Chapter 29. Group Therapy

 

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Chapter 29. Group Therapy

GROUP THERAPY: INTRODUCTION

Group therapy has become the most widely used psychosocial treatment for substance abuse and

addiction, and for most patients it remains the treatment of choice. Group therapy has been found

to be clinically effective and cost-effective for both the prevention and treatment of substance

abuse. The use of group therapy can address some of the relevant psychosocial issues leading to

substance abuse, many of the symptoms and difficulties resulting from substance abuse and

dependence, and the treatment of co-occurring psychiatric disorders. The etiology of substance

abuse is most likely multifactorial, including genetic, developmental, familial, physiological,

intrapsychic, interpersonal, sociocultural, and environmental factors and interpersonal attachment

issues. Therefore, the treatment of substance abuse and dependence must also be

multidisciplinary, using a biopsychosocial framework and including the use of medications;

outpatient, inpatient, and residential treatment; and psychosocial interventions. Substance abuse

may be regarded as a familial disorder, so that the parent–child mutual attachment relationship,

peer interactions, personality and behavioral issues, and cultural factors such as ethnic

identification (J. S. Brook et al. 2006), are important areas to explore in group therapy. Such a

broad multidisciplinary approach has allowed group therapists to address diverse areas in the

treatment of patients (Vannicelli 1992, 1995).

Group therapy can be especially effective in the prevention and treatment of behavioral risk

factors. Psychosocial and cultural risk factors (and corresponding protective factors) may be

targets for change through the use of group therapy. Psychosocial and cultural risk and protective

factors have been identified in a number of developmental areas, including the personality, the

parent–child relationship, the spouse/significant other attachment relationship, interactions with

peers, and ethnic, cultural, and environmental factors (D. W. Brook et al. 2003; J. S. Brook et al.

1990,1998b). One model of the interaction of risk and protective factors in the etiology and

maintenance of substance abuse is family interactional theory. This theoretical formulation is

discussed in further detail in Chapter 3 of this volume, “Epidemiology of Addiction.”

Group interactions play an important part in the development of substance abuse disorders (D. W.

Brook 1996; J. S. Brook et al. 2006), such that group therapy can play a significant role in the

prevention and treatment of these disorders. The successful use of group approaches depends first

on the development of the therapeutic alliance between the group therapist and each group

member, as well as on the development of group cohesion, the attachment that forms between

group members over the course of treatment. Group cohesion is of great importance because

patients with substance use disorders have a disturbed ability to establish and maintain an

attachment to other people (Flores 2001). Other functional disturbances seen in patients with

substance abuse and dependence include emotional dysregulation, decreased self-esteem, and an

inability to care for oneself adequately (Albanese and Khantzian 2002; Khantzian 2001). The

defenses of substance abusers tend to be rather primitive, with particular use of denial, projection,

and rationalization. These disturbances can result in a loss of contact with other people, emotional

lability, and self-destructive behavior, all of which can be addressed through group therapy.

The mutual understanding developed by group members can have a positive effect on parent–child

interactions, relationships with significant others and peers, the course of further emotional

development, and the maintenance of health. The group has the ability to provide support, and

confirmation that others share problems is supportive to the patient and has a therapeutic effect in

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establish relationships with other people and offer them relief from shame and social isolation.

Over time, the group process and interactions in the group can help group members establish more

mature defenses and can provide symptomatic relief. In general, better treatment outcome is

related to longer duration of group treatment. Groups can help substance-abusing patients control

the urge to use substances, particularly through their ability to help group members establish

satisfying relationships with other members (Flores 2004).

SPECIFIC ISSUES

Because of the characteristics of patients with substance abuse problems (detailed in the previous

section), specific features of group treatments are necessary in order to address the particular

needs of these patients, including the appropriate selection of patients for each group, pre-group

preparation, the establishment and maintenance of group structure and safety, the use of

supportive confrontation in the group process, and the particular role of the group therapist.

The selection of appropriate patients for each group is important for the effectiveness and longevity

of the group. For example, patients who appear likely to give or sell substances of abuse to other

group members require a special group structure. Acutely suicidal patients, homicidal patients,

acutely psychotic patients, and patients with serious organicity, which precludes their participation

in the group discussion, are not suitable for most groups, though they may be suitable for specific

groups under carefully delimited circumstances.

Pre-group preparation sessions with each individual member help increase members’ motivation

and reduce premature dropouts. These preparatory sessions help new group members learn the

ground rules of the group, which most often include confidentiality, the need for regular and

prompt attendance, understanding that the eventual goal is abstinence, and understanding the

gains possible through membership in the group (Hoffman 1999). The expectations of each

potential group member may be clarified in these sessions, and the therapeutic alliance between

each group member and the group therapist has its beginning in the statement and acceptance of

the group contract and in the relationship formed in such preparatory sessions.

Group structure is enhanced by the development of shared group norms, the shared goal of

eventual abstinence from substances of abuse, and the shared understanding about the goals of

treatment. Such structure in the group is important because of the relative lack of internal and

external structures in the lives and experiences of the group members. Safety in the group is

focused on setting appropriate limits, helping members attend to caring for themselves

appropriately with feedback from the other group members, and becoming aware of the early signs

of relapse.

Because individuals who abuse substances tend to experience extremely painful emotions, which

often result in self-destructive behavior, it is important for the group to provide a safe environment

for the shared acknowledgment of these feelings. This can be accomplished by the use of

supportive confrontation, which can provide an empathic “holding” environment where members

can address each other’s painful feelings and self-destructive behaviors with mutual understanding

and support (Ganzarain 1992). Self-destructive behaviors or loss of control of emotions can be

addressed without blame or shame.

