A Treatment Improvement Protocol Substance Abuse Treatment: Group Therapy TIP41 GROUP THERAPY U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov A Treatment Improvement Protocol Substance Abuse Treatment: Group Therapy TIP41 GROUP THERAPY U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov Substance Abuse Treatment: Group Therapy This TIP, Substance Abuse Treatment: Group Therapy, presents an overview of the role and efficacy of group therapy in substance abuse treatment planning. This TIP offers research and clinical findings and distills them into practical guidelines for practitioners of group therapy modalities in the field of substance abuse treatment. The TIP describes effective types of group therapy and offers a theoretical basis for group therapy’s effectiveness in the treatment of substance use disorders. This work also will be a useful guide to supervisors and trainers of beginning counselors, as well as to experienced counselors. Finally, the TIP is meant to provide researchers and clinicians with a guide to sources of information and topics for further inquiry. Collateral Products Based on TIP 41 Quick Guide for Clinicians DHHS Publication No. (SMA) 05-3991 Printed 2005 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment GROUP THERAPY Substance Abuse Treatment: Group Therapy TIP 41 GROUP THERAPY Substance Abuse Treatment: Group Therapy TIP 41 Substance Abuse Treatment: Group Therapy Philip J. Flores, Ph.D. Consensus Panel Chair Jeffrey M. Georgi, M.Div., CGP, CSAC, LPC, CCS Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 41 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments Numerous people contributed to the development of this TIP (see pp. ix, xi, and appendices F, 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 the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Karl D. White, Ed.D., and Andrea Kopstein, Ph.D., M.P.H., served as the Center for Substance Abuse Treatment (CSAT) Government Project Officers. Christina Currier served as the CSAT TIPs Task Leader. Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP Executive Deputy Project Director. Shel Weinberg, Ph.D., served as the CDM KAP Senior Research/Applied Psychologist. Other CDM KAP personnel included Raquel Witkin, M.S., Deputy Project Manager; Susan Kimner, Managing Editor; James Girsch, Ph.D., Editor/Writer; Michelle Myers, Quality Assurance Editor; and Sonja Easley, Editorial Assistant. In addition, Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Jonathan Max Gilbert, M.A., Susan Hills, Ph.D., and Mary Lou Rife, Ph.D., were writers. Disclaimer The opinions expressed herein are the views of the Consensus Panel members and do not necessarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources described in this document are intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA/CSAT or the authors. Do not reproduce or distribute this publication for a fee without specific, written authorization from SAMHSA’s Office of Communications. Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 7296686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889, or electronically through the following Internet World Wide Web site: www.ncadi.samhsa.gov. Recommended Citation Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series 41. DHHS Publication No. (SMA) 05-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005. Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. DHHS Publication No. (SMA) 05-3991 Printed 2005 Acknowledgments Contents What Is a TIP?............................................................................................................vii Consensus Panel ..........................................................................................................ix KAP Expert Panel and Federal Government Participants ....................................................xi Foreword ..................................................................................................................xiii Executive Summary .....................................................................................................xv Chapter 1—Groups and Substance Abuse Treatment ...........................................................1 Overview......................................................................................................................1 Introduction .................................................................................................................1 Defining Therapeutic Groups in Substance Abuse Treatment ....................................................2 Advantages of Group Treatment ........................................................................................3 Modifying Group Therapy To Treat Substance Abuse .............................................................6 Approach of This TIP .....................................................................................................8 Chapter 2—Types of Groups Commonly Used in Substance Abuse Treatment ..........................9 Overview......................................................................................................................9 Introduction .................................................................................................................9 Five Group Models .......................................................................................................12 Specialized Groups in Substance Abuse Treatment................................................................29 Chapter 3—Criteria for the Placement of Clients in Groups................................................37 Overview ....................................................................................................................37 Matching Clients With Groups .........................................................................................37 Assessing Client Readiness for Group ................................................................................38 Primary Placement Considerations ...................................................................................40 Stages of Recovery ........................................................................................................43 Placing Clients From Racial or Ethnic Minorities .................................................................44 Diversity and Placement.................................................................................................52 Chapter 4—Group Development and Phase-Specific Tasks .................................................59 Overview ....................................................................................................................59 Fixed and Revolving Membership Groups ...........................................................................59 Preparing for Client Participation in Groups.......................................................................61 Phase-Specific Group Tasks ............................................................................................72 Chapter 5—Stages of Treatment ....................................................................................79 Overview ....................................................................................................................79 Adjustments To Make Treatment Appropriate .....................................................................79 The Early Stage of Treatment ..........................................................................................80 The Middle Stage of Treatment ........................................................................................85 The Late Stage of Treatment............................................................................................88 Chapter 6—Group Leadership, Concepts, and Techniques..................................................91 Overview ....................................................................................................................91 The Group Leader ........................................................................................................92 Concepts, Techniques, and Considerations ........................................................................105 Chapter 7—Training and Supervision............................................................................123 Overview...................................................................................................................123 Training....................................................................................................................123 Supervision................................................................................................................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 Figures 1-1 Differences Between 12-Step Self-Help Groups and Interpersonal Process Groups ...................4 2-1 Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models .............11 2-2 Characteristics of Five Group Models Used in Substance Abuse Treatment ...........................13 2-3 Group Vignette: Joe’s Argument With His Roommate.......................................................26 2-4 Joe’s Case in an Individually Focused Group .................................................................27 2-5 Joe’s Case in an Interpersonally Focused Group.............................................................28 2-6 Joe’s Case in a Group-As-A-Whole Focused Group..........................................................29 2-7 The SageWind Model for Group Therapy......................................................................33 3-1 Eco-Map ...............................................................................................................38 3-2 Client Placement by Stage of Recovery .........................................................................43 3-3 Client Placement Based on Readiness for Change............................................................44 3-4 What Is Culture? ....................................................................................................45 3-5 Diversity Wheel ......................................................................................................46 3-6 When Group Norms and Cultural Values Conflict ...........................................................48 3-7 Three Resources on Culture and Ethnicity ....................................................................48 3-8 Guidelines for Clinicians on Evaluating Bias and Prejudice...............................................49 3-9 Self-Assessment Guide ..............................................................................................50 3-10 Preparing the Group for a New Member From a Racial/Ethnic Minority..............................54 3-11 Culture and the Perception of Conflict ........................................................................57 4-1 Characteristics of Fixed and Revolving Membership Groups..............................................62 4-2 The Family Care Program of the Duke Addictions Program ..............................................66 4-3 SageWind..............................................................................................................67 4-4 Examples of Agreements About Time and Attendance ......................................................69 4-5 Examples of Agreements About Group Participation........................................................71 4-6 Reminders for Each Group Session .............................................................................74 6-1 Shame ..................................................................................................................95 6-2 Confidentiality and 42 C.F.R., Part 2.........................................................................110 6-3 Jody’s Arm ..........................................................................................................121 7-1 How Important Is It for a Substance Abuse Group Leader To Be in Recovery?.....................126 7-2 Does Online Communication Impede Attachment? .........................................................132 7-3 Group Experiential Training ....................................................................................133 Contents What Is a TIP? Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (DHHS), are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem. CSAT’s Knowledge Application Program (KAP) Expert Panel, a distinguished group of experts on substance use disorders and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the field’s current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Then recommendations are communicated to a Consensus Panel composed of experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group’s collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet at the URL: www.kap.samhsa.gov. The move to electronic media also means that the TIPs can be updated more easily so that they continue to provide the field with state-of-the-art information. While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey “front-line” information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists’ clinical experience or the literature. If research supports a particular approach, citations are provided. This TIP, Substance Abuse Treatment: Group Therapy, presents an overview of the role and efficacy of group therapy in substance abuse treatment planning. The goal of this TIP is to offer the latest research and clinical findings and to distill them into practical guidelines for practitioners of group therapy modalities in the field of substance abuse treatment. The TIP describes effective types of group therapy and offers a theoretical basis for group therapy’s effectiveness in the treatment of substance use disorders. This work also will be a useful guide to supervisors and trainers of beginning counselors, as well as to experienced counselors. Finally, the TIP is meant to provide researchers and clinicians with a guide to sources of information and topics for further inquiry. What Is a TIP? Consensus Panel Chair Philip J. Flores, Ph.D., COP, FAGPA Adjunct Clinical Supervisor Department of Psychology Georgia State University Atlanta, Georgia Co-Chair Jeffrey M. Georgi, M.Div., CGP, CSAC, LPC, CCS Clinical Director Department of Behavioral Science Duke School of Nursing and Duke University Medical Center Senior Clinician Duke Addictions Program Duke University Medical Center Durham, North Carolina Workgroup Leaders David W. Brook, M.D., CGP Department of Community and Preventive Medicine Mount Sinai Medical Center New York, New York Frederick Bruce Carruth, Ph.D., LCSW Private Practice Boulder, Colorado Sharon D. Chappelle, Ph.D., M.S.W., LCSW President Chief Executive Officer Chappelle Consulting and Training Services, Inc. Middletown, Connecticut David E. Cooper, Ph.D. Psychologist/Psychoanalyst Chestnut Lodge Hospital Chevy Chase, Maryland Charles Garvin, Ph.D. Professor of Social Work School of Social Work University of Michigan Ann Arbor, Michigan Panelists Marilyn Joan Freimuth, Ph.D. Psychologist/Faculty Member The Fielding Institute Bedford, New York Barbara Hardin-Perez, Ph.D. Director Student Health and Mental Health Services St. Mary’s University San Antonio, Texas Frankie D. Lemus, Jr., M.A. Clinical Director SageWind (Oikos, Inc.) Reno, Nevada Marilynn Morrical, CCDN, NCACII (Deceased 2002) Alcohol, Tobacco, and Drug Consultant Marilynn Morrical Consulting and Rehabilitation Reno, Nevada Tam K. Nguyen, M.D., LMSW, CCJS, DVC, MAC President Employee & Family Resources Polk City, Iowa Candace M. Shelton, M.S., CADAC Clinical Director Native American Connections, Inc. Tucson, Arizona Darren C. Skinner, Ph.D., LSW, CAC Director Gaudenzia, Inc. Gaudenzia House West Chester West Chester, Pennsylvania Judith S. Tellerman, Ph.D., MAT, M.Ed., Marsha Lee Vannicelli, Ph.D., FAGPA CGP Associate Clinical Professor Assistant Clinical Professor Department of Psychiatry College of Medicine Harvard Medical School University of Illinois Belmont, Massachusetts Chicago, Illinois Consensus Panel KAP Expert Panel and Federal Government Participants Barry S. Brown, Ph.D. Adjunct Professor University of North Carolina at Wilmington Carolina Beach, North Carolina Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS Professor of Clinical Psychiatry College of Medicine University of Cincinnati Cincinnati, Ohio Deion Cash Executive Director Community Treatment and Correction Center, Inc. Canton, Ohio Debra A. Claymore, M.Ed.Adm. Owner/Chief Executive Officer WC Consulting, LLC Loveland, Colorado Carlo C. DiClemente, Ph.D. Chair Department of Psychology University of Maryland Baltimore County Baltimore, Maryland Catherine E. Dube, Ed.D. Independent Consultant Brown University Providence, Rhode Island Jerry P. Flanzer, D.S.W., LCSW, CAC Chief, Services Division of Clinical and Services Research National Institute on Drug Abuse Bethesda, Maryland