- Motivate clients in substance abuse treatment
- Ensure emotional safety in the group
- Maintain a safe therapeutic setting (which involves deflecting defensive behavior without shaming the offender, recognizing and countering the resumption of substance use, and protecting physical boundaries according to group agreements)
- Curtail emotion when it becomes too intense for group members to tolerate
- Stimulate communication among group members
Key concepts and techniques used in group therapy for substance abuse follow.
Interventions are any action by a leader to intentionally affect the processes of the group. Interventions may be used, for example, to clarify understanding, redirect energy, or stop a damaging sequence of interactions. Effective leaders do not overdo intervention. To do so would result in a leader-centered group, which is undesirable, because in therapy groups the healing comes from the connections forged between group members. One type of intervention, confrontation, deftly points out inconsistencies in clients' thinking.
Confidentiality restricts the information that providers can reveal about clients and that clients may reveal about each other. Group leaders and clients should understand the exact provisions of this important boundary.
Diversity plays a highly important role in group therapy, for it may affect critical aspects of the process, such as what clients expect of the leader and how clients may interpret other clients' behavior. Clinicians should be open to learning about other belief systems, should not assume that every person from a specific group shares the same characteristics, and should avoid appearing as if they are trying to persuade clients to renounce their cultural characteristics.
Many people in treatment for substance abuse have other complex problems, such as co-occurring mental disorders, homelessness, or involvement with the criminal justice system. For many clients, group therapy may be one element in a larger plan that also marshals biopsychosocial and spiritual interventions to address important life issues and restore faith or belief in some force beyond the self.
Integrated care from diverse sources requires cooperation with other health care providers. For example, it is critical that all providers working with clients with multiple disorders know what medications they are taking and why.
Two aspects of group management relate to conflict and subgroups. Properly managed, conflict can promote learning about respect for different viewpoints, managing emotions, and negotiation. Part of the therapist's job as a conflict manager is to reveal covert conflicts and expose repetitive and predictable arguments. The therapist also reveals covert subgroups and intervenes to reconfigure negative subgroups that threaten the group's progress.
Various types of disruptive behavior may require the group leader's attention. Such problems include clients who talk nonstop, interrupt, flee a session, arrive late or skip sessions, decline to participate, or speak only to the problems of others. The leader also should have skills to handle people with psychological emergencies or people who are anxious about disclosing personal information.
Refer to the "Descriptions of Implementation Strategy" field in this summary for information on Training and Supervision.