It is important for the group therapist to play an active role, enhancing the sense of safety and

structure felt by the group members and promoting the ability of the group members and the group

therapist to set appropriate limits, help the group members deal with anxiety and acting-out

behavior, and maintain the group contract. This stance of the group therapist helps the group form

stable cohesion and progress with the work of the group process. Experienced group leaders

develop specific methods to keep the group process active in the face of frustrations and conflicts

in therapy (Vannicelli 2001). Early signs of patient relapse are identified by the group leader and by

group members paying attention to “people, places, and things” that might serve as triggers or

cues to resume substance abuse. The therapist and group members utilize the “here and now”

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with the adverse consequences of substance abuse and dependence. In addition to psychosocial

and interpersonal consequences, the group leader and group members can use the group process to

help group members cope with traumatic and medical consequences of substance abuse.

Managed care issues may arise during the course of group treatment of substance abusers and

addicts. Third-party payers may require specific patient characteristics or goals to be met, or they

may be reluctant to provide payment for the treatment of patients unless the group therapist

carefully explains the utility and cost-effectiveness of group treatment for each patient. Another

managed care issue is the requirement for the group therapist to ensure confidentiality for the

group members. (For a more detailed discussion of these and other managed care issues, please

see MacKenzie 1995; Spitz 1995, 2002.)

TYPES OF GROUPS

A number of types of group treatments are available for patients with substance abuse and

dependence issues and for patients with co-occurring psychiatric disorders, including self-help

groups, groups using the concepts and techniques of interpersonal group psychotherapy (IGP),

cognitive-behavioral therapy groups, psychodynamically oriented groups using the concepts of

modified dynamic group therapy (MDGT), phase models of group treatment, relapse prevention

groups, groups in therapeutic communities, and a variety of homogeneous groups used to treat

specific populations and patients abusing or addicted to specific drugs of abuse. Group therapy is

used in treatment programs in a wide variety of settings, including outpatient, inpatient, and

partial hospitalization.

Self-Help Groups

General group features

Self-help groups may make up the greatest number of groups used for treatment today. Such

groups are usually composed of members who share something in common, such as experiences as

substance abusers and addicts (Lieberman and Humphreys 2002). Self-help groups utilize the

relationships between members as the therapeutic force for change; therapeutic forces include

cognitive and behavioral elements aimed at changing thinking and behavior, as well as group

support and mutual understanding and caring. Such groups establish and maintain their own

norms, with an emphasis on the creation of close relationships, talking about feelings, and not

engaging in self-destructive behaviors, particularly around the use of alcohol in the case of

Alcoholics Anonymous (AA). The large self-help group may have no formal structure, and each

group may offer interactions with other people in person or over the phone. Attendance at groups is

free of charge, and groups support themselves.

A wide variety of self-help groups exist to serve people with any number of behavioral and

substance use disorders. Self-help groups for substance abusers and addicts may serve as the only

source of treatment for such patients or may be utilized along with psychosocial and medical

treatments offered by health care professionals. Most substance abuse and addiction professionals

emphasize the need for patients to join self-help groups in addition to utilizing other treatment

methods.

Twelve-step groups

The 12-step group is one particular type of self-help treatment and is discussed in depth in Chapter

26 of this volume, “Twelve-Step Facilitation: An Adaptation for Psychiatric Practitioners and

Patients.” This section provides a brief summary, focusing primarily on aspects of the group

dynamics noted in such groups.

Self-help groups have a long history, resulting in the formation of the 12-step movement and AA.

The founding of AA dates to 1935, when two men, William Griffith Wilson (known as Bill Wilson)

and Dr. Robert Holbrook Smith (known as Bob Smith or Dr. Bob), formed an alliance in an effort to

help each other manage their alcoholism. Their fellowship was historically related to earlierPrint: Chapter 29. Group Therapy

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examples of Christian self-help fellowship groups. Indeed, for a number of years alcoholic

individuals met for mutual support under the aegis of the Oxford Group, which emphasized the

importance of confession and redeeming oneself for one’s sins among a group of peers. In an effort

to separate themselves from the Oxford Group’s religious nature and rigid structure, alcoholics

formed their own group. The “big book” of AA, Alcoholics Anonymous, was published in 1939

(Alcoholics Anonymous 1939) and outlines the focus of the 12-step process of AA, including the

acceptance of one’s self as an alcoholic, the acceptance of a “higher power,” the examination of

one’s self to identify needed changes, the recognition of defects in character, making restitution for

harm done to other people, and working with others (Orford 1985, p. 309). The functions of AA

were codified in another publication in 1953, Twelve Steps and Twelve Traditions (Alcoholics

Anonymous 1953). AA has additional available publications and online information (Alcoholics

Anonymous 1976, 2007). AA groups currently exist in many countries and serve millions of

members, by some estimates.

Using AA as an example, self-help groups usually consist of a large group treatment as well as

additional smaller groups. Members of self-help groups agree that they share a common condition

and a common goal, usually the achievement of long-term abstinence. Both large and small groups

are conducted by the members, without the presence or assistance of professional group leaders or

mental health professionals. There is no charge for attendance at the meetings, and relationships

made in the group are encouraged and commonly continue outside of the group setting. In AA,

particular importance is placed on the relationship with a sponsor, a more experienced group

member to whom an individual entering AA can turn for help and with whom a special relationship

may develop. Twelve-step self-help groups provide mutual support and encourage adherence to

group norms. The new group member is expected to accept the ongoing group’s values and beliefs

about the use of alcohol.

Examination of the 12 steps of AA reveals that alcohol is mentioned only once, in the first step, and

that the other steps consist of gradual movement toward self-assessment, reestablishment of

successful relationships with others, and eventual personality change. AA members become aware

of the inability to control drinking. In AA’s perspective, alcoholism is a disease. The disease process

can be stopped, but the disease itself is incurable. Therefore, recovery is an ongoing process that

takes place over the course of each person’s life. The last step (step 12) focuses on the altruistic

goal of AA members helping other people enter into the recovery process. Group members

participate over the course of a person’s lifetime, and members may attend continuously or on an

as-needed basis. Group acceptance, spirituality, and the wish to help others are seen as having

therapeutic value and the ability to generate personality and behavioral change.