Michael Galer, D.B.A., M.B.A., M.F.A. Independent Consultant Westminster, Massachusetts Renata J. Henry, M.Ed. Director Division of Alcoholism, Drug Abuse, and Mental Health Delaware Department of Health and Social Services New Castle, Delaware Joel Hochberg, M.A. President Asher & Partners Los Angeles, California Jack Hollis, Ph.D. Associate Director Center for Health Research Kaiser Permanente Portland, Oregon Mary Beth Johnson, M.S.W. Director Addiction Technology Transfer Center University of Missouri—Kansas City Kansas City, Missouri Eduardo Lopez, B.S. Executive Producer EVS Communications Washington, DC Holly A. Massett, Ph.D. Academy for Educational Development Washington, DC Diane Miller Chief Scientific Communications Branch National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland Harry B. Montoya, M.A. President/Chief Executive Officer Hands Across Cultures Espanola, New Mexico Richard K. Ries, M.D. Director/Professor Outpatient Mental Health Services Dual Disorder Programs Seattle, Washington Gloria M. Rodriguez, D.S.W. Research Scientist Division of Addiction Services NJ Department of Health and Senior Services Trenton, New Jersey Everett Rogers, Ph.D. Center for Communications Programs Johns Hopkins University Baltimore, Maryland Jean R. Slutsky, P.A., M.S.P.H. Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, Maryland Nedra Klein Weinreich, M.S. President Weinreich Communications Canoga Park, California Clarissa Wittenberg Director Office of Communications and Public Liaison National Institute of Mental Health Kensington, Maryland Consulting Members of the KAP Expert Panel Paul Purnell, M.A. Vice President Social Solutions, L.L.C. Potomac, Maryland Scott Ratzan, M.D., M.P.A., M.A. Academy for Educational Development Washington, DC Thomas W. Valente, Ph.D. Director, Master of Public Health Program Department of Preventive Medicine School of Medicine University of Southern California Alhambra, California Patricia A. Wright, Ed.D. Independent Consultant Baltimore, Maryland KAP Expert Panel and Federal Government Participants Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission of building resilience and facilitating recovery for people with or at risk for mental or substance use disorders by providing best-practices guidance to clinicians, program administrators, and payors to improve the quality and effectiveness of service delivery, and, thereby promote recovery. 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 clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped to bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people who abuse substances. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Charles G. Curie, M.A., A.C.S.W. Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Executive Summary With the recognition of addiction as a major health problem in this country, demand has increased for effective treatments of substance use disorders. Because of its effectiveness and economy of scale, group therapy has gained popularity, and the group approach has come to be regarded as a source of powerful curative forces that are not always experienced by the client in individual therapy. One reason groups work so well is that they engage therapeutic forces—like affiliation, support, and peer confrontation—and these properties enable clients to bond with a culture of recovery. Another advantage of group modalities is their effectiveness in treating problems that accompany addiction, such as 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 group leader, the potential healing powers inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer reinforcement, act as a forum for self-expression, and teach new social skills. In short, group therapy can provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual therapy. Group therapy and addiction treatment are natural allies. One reason is that people who abuse substances are often more likely to stay sober and committed to abstinence when treatment is provided in groups, apparently because of rewarding and therapeutic benefits like affiliation, confrontation, support, gratification, and identification. This capacity of group therapy to bond patients to treatment is an important asset because the greater the amount, quality, and duration of treatment, the better the client’s prognosis (Leshner 1997; Project MATCH Research Group 1997). The primary audience for this TIP is substance abuse treatment counselors; 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 counselors in enhancing their therapeutic skills in regard to leading groups. The consensus panel for this TIP drew on its considerable experience in the group therapy field. The panel was composed of representatives from all of the disciplines involved in group therapy and substance abuse treatment, including alcohol and drug counselors, group therapists, mental health providers, and State government representatives. This TIP comprises seven chapters. Chapter 1 defines therapeutic groups as those with trained leaders and a primary intent to help people recover from substance abuse. It also explains why groups work so well for treating substance abuse. Chapter 2 describes the purpose, main characteristics, leadership, and techniques of five group therapy models, three specialty groups, and groups that focus on solving a single problem. Chapter 3 discusses the many considerations that should be weighed before placing a client in a particular group, especially keying the group to the client’s stage of change and stage of recovery. This chapter also concentrates on issues that arise from client diversity. Chapter 4 compares fixed and revolving types of therapy groups and recommends ways to prepare clients for participation: pregroup interviews, retention measures, and most important, group agreements that specify clients’ expectations of each other, the leader, and the group. Chapter 4 also specifies the tasks that need to be accomplished in the early, middle, and late phases of group development. Chapter 5 turns to the stages of treatment. In the early, middle, and late stages of treatment, clients’ conditions will differ, requiring different therapeutic strategies and approaches to leadership. Chapter 6 is the how-to segment of this TIP. It explains the characteristics, duties, and concepts important to promote effective group leadership in treating substance abuse, includ ing how confidentiality regulations for alcohol and drug treatment apply to group therapy. Chapter 7 highlights training opportunities available to substance abuse treatment professionals. The chapter also recommends the supervisory group as an added measure that improves group leadership and gives counselors in the group insights about how clients may experience groups. Throughout this TIP, the term “substance abuse” has been used to refer to both substance abuse and substance dependence (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision [DSM-IV-TR] [American Psychiatric Association 2000]). This term was chosen partly because substance abuse treatment professionals commonly use the term “substance abuse” to describe any excessive use of addictive substances. In this TIP, the term refers to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders described by DSM-IV. The sections that follow summarize the content in this TIP and are grouped by chapter. 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 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 Executive Summary 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. Executive Summary 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 (42 C.F.R., Part 2) •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 sub stances 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 pre- group 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 (Margolis and Zweben 1998). 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. Executive Summary 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. Executive Summary 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 cooccurring 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 healthcare 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. Training and Supervision National professional organizations are a rich source of training. Through conferences or regional chapters, national associations provide training—both experiential and direct instruction— geared to the needs of a wide range of persons, from graduate students to highly experienced therapists. More training options are usually available in large urban areas. It is likely, however, that online training will make some types of professional development accessible to a greater number of counselors in remote areas. Clinical supervision as it pertains to group therapy often is best carried out within the context of group supervision. Group dynamics and group process facilitate learning by setting up a microcosm of a larger social environment. Each group member’s style of interaction will inevitably show up in the group transactions. As this process unfolds, group members, guided by the supervisor, learn to model effective behavior in an accepting group context. Supervisory groups reduce, rather than escalate, the level of threat that can accompany supervision. In place of isolation and alienation, group participation gives counselors a sense of community. They find that others share their worries, fears, frustrations, temptations, and ambivalence. This reassurance is of particular benefit to novice group counselors. Executive Summary In This Chapter… Introduction Defining Therapeutic Groups in Substance Abuse Treatment Advantages of Group Treatment Modifying Group Therapy To Treat Substance Abuse Approach of This TIP 1 Groups and Substance Abuse Treatment Overview The natural propensity of human beings to congregate makes group therapy a powerful therapeutic tool for treating substance abuse, one that is as helpful as individual therapy, and sometimes more successful. One reason for this efficacy is that groups intrinsically have many rewarding benefits—such as reducing isolation and enabling members to witness the recovery of others—and these qualities draw clients into a culture of recovery. Another reason groups work so well is that they are suitable especially for treating problems that commonly accompany substance abuse, such as depression, isolation, and shame. Although many groups can have therapeutic effects, this TIP concentrates only on groups that have trained leaders and that are designed to promote recovery from substance abuse. Great emphasis is placed on interpersonal process groups, which help clients resolve problems in relating to other people, problems from which they have attempted to flee by means of addictive substances. While this TIP is not intended as a training manual for individuals training to be group therapists, it provides substance abuse counselors with insights and information that can improve their ability to manage the groups they currently lead. Introduction The lives of individuals are shaped, for better or worse, by their experiences in groups. People are born into groups. Throughout life, they join groups. They will influence and be influenced by family, religious, social, and cultural groups that constantly shape behavior, self-image, and both