AA remains neutral to political or social issues and has no formal relationship with organized

medicine. However, AA members have been involved in furthering the treatment of alcoholism, and

AA approaches and methods have become essential parts of a number of treatment programs. The

widespread success of AA in the seven decades since its foundation has led to its use as a model for

other, similar 12-step programs that focus on a variety of other kinds of addictive behaviors.

Twelve-step groups have been formed for the treatment of a variety of kinds of drug use, as well as

compulsive behavior, such as gambling and compulsive sexual behavior. AA itself has a spiritual,

religious basis, but a number of other self-help groups have been formed without this emphasis.

Although research efforts involving AA members and AA groups are difficult to conduct, there have

been some successful studies of the process and outcome; their findings have indicated that

regular attendance at AA meetings may result in a reduction in drinking and an increase in a

member’s ability to function successfully (Emrick et al. 1993).

Interpersonal Group Psychotherapy

IGP focuses on the view that interpersonal relationships and attachments affect and regulate all

aspects of living. The development of IGP has been greatly influenced by the work of Irvin D. Yalom

(Yalom 1995; Yalom and Leszcz 2005) and others, such as Philip J. Flores and Molyn Leszcz (Flores

2004; Leszcz 1992). According to the IGP perspective, substance abuse and addiction may be seenPrint: Chapter 29. Group Therapy

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as attachment disorders caused by genetic and early developmental failures, which lead to

inadequate and self-destructive attempts at self-repair. Attachment theory lends itself to a

comprehensive understanding of the vicissitudes of the substance use disorders (Flores 2001,

2002): the substance-abusing or addicted individual attempts to use drugs and alcohol as a

substitute for satisfying and fulfilling interpersonal relationships (Flores 1993). Such individuals

have severely impaired object relations and therefore are unable to form mutually satisfying and

mutually regulating relationships with other people. According to Matano and Yalom (1991),

substance abusers can be defiant, grandiose, and cunning. Such difficulties in both the internal and

external regulation of connections with other people also have an adverse effect on the internal

homeostatic and neurophysiological mechanisms used by these patients to regulate and care for

themselves. The occurrence of physical dependence leads to further loss of function and further

difficulty in affect regulation, self-care, interpersonal relationships, the ability to verbalize feelings,

and the capacity to empathize with other people and to experience pleasure.

These basic formulations of IGP can lead to effective group treatment methods. The focus of IGP is

on the here-and-now interactions in the group, with the active approach of the group leader

encouraging the establishment of group cohesion, therapeutic norms, and member interactions.

The group leader’s ability to establish a therapeutic alliance with each group member and to form

empathic interactions with members enhances the development of interpersonal relationships in

the group and encourages the development and maintenance of group cohesion; therefore, the

group leader focuses less on the group as a whole perspective. IGP assists members in achieving

and maintaining abstinence, and group members are encouraged to join 12-step programs (Flores

1997). Group therapy can be used in a collaborative relationship with 12-step programs (Freimuth

2000).

IGP differentiates early-stage treatment from later-stage treatment. In early-stage treatment, the

emphasis in the group is on the continued development of the therapeutic alliance and on helping

patients develop the capacity to express feelings appropriately. Early-stage treatment also

emphasizes the ongoing importance of continued efforts at relapse prevention.

Later-stage treatment focuses more on assisting each group member in the development and

maintenance of self-care and also emphasizes the mutuality of treatment interactions. With the

development of group cohesion and the active interventions of the group leader, group members

develop the ability to resolve intrapersonal and interpersonal conflicts without using drugs to

regulate affect. Group members become increasingly able to cope with internal deficits, and feel

enhanced self-esteem and decreased shame. During the course of group interactions, group

members become increasingly able to empathize with one another. The development of more

satisfying relationships in the group helps group members to achieve the capacity to have

satisfactory relationships outside of the group without the use of substances of abuse. An

important aspect of later-stage treatment is the growth in members’ abilities to repair disturbances

in the therapeutic alliance, and the growth of group cohesion over time enables group members to

change earlier self-destructive ways of interacting with people and to establish mutuality and

emotionally healthy relationships with other people outside of the group setting.

Cognitive Therapy Groups

Cognitive-behavioral theories of substance abuse and dependence have played an important role in

the formulation and development of cognitive therapy groups (Marlatt 1985; Rose 2002). These

theories have focused on relapse prevention and harm reduction, and cognitive-behavioral concepts

play a substantial role in the techniques of other kinds of groups and group processes as well.

Group therapy using cognitive-behavioral principles focuses on changing cognitive processes, such

as thoughts, opinions, and assumptions, around substance abuse and dependence (Liese et al.

2002; Rose 2002). These cognitive processes interact with environmental, physiological,

developmental, and affective processes, resulting in the development of addictive behavior (Beck

and Liese 2005).

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treat the addictive behaviors of members. At each highly structured group session, the group leader

reviews the model of cognitive processes in order to help group members understand the

relationship of these processes to their life difficulties and addictive behaviors. The group leader or

facilitator plays an active role in setting goals for group members and in modeling behavior.

As described by Liese et al. (2002), a wide range of mental activities are examined during the

course of cognitive therapy groups. These mental activities include activating stimuli consisting of

triggers or cues. Internal cues may be felt as disturbing emotions, such as anxiety and depression,

that motivate individuals to use substances of abuse as a coping mechanism. The anticipated

positive feelings resulting from the use of substances of abuse in turn may motivate individuals

toward addictive behaviors. External cues, consisting of exposure to people, places, and things

associated with substance abuse, serve as triggers in the environment that motivate addictive

behaviors. Cognitive processes also include urges and cravings, which may be experienced

physically. An urge may be thought of as a “relatively sudden impulse to engage in an act,” while a

craving represents “the subjective desire to experience the effects or consequences of a given act”

(Marlatt 1985, p. 48). Group members learn to deal with urges and cravings rather than to gratify

them.