physical 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 biologically determined, we are, from the start, social creatures. This propensity to congregate is a powerful therapeutic tool. Formal therapy groups can be a compelling source of persuasion, stabilization, and support. Groups organized around therapeutic goals can enrich members with insight and guidance; and during times of crisis, groups can comfort and guide people who otherwise might be unhappy or lost. In the hands of a skilled, well-trained group leader, the potential curative forces inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer reinforcement, act as a forum for self- expression, and Groups provide teach new social skills. In short, group therapy can positive peer provide a wide range of therapeutic ser support and vices, comparable in efficacy to those pressure to abstain delivered in individual therapy. In some from substances cases, group therapy can be more benefi of abuse. cial than individual therapy (Scheidlinger 2000; Toseland and Siporin 1986). Group therapy and addiction treatment are natural allies. One reason is that people who abuse substances often are more likely to remain abstinent and committed to recovery when treatment is provided in groups, apparently because of rewarding and therapeutic forces such as affiliation, confrontation, support, gratification, and identification. This capacity of group therapy to bond patients to treatment is an important asset because the greater the amount, quality, and duration of treatment, the better the client’s prognosis (Leshner 1997; Project MATCH Research Group 1997). The effectiveness of group therapy in the treatment of substance abuse also can be attributed to the nature of addiction and several factors associated with it, including (but not limited to) depression, anxiety, isolation, denial, shame, temporary cognitive impairment, and character pathology (personality disorder, structural deficits, or an uncohesive sense of self). Whether a person abuses substances or not, these problems often respond better to group treatment than to individual therapy (Kanas 1982; Kanas and Barr 1983). Group therapy is also effective because people are fundamentally relational creatures. Defining Therapeutic Groups in Substance Abuse Treatment All groups can be therapeutic. Anytime someone becomes emotionally attached to other group members, a group leader, or the group as a whole, the relationship has the potential to influence and change that person. Identifying a group as “therapy” does not imply that other groups are not therapeutic. In preparing this TIP, the consensus panel debated at length what constitutes “group therapy” and what distinguishes therapy groups from other types of groups. Although many types of groups can have therapeutic elements and effects, the group types included in this TIP are based on the goals and intentions of the groups, as well as the intended audience of the TIP (especially substance abuse treatment counselors and other substance abuse treatment professionals). Thus, this TIP is limited to groups that (1) have trained leaders and (2) intend to produce some type of healing or recovery from substance abuse. This TIP describes (in chapter 2) five models of group therapy currently used in substance abuse treatment: •Psychoeducational groups, which teach about substance abuse. Groups and Substance Abuse Treatment •Skills development groups, which hone the skills necessary to break free of addictions. •Cognitive–behavioral groups, which rearrange patterns of thinking and action that lead to addiction. •Support groups, which comprise a forum where members can debunk each other’s excuses and support constructive change. •Interpersonal process group psychotherapy (referred to hereafter as “interpersonal process groups” or “therapy groups”), which enable clients to recreate their pasts in the here-and-now of group and rethink the relational and other life problems that they have previously fled by means of addictive substances. Treatment providers routinely use the first four models and various combinations of them. The last is not as widely used, chiefly because of the extensive training required to lead such groups and the long duration of the groups, which demands a high degree of commitment from both providers and clients. All the same, many people enter substance abuse treatment with a long history of failed relationships exacerbated by substance use. In these cases, an extended period of therapy is warranted to resolve the client’s problems with relationships. The reality that extended treatment is not always feasible does not negate its desirability. This TIP does not discuss multifamily and multicouple groups, which are discussed in TIP 39, Substance Abuse Treatment and Family Therapy (Center for Substance Abuse Treatment 2004). Even though multifamily and multicouple groups typically are made up of unrelated groups of families, they focus on family relations as they affect and are affected by 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 of peer-led self-help groups such as Alcoholics Anonymous (AA) or group activities like social events, religious services, sports, and games. Any or all may have one or more therapeutic Groups and Substance Abuse Treatment effects, but are not specifically designed to achieve that purpose. Figure 1-1 (see p. 4) shows other differences between self-help groups and interpersonal process groups. In most aspects, the comparison would apply to the other four group models as well. Advantages of Group Treatment Treating adult clients in groups has many advantages, as well as some risks. Any treatment modality—group therapy, individual therapy, family therapy, and medication—can yield poor results if applied indiscriminately or administered by an unskilled or improperly trained therapist. The potential drawbacks of group therapy, however, are no greater than for any other form of treatment. Some of the numerous advantages to using groups in substance abuse treatment are described below (Brown and Yalom 1977; Flores 1997; Garvin unpublished manuscript; Vannicelli 1992). •Groups provide positive peer support and pressure to abstain from substances of abuse. Unlike AA, and, to some degree, substance abuse treatment program participation, group therapy, from the very beginning, elicits a commitment by all the group members to attend and to recognize that failure to attend, to be on time, and to treat group time as special disappoints the group and reduces its effectiveness. Therefore, both peer support and pressure for abstinence are strong. •Groups reduce the sense of isolation that most people who have substance abuse disorders experience. At the same time, groups can enable participants to identify with others who are struggling with the same issues. Although AA and treatment groups of all types provide these opportunities for sharing, for some people the more formal and deliberate nature of participation in process group therapy increases their feelings of security and enhances their ability to share openly. Figure 1-1 Differences Between 12-Step Self-Help Groups and Interpersonal Process Groups Self-Help Group Interpersonal Process Group Size Unlimited (often large) Small (8–15 members) Leadership • Peer leader or individual in recovery • Leadership is earned over time • Implicit hierarchical leadership structure • Trained professional • Appointed leader • Formal hierarchical leadership structure Participation 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 behavior and 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, morale building, catharsis, immediate positive feedback, 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) Group Goals • Positive goal setting, behaviorally oriented • Focus on the group as a whole and the similarities among members • Ambitious goals: immediate problem plus individual personality issues • Individual as well as group focus Leader Activity • Educator/role model, catalyst for learning • Less member-to-leader distance • Responsible for directing therapeutic group experience • More member-to-leader distance Use of PsychodynamicTechniques No Yes Confidentiality Anonymity preserved Anonymity strongly emphasized and includes everything that occurs in the group, not just the identity of group members Groups and Substance Abuse Treatment Self-Help Group Interpersonal Process Group SponsorshipProgram Yes (usually same sex) None Determination of Time in Group • Members may leave group at their own choosing • Members may avoid self-disclosure or discussion of any subject • Predetermined minimal term of group membership • Avoidance of discussion seen as possible “resistance” Involvement in Other Therapies Yes Yes—eclectic models No—psychodynamic models Time Factors Unlimited group participation possible over years Often time-limited group experiences Frequencyof Meetings Active encouragement of dailyparticipation Meets less frequently (often once or twice weekly) Source: Adapted from Spitz 2001. Used with permission. •Groups enable people who abuse substances to witness the recovery of others. From this inspiration, people who are addicted to substances gain hope that they, too, can maintain abstinence. Furthermore, an interpersonal process group, which is of long duration, allows a magnified witnessing of both the changes related to recovery as well as group members’ intra- and interpersonal changes. • Groups help members learn to cope with their substance abuse and other problems by allowing them to see how others deal with similar problems. Groups can accentuate this process and extend it to include changes in how group members relate to bosses, parents, spouses, siblings, children, and people in general. •Groups can provide useful information to clients who are new to recovery. For example, clients can learn how to avoid certain triggers for use, the importance of abstinence as a priority, and how to self-identify as a person recovering from substance abuse. Group experiences can help deepen these insights. For example, self-identifying as a Groups and Substance Abuse Treatment person recovering from substance abuse can be a complex process that changes significantly during different stages of treatment and recovery and often reveals the set of traits that makes the system of a person’s self as altogether unique. •Groups provide feedback concerning the values and abilities of other group members. This information helps members improve their conceptions of self or modify faulty, distorted conceptions. In terms of process groups in particular, as specific themes emerge in a client’s group experience, repetitive feedback from multiple group members and the therapist can chip away at those faulty or distorted conceptions in slightly different ways until they not only are correctable, but also the very process of correction and change is revealed through the examination of the group processes. •Groups offer family-like experiences. Groups can provide the support and nurturance that may have been lacking in group members’ families of origin. The group also gives members the opportunity to practice healthy ways of interacting with their families. •Groups encourage, coach, support, and reinforce as members undertake difficult or anxiety-provoking tasks. •Groups