Other kinds of cognitive processes, such as beliefs about addictive behaviors, also play a role in the

development of substance abuse. For example, anticipatory beliefs focus on the benefits resulting

from the use of substances of abuse, and relief-oriented beliefs focus on the reduction of negative

feelings. Facilitating beliefs and instrumental beliefs are cognitive processes that substance

abusers utilize to help themselves participate in addictive behaviors.

In cognitive therapy groups, group members are helped by the group leader’s active interventions

to understand, control, and change members’ thought processes and behaviors around substance

abuse and dependence. Such groups use psychoeducational techniques as well as the group

process, and group members are taught specific coping skills, such as affect regulation, crisis

management, and maintenance of nonconflictual relationships with other people. Group members

are given homework assignments to develop specific coping skills and to achieve specific goals

(Center for Substance Abuse Treatment 2005, pp. 16–17). Group leaders may adopt a

harm-reduction approach as a preliminary but necessary phase toward the achievement of

long-term abstinence.

The identification of goals is an important step for group members. Goals may help members to

focus on achievements that are possible and to utilize internal and external resources in the further

development of effective coping without the use of substances of abuse.

Modified Dynamic Group Therapy

MDGT relies on explanations proposed by the self-medication hypothesis to understand substance

abuse as a self-regulation disorder (Albanese and Khantzian 2002). The self-medication hypothesis

is based on clinical findings that deficits in the personality structure of substance abusers result in

impairments of the self-regulation mechanism; these impairments in self-regulation may be seen in

difficulty with regulation of affect, impairment in self-care, an impediment in regulating

self-esteem, and difficulties in maintaining interpersonal relationships (Golden et al. 1993).

Difficulties in regulating affect include poor tolerance of changes in affect, loss of emotional

control, and difficulty in neutralizing internalized affect, with particular reference to feelings of

anger, shame, and isolation. Substance abuse patients may experience extremes of affect—feeling

too intensely or having a less-than-appropriate amount of affect (Khantzian 1997). In some

patients, feelings are so vague that patients are unable to distinguish what they are feeling

(alexithymia); in other patients, feelings of overwhelming anger and loss of emotional control

dominate—such patients use substances of abuse to control painful affective states.

Patients with difficulty taking care of themselves are unable to adequately consider future

consequences of their actions. Such difficulties may affect their decisions about using substances of

abuse as well as decisions relating to other aspects of their lives. With regard to difficulties in thePrint: Chapter 29. Group Therapy

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maintenance of self-esteem, substance-abusing patients have difficulty in mobilizing inner

resources to soothe themselves. Therefore, they may turn to substances of abuse to make

themselves feel more at ease and better about themselves. Perhaps because of early

developmental defects in parent–child relationships, substance abusers may experience difficulty in

relating to other people and maintaining relationships with mutuality and appropriate interactions.

Substance abusers may become either manipulative of other people or detached and uncaring

about others.

Because of deficits in self-regulation, such individuals turn to the use of substances of abuse as

external sources of self-regulation and self-comfort. Substance abusers may utilize specific

substances of abuse to regulate specific painful effects or to make themselves feel good, or feel

better. For example, opiate abusers may use opiates to control feelings of overwhelming anger,

while patients with ongoing depressive symptoms may turn to the abuse of stimulants, such as

cocaine. Individuals with attention-deficit/hyperactivity disorder may also abuse stimulants as

self-treatment, whereas patients with feelings of overwhelming anxiety and fear of closeness to

others may treat themselves with alcohol or sedative-hypnotic drugs—such drugs may allow these

patients to overcome feelings of shyness and inhibition and to reach out to other people to

establish relationships based on their common use of alcohol. Although drugs are used in an effort

to achieve temporary relief from pain and difficulty in relating to others, their use leads to further

difficulties with self-regulation.

MDGT utilizes these concepts of the self-medication hypothesis to help group members examine

substance abuse through a focus on an interpersonal approach toward the treatment of

characterological problems, which stem from ego deficits in self-regulation. The group provides a

corrective emotional experience for members (Khantzian 2001). While the group leader works to

facilitate a safe environment within the group, group members examine shared difficulties with

self-regulation, isolation, and shame. The group leader serves as a model for group members to

achieve self-control, sets the goal of the group as abstinence, and helps group members achieve

and maintain abstinence through an examination of interactions in the group, with special attention

to self-destructive behaviors, painful affects, and loss of emotional control. Through sharing

feelings and identifying shared difficulties, group members learn about their own difficulties with

affect regulation, low self-esteem, difficulties in relationships with peers, and shared difficulties in

self-care. MDGT helps group members identify such deficits and self-destructive behaviors, using

the interactions in the group to help group members learn new or more satisfactory ways of dealing

with affects and relating to each other. Group members help each other look at the use of drugs as

a way to help control painful feelings, and they help each other understand how particular affects

may lead to the use of particular drugs. Through mutual support, sharing, and caring about one

another and with the help of the group leader, the group members become able to utilize healthy

measures of self-regulation and to achieve and maintain abstinence from substances of abuse.

Phase Models of Treatment

A number of models of treatment have been developed that utilize the movement of group

members from one phase of treatment to the next. Each phase involves the completion of

phase-specific tasks, and patients only move to the next phase upon completion of the previous

phase. Such a phase model of treatment using group therapy has been described in detail by Banys

(2002). This model uses four specific phases: crisis, abstinence, sobriety, and recovery. The tasks

of treatment include the repair of damaged interpersonal relationships and the achievement and

maintenance of abstinence. In those cases in which self-destructive behavior has led to a

disruption of relationships, therapeutic efforts may focus on dealing with loss, shame, sorrow, and

guilt. Each phase of treatment requires specific therapeutic techniques to help group members

successfully master the tasks of each specific phase. Early phases focus on meeting the

requirements of the treatment program and managing behavior. Later phases emphasize learning

to verbalize feelings and identify affects.

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to a return to earlier-phase groups, with more focus on behavioral control and the maintenance of

abstinence. Using this model, group members in the crisis phase focus on problem solving and

achieving behavioral control and abstinence. In this phase, a clear understanding of each group

member’s specific difficulty is essential, as is taking concrete steps to assist the patient in dealing

with a particular life crisis. The support of the other group members helps each patient deal with

his or her psychosocial crisis; concurrent individual sessions and group sessions are often most

helpful. The needed intervention must be appropriate to the particular crisis with which the patient

presents. In the abstinence phase, group members focus on relapse prevention techniques using

cognitive-behavioral methods. In the sobriety phase, which is regarded as an advanced phase,

group members focus on difficulties with affect, especially depression, grief, and sorrow. The

recovery phase, a still more advanced phase, focuses on establishing and maintaining relationships

in the group and on the here and now of the group’s interactions.

With this method of behavior-focused group treatment, the behavior of each group member must

be carefully observed. Particularly in the earlier phases of treatment, what patients say is not as

important as how they behave. Group members may become very involved with intellectual

explanations of their behavior, while continuing to abuse drugs. Therefore, an insight-oriented

approach may be counterproductive (Greif [1996] has addressed a number of other common errors

in group treatment). Group cohesion can be helpful as group members assist one another in

bringing about and maintaining behavioral change.

Relapse Prevention Groups

Formal relapse prevention groups focus on the specific stages that substance abusers go through

as they move toward recovery and the maintenance of abstinence. Rawson and Obert (2002)

discussed an approach to relapse prevention groups that is based on a model developed by Marlatt

(1985), in which the treatment of substance abuse and addiction involves a change in habits. This

differs from the AA view of addiction as a disease. This approach considers relapse a result of a

sequence of cognitive and behavioral steps and maintains that it has identifiable precursors. Using

this approach, the specific risks to relapse can be identified and addressed using a variety of coping

methods—specifically, cognitive and behavioral methods are used to develop strategies to avoid

such risks and to achieve constructive behaviors. The use of a psychoeducational approach to teach

group members about issues involved with substance abuse and dependence helps patients achieve

changes in behavior and relationships and helps people cope with risks for relapse.

Relapse prevention groups can include motivational components in order to enable members to

become aware of the reasons for changing substance use behaviors (Miller et al. 2002). Groups

may also address issues related to abstinence in order to assist members in the action stage of

change to alter behavior and stop substance use (Prochaska and DiClemente 1986).

Relapse prevention groups are time limited and focus on the maintenance of abstinence through

the use of cognitive-behavioral techniques, including education, peer support, and an active

therapeutic approach. Under certain conditions, a harm-reduction approach is also useful (Marlatt

and Tapert 1993; Marlatt and Carlini-Marlatt 2005). The active group leader helps group members

formulate topics for discussion and plays a directive role in helping members learn to deal with

problems. Interventions may address any behavioral issues evident in the group or brought up by

the group members. Group members commit themselves to abstinence for the duration of the group

treatment and are encouraged to attend self-help groups as well. Many patients are not able to

make the commitment to abstinence that is necessary for participation in a relapse prevention

group. Such patients may be treated in a series of preparatory groups, each of which has a specific

technique and goals related to the particular needs of the patients.

The transtheoretical stages of change model (Prochaska and DiClemente 1986; Velasquez et al.

2001) is useful in identifying stages of change that patients experience on the road to changing

substance abuse behaviors. The stages of change identified by Prochaska and DiClemente include

1) the precontemplation stage, in which the patient does not realize that substance abuse behavior

is problematic; 2) the contemplation stage, in which the patient experiences indecision or difficultyPrint: Chapter 29. Group Therapy

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in dealing with substance abuse behavior that is now seen as problematic; 3) the preparation

stage, in which the patient decides change is needed and action is necessary and prepares to take

action; 4) the action stage, in which the patient has decided on a pathway to change and takes

action to change substance abuse behavior; and 5) the maintenance stage, in which the patient

attempts to maintain abstinence and avoid relapse. In this structure of stages of change, relapse is

seen as regressing backward from one stage of change to a previous stage.

Using this model, one can identify particular interventions most appropriate for patients in each

stage. Preparatory group interventions are appropriate for patients in the stages of

precontemplation, contemplation, or preparation; beginning techniques of abstinence are

appropriate for patients in the action stage; and relapse prevention techniques are most useful for

patients in the maintenance stage. Suggestions for such preparatory or beginning group treatments

have been proposed by Washton (2002). For example, a self-evaluation group (SEG) is a group

intervention most suitable for patients who are in one of the three stages of change prior to the

action stage. These include patients who show signs of substance use in their behavior and physical

condition, yet deny it or do not see it as problematic. Such patients may have fairly good

psychosocial functioning or may fit the diagnostic criteria for substance abuse or dependence.

Patients with cognitive difficulties, suicidal behavior, or a major Axis I psychiatric disorder are not

suitable for such a group (Washton 2002). The goal of this group is to help people assess the

problematic nature of substance abuse behavior and to evaluate each group member’s motivation

for further change. Members in this group have not yet made the decision that they want to enter

formal treatment, and the group leader does not urge them to. Instead, the group leader actively

encourages group members to engage in self-evaluation and mutual understanding, with the goal

of helping each other identify substance abuse and resulting behaviors. The group is time limited,

and members are asked to refrain from substance use during the period of group treatment even if

they eventually decide not to maintain abstinence. The SEG is a structured intervention, which

encourages active participation of group members as they attempt to assess the problematic nature

of substance abuse and decide whether or not to take action regarding substance abuse.

Another preparatory group is the initial abstinence group (IAG), which is most appropriate for

patients in the action stage who have decided to change behavior and stop substance abuse, at

least for a trial period (Washton 2002). The goal of participation in the IAG is the eventual

determination to maintain abstinence. Following successful participation in an IAG, patients may

move into formal relapse prevention groups. The IAG is also a time-limited group, which meets

frequently over 8–12 weeks. Group members agree to abstain from substances of abuse for the

duration of the group, to have urine testing regularly and as needed, to attend group sessions

regularly and on time, and to avoid inappropriate sexual or emotional involvement with other group

members. Group members focus on the achievement of specific goals, which include 1)

understanding the motivation for abstinence; 2) maintaining a realistic perspective of substance

abuse and dependence; 3) acquiring skills such as avoiding people, places, and things that might

put the member at risk and appropriately managing anger without engaging in inappropriate

self-destructive behavior; 4) participating regularly in the group and in the interactions of the

group; and 5) beginning attendance at 12-step meetings. Patients remain in the IAG for variable

lengths of time and the progress of each group member is discussed on a regular basis. Supervised

urine testing is used to validate stated abstinence (Washton 2004). By validating behavior, urine

testing may deter further use and deter lying about behavior and may serve to verify progression in

treatment.

During the course of achieving initial abstinence, each group member attends the group meetings

regularly, which provide structure, support, and continuing psychoeducation. Learning specific

coping skills helps group members maintain initial abstinence and also enhances the motivation of

group members to maintain long-term abstinence. The IAG gives group members mutual support, a

chance to share experiences, and an opportunity to learn new coping skills to avoid risk-taking

behavior. If a group member has a slip, this must be discussed at once, and the group leader must

help the group avoid using members who experience repeated slips as scapegoats. The group mustPrint: Chapter 29. Group Therapy

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reach a mutual decision about temporary exclusion of a member with repeated slips. Membership in

the group is open, with the group size ranging from 8 to 12 members.

Eventual participation in a formal relapse prevention group follows the achievement of stable

abstinence. As noted, relapse prevention group sessions include psychoeducation, group support,

the further development of coping skills, and participation in recovery-based treatment.

Participation in a longer relapse prevention group may involve addressing changes in each group

member’s self-destructive patterns of thinking and behavior and may promote more satisfying and

appropriate interpersonal relationships as well as the maintenance of abstinence.

Group Therapy in Therapeutic Communities

A therapeutic community is a group of individuals living together for therapeutic purposes.

According to the work of De Leon (2002), a variety of group-based intervention types are used in

therapeutic communities. The basic treatment element of the therapeutic community is the

community of peers itself (i.e., the large group) acting as the motivating force to bring about

change in substance use. Group process is basic to therapeutic community treatment programs.

Group process occurs in regularly held community meetings, in smaller therapeutic groups, and in

educational groups. Group process also takes place as residents of the therapeutic community

interact with one another informally and in peer groups. A number of small groups in the

therapeutic community explore issues of interest to individual community residents, including

treatment and educational issues. As noted above, group processes and interactions set the stage

for progress and treatment.

Therapeutic communities may be used in a variety of settings, including residential and day

treatment programs, although the typical therapeutic community is located in a residential setting

composed of members of the therapeutic community. Although therapeutic communities help

members in many practical ways, the basic method of treatment is self-help, as the community of

peers helps to bring about change in its members through group processes. All activities in

therapeutic communities are focused on treatment efforts. Members of the therapeutic community

working together in a cohesive manner enhance the alliance between each member and the group

as a whole. Use of group processes in the peer group improves trust among the members and

brings about a safe environment within which change may occur. Daily functioning at work roles in

the therapeutic community brings about an increase in self-esteem and responsibility. Shared

experiences are discussed publicly, and an examination of interactions among members is essential

for the maintenance of recovery. Although trained professionals at times may participate in the

community, they are also regarded as community members, and all community members serve as

role models.

There are a variety of kinds of groups utilized in the therapeutic community, including clinical

groups focused on individual issues; “probes” that help members explore feelings and history in

depth; “marathons,” which are large groups intended to bring about a focused resolution of

conflicts; and encounter groups, which are fundamental to the group process in the therapeutic

community and which utilize confrontation and sharing to facilitate change. Psychoeducational

groups with an emphasis on enhancing cognitive and behavioral skills include seminars, which

attempt to bring about cognitive change, and tutorials, which are theme related and emphasize

personal growth, job skills, and clinical skills necessary for the more effective use of encounter

groups in the therapeutic community. Therapeutic communities also offer groups with specific

themes that are often conducted by trained staff. These may include family-based groups to foster

familial support of the therapeutic community treatment program.

Although space limitations prevent a further, more detailed explanation of the use of group therapy

in the therapeutic community, the use of such groups has been extensively described in the

literature (e.g., De Leon 2002; Jainchill 1994).

Group Therapy for Adolescent Substance Abusers

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presents unique problems for group therapists (D. W. Brook 1996). Adolescents undergo a series of

fundamental and often tumultuous changes over the course of a relatively short time span; the

developmental milestones experienced during this period include psychosexual development and

pubertal growth, with their accompanying psychological and physical changes; the development of

increasingly important and close relationships with peers of both genders; separation from the

family of origin; the establishment of independence; and the achievement of educational and

vocational goals. The peer group becomes increasingly important over the course of adolescence,

as does the relationship with a number of other groups, which are often related to school.

Furthermore, there is a change of emotional focus and psychosocial attachments as the adolescent

moves away from parents and develops increasingly important relationships with other people.

Substance dependence, with some exceptions (e.g., tobacco), is less common than substance abuse

over the course of adolescence, perhaps because of the short time span involved and the initial

period of experimentation with substances, which precedes heavier use and the development of

dependence. However, substance abuse by adolescents is especially harmful because both the

psychosocial and cultural aspects of substance abuse and the psychopharmacological effects of

such substances interfere with the usual developmental tasks of adolescence. Growth and

development may be delayed during adolescence or may proceed in pathological directions, leading

to the development of concurrent or later psychiatric disorders (D. W. Brook 1996). Therefore,

group therapists who treat adolescent substance abusers must be familiar with child and

adolescent development, family issues, group and individual therapy, psychopathology and the

substance use disorders, and issues of prevention and treatment.

Substance abuse commonly begins in early adolescence or a few years before that; it is relatively

unusual to encounter adult substance abusers who have not used substances of abuse over the

course of adolescence. Certain substances of abuse are more commonly used during adolescence,

including tobacco, alcohol, marijuana, and inhalants, although stimulant abuse is also a significant

problem during this period. Adolescent substance abuse often occurs in a setting of disturbed

familial functioning, such that some therapists prefer the use of family therapy, either alone or in

conjunction with group therapy (Liddle and Rowe 2002). However, group therapy for adolescent

substance abusers is by itself “safe and effective” (Burleson et al. 2006).

The psychosocial risk and protective factors for adolescent substance use have been extensively

studied (D. W. Brook et al. 2003; J. S. Brook et al. 2006). The development of problem behaviors

and co-occurring psychiatric disorders in conjunction with substance abuse during adolescence is

the rule (D. W. Brook 1996; J. S. Brook et al. 1998a). The most common comorbid psychiatric

disorders noted in adolescent substance abusers are affective disorders, conduct disorders, and

anxiety disorders (Kaminer and Bukstein 2005). There is a strong relationship between substance

abuse and gender, as well as between substance abuse and adolescent suicide, substance abuse

and physical and sexual abuse of adolescents of both genders, and substance abuse and risky

sexual behavior (D. W. Brook et al. 2006).

The goals of group therapy for adolescent substance abuse include the development of mutually

satisfying and appropriate relationships with others; the development of responsibility; the

establishment of affective control (especially anger); cessation of self-destructive behavior,

including risky sexual behavior; and the achievement and maintenance of abstinence from

substances of abuse (Spitz and Spitz 1996). Involvement of family members often plays a crucial

role in the effectiveness of therapy; family therapy and multiple family group therapy may be

helpful in this regard (Kymissis et al. 1995).

Group therapy has been the most commonly used treatment method for adolescents with substance

use disorders (Kaminer and Bukstein 2005). Several types of group treatments are appropriate for

use with this population, all of which require clearly stated therapeutic contracts (Vannicelli 1995)

and clearly stated goals; adolescent substance abusers should know what to expect from

treatment—for example, an important goal is to substitute the ties of constructive relationships for

those of substance abuse and dependence (Flores 2004). These groups may include a substancePrint: Chapter 29. Group Therapy

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abuse education group, a relapse prevention group, separate male and female groups, a

problem-solving coping skills group, a family issues group, and a group focused on health. Groups

may have members of both sexes or of a single sex. Although some therapists prefer to treat

adolescent substance abusers in a homogeneous group of substance abusers, other therapists add

one or two substance abusers to a mixed-diagnosis adolescent group.

In general, for adolescents, behavioral techniques based more on interventions focused on the here

and now in the group are often more useful than more interpretive techniques (Galanter et al.

2005). However, an interactional approach (Vannicelli 1992) that encourages self-disclosure and

mutual acceptance may also be useful; the confrontation of denial and limit setting may be more

effective through the interventions of other group members rather than the group therapist. The

group therapist should actively focus on helping adolescent group members stop substance-abusing

behavior. Although this goal is of primary importance, dealing with interpersonal conflicts and the

expressions of emotions in the group is also of great importance. Adolescent group members need

help focusing both on the group and group issues as well as on issues concerning each individual

group member. In all such groups, peer support and supportive peer confrontation play essential

therapeutic roles. Psychoeducational groups, which are used to provide information, may also

result in behavioral changes through patient interactions and discussions of the expression of

affect and problem-solving skills. Most meaningful changes in behavior occur in the here-and-now

interactions of the group process, with a focus on such interactions despite interpersonal conflict,

denial, and emotional outbursts.

Active limit setting and the use of structured guidelines are important in the provision of a safe and

supportive group environment. The group therapist should be able to help group members deal

with impulsivity and acting out, both of which are characteristics of adolescents in general and of

adolescent substance abusers specifically, in order to minimize any possible iatrogenic effects of

the group (Kaminer 2005). Peer support and peer pressure are useful in bringing about changes in

behavior in group members.

Groups for the treatment of adolescent substance abusers may be time limited or long-term; the

goals of treatment, the treatment setting, and practical issues all play a role in making this

decision. The group treatment of adolescents with comorbid substance abuse and psychiatric

disorders may utilize a special relational approach (Pressman et al. 2001).

Network therapy, an innovative treatment (Galanter et al. 2005) that combines aspects of both

group therapy and family therapy, has been tested empirically and proven effective. Network

therapy is described in more detail in Chapter 28 of this volume, “Network Therapy.”

Other Types of Group Therapies

Although space limitations preclude discussion of other group types for substance-abusing patients,

it is important to note that homogeneous groups for female substance abusers (Najavits et al.

1996), elderly substance abusers (a problem of increasing prevalence), and substance-abusing gay

men and lesbians (McDowell 2002) all present specific treatment issues and require specific

treatment techniques. Medically ill patients who abuse substances and patients with co-occurring

substance abuse and psychiatric disorders also benefit from group therapy. Also of value are

homogeneous groups for patients abusing or dependent on specific substances of abuse (Daley and

Mercer 2002; Reilly and Shropshire 2000). Ethnically homogeneous groups can present unique

problems and opportunities (D. W. Brook et al. 1998). Group therapy approaches are also useful for

inpatients and in partial hospitalization settings. Many groups for substance abusers have a

time-limited format (Piper and Joyce 2002).

RESEARCH IN GROUP THERAPY FOR SUBSTANCE ABUSE

Although a number of authors have addressed research issues concerning group therapy for

substance-abusing or addicted patients, much remains to be learned about the use of groups with

these patients (Leshner 1997). A number of reviews of the literature indicate a dearth of

well-designed and carefully conducted studies; many studies have methodological limitations and aPrint: Chapter 29. Group Therapy

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lack of clarity regarding treatment methods and outcomes. As noted by Greene (2002), a number of

studies have focused on a cognitive-behavioral approach while omitting a consideration of the

group process.

In a comprehensive review, titled “Group Therapy for Substance Use Disorders: What Do We

Know?” Weiss et al. (2004) examined 24 prospective treatment outcome studies assessing the

effectiveness of group therapy for substance use disorders. These studies compared group therapy

with other methods of treatment or compared types of group therapy (e.g., Litt et al. 2003). The

authors noted three important patterns: 1) added specialized group therapy increased the

effectiveness of “treatment as usual”; 2) there were no differences between group therapy and

individual therapy; and 3) there were few differences when different kinds of group therapies were

compared, and no specific type of group therapy was better than any other type. The authors found

no evidence of a “unique benefit” of group therapy for substance abusers. In a cogent discussion

with reference to outcome, the authors noted that “a failure to detect differences does not

necessarily imply equivalence” (p. 347) and pointed out the likelihood that, in some cases at least,

a failure to find such differences might be related to insufficient statistical power.

As Weiss et al. (2004) further stated, despite the widespread enthusiasm of clinicians for the use of

group therapy for treatment of the substance use disorders, there is a lack of well-designed,

carefully conducted, and carefully analyzed outcome studies in the field. As they stated,

conclusions about the effectiveness of particular treatments remain unclear. Research has shown

the risks for the development of comorbid disorders with substance use (D. W. Brook et al. 2002).

Research into the group treatment of comorbid disorders shows the value of integrated group

treatment (Weiss et al. 2007).

There are a number of difficulties that enter into research efforts in this field, including finding

adequate and appropriate numbers of groups and group members, maintaining group membership

throughout the period of study, maintaining a treatment plan that is suitable for all group

members, and managing problems related to the likelihood of changes in group membership over

time and their effects.

Although group therapists treating substance abusers and substance-dependent patients think they

understand the processes of change that result in effective treatment, little clinical research to date

validates their beliefs. A number of theorists and clinicians are interested in pursuing further

research in the use of group therapy and group process in the treatment of substance abusers

(Liese et al. 2002; Piper 1993). It may be that, despite the many difficulties that are involved in

designing, conducting, and analyzing both processes of change and outcome and effectiveness over

the course of the group therapy of these patients, future research using sophisticated conceptual,

methodological, and statistical approaches may result in enhancing our understanding of both

group process and group outcome. Both process and outcome studies are necessary in order to

further more effective group therapy treatment efforts. As Greene (2002) noted, such research can

add to our understanding of “how, when, why, and for whom group treatment works” (p. 406). In

spite of the difficulties in conducting research on the group therapy of substance abusers, the

National Institute on Drug Abuse is interested in research on this topic (National Institute on Drug

Abuse 2003; Weiss et al. 2004).

CONCLUSION

The group treatment of substance abusers has been found by clinicians to be therapeutically

effective and cost-effective. The type of group chosen and the techniques and goals of treatment

depend on the stage of treatment of each patient; the therapist should create a treatment plan that

is unique and specific for each patient. Positive therapeutic changes in groups depend primarily on

the therapist’s understanding and use of the attachments of group members to each other and the

interactions between them. The sociocultural context must be taken into account in substance

abuse treatment, as ethnic and cultural factors influence the development and expression of

substance abuse and dependence. Linguistic and cultural understanding and competence are

necessary for effective treatment (D. W. Brook 2002). Multicultural treatment programs are of Print: Chapter 29. Group Therapy

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increasing importance given the extent of immigration to the United States and the presence of

people of varying ethnic groups living together in close proximity. The therapeutic alliance and

group cohesion can have powerful therapeutic effects. Group therapy for substance abusers can

provide corrective emotional experiences (Khantzian 2001) with regard to specific issues in the

lives of substance abusers, including difficulties in relationships with other people, the regulation

of emotions, self-esteem, and self-care.

KEY POINTS

Substance abuse and dependence are biopsychosocial disorders. Group therapy is a particular kind of

psychosocial intervention for the treatment of these disorders. However, group therapy may be used in

conjunction with other treatment methods, including individual therapy, psychopharmacological approaches,

and other methods still in development. Concurrent individual sessions held at appropriate times may

enhance the effectiveness of group therapy.

Patients should be encouraged to attend some type of 12-step program in addition to ongoing group

therapy treatment, with some exceptions.

Abstinence should be the goal of treatment, although a harm-reduction approach may be useful in the

course of achieving abstinence.

The therapist should maintain a relatively active role, regardless of the kind of group therapy approach he

or she utilizes.

Substance abuse and dependence may be viewed as chronic, relapsing disorders of the brain with

psychosocial, behavioral, and cultural antecedents and consequences. Psychosocial and cultural risk factors

(and corresponding protective factors) that influence the development and course of substance abuse include

the parent–child mutual attachment relationship, as well as peer and significant other interactions,

personality and behavioral issues, and cultural factors, including ethnic identification. Viewed from this

perspective, substance abuse and dependence have important familial and group-related etiological

components. Not only are family and group issues important in the development of substance abuse, a group

approach to the treatment of such issues can have important therapeutic effects. Consequences of substance

abuse also almost inevitably involve family members, and are relevant for group therapy.

Because of the chronic nature of these disorders, patients may return to group therapy again and again.

Although group therapy may be given in time-limited doses, its use should be viewed as part of a long-term

treatment approach often necessary for the successful treatment of these patients. Many patients remain in

treatment throughout their lives.

Cultural and linguistic understanding and competence are essential for the effective treatment of substance

abusers. Poor communication between the group therapist and the group members will lead to poor

treatment outcome and early dissolution of the therapy group.

Relationships in the group and group interactions during the course of the group process come to take the

place of “relationships” with substances of abuse and interactions with “people, places, and things” that serve

as risk factors for relapse.

Early-stage treatment techniques and goals differ from later-stage treatment techniques and goals.

A number of different types of group therapy use similar techniques with many points in common to treat

the adverse effects of the genetic, developmental, and cognitive deficits seen in substance abusers and

addicts.

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