offer members the opportunity to learn or relearn the social skills they need to cope with everyday life instead of resorting to substance abuse. Group members can learn by observing others, being coached by others, and practicing skills in a safe and supportive environment. •Groups can effectively confront individual members about substance abuse and other harmful behaviors. Such encounters are possible because groups speak with the combined authority of people who have shared common experiences and common problems. Confrontation often plays a part of substance abuse treatment groups because group members tend to deny their problems. Participating in the confrontation of one group member can help others recognize and defeat their own denial. •Groups allow a single treatment professional to help a number of clients at the same time. In addition, as a group develops, each group member eventually becomes acculturated to group norms and can act as a quasi-therapist himself, thereby ratifying and extending the treatment influence of the group leader. •Groups can add needed structure and discipline to the lives of people with substance use disorders, who often enter treatment with their lives in chaos. Therapy groups can establish limitations and consequences, which can help members learn to clarify what is their responsibility and what is not. •Groups instill hope, a sense that “If he can make it, so can I.” Process groups can expand this hope to dealing with the full range of what people encounter in life, overcome, or cope with. •Groups often support and provide encouragement to one another outside the group setting. For interpersonal process groups, though, outside contacts may or may not be disallowed, depending on the particular group contract or agreements. Modifying Group Therapy To Treat Substance Abuse Modifying group therapy to make it applicable to and effective with clients who abuse substances requires three improvements. One is specific training and education for therapists so that they fully understand therapeutic group work and the special characteristics of clients with substance use disorders. The importance of understanding the curative process that occurs in groups cannot be underestimated. Most substance abuse counselors have responded by adapting skills used in individual therapy. Counselors have also sought direction, clinical training, and practical suggestions. Despite individual efforts, however, group therapy often is conducted as individual therapy in a group. Individual therapy is not equivalent to group therapy. Some principles that work well with individuals are inappropriate for group therapy. Using the wrong approach may lead to several undesirable results. First, the rich potential of groups––self-understanding, psychological growth, emotional healing, and true intimacy–– will be left unfulfilled. Second, group leaders who are unfamiliar with and insensitive to issues that manifest themselves in group therapy may find themselves in a difficult situation. Third, therapists who think they are doing group therapy when they actually are not may observe the poor results and conclude that group therapy is ineffective. Compounding all these difficulties is the fact that group therapy is so ubiquitous. Thus, poorly conceived approaches are being used frequently. Group therapy also is not equivalent to 12-Step program practices. Many therapists who lack full qualifications for group work have adapted practices from AA and other 12-Step programs for use in therapeutic groups. To say that this borrowing is inadvisable is not to say that the principles of AA are inadequate. On the contrary, many people seem to be unable to recover from dependency without AA or a program Groups and Substance Abuse Treatment similar to it. For this reason, most effective treatment programs make attendance at AA or another 12-Step program a mandatory part of the treatment process. By the same token, AA and other 12-Step programs are not group therapy. Rather, they are complementary components to the recovery process. Twelve-Step programs can help keep the individual who abuses substances abstinent while group therapy provides opportunities for these individuals to understand and explore the emotional and interpersonal conflicts that can contribute to substance abuse. Progress toward optimal group therapy has also been hindered by the misconception that group therapy with clients who have addictions does not require specially qualified leaders. This notion is false. Therapy groups cannot just take care of themselves. Group therapy, properly conducted, is difficult. One reason that it is challenging has to do with the nature of the clients; an addicted population poses unique problems for the group therapy leader. A second reason is the complexity of group therapy; the leader requires a vast amount of specialized knowledge and skills, including a clear understanding of group process and the stages of development of group dynamics. Such mastery only comes with extended training and experience leading groups. Many groups led by untrained or poorly trained leaders have not fulfilled their potential and may even have had negative effects on a client’s recovery. It matters little whether the inadequately trained group therapist is a person who once abused substances or someone who developed knowledge in a traditional course of academically based training. Where problems exist, they usually relate to one of two deficiencies: a lack of effective group therapy training or use of a group therapy model that is inadequate for clients who are chemically dependent. Additional training and education is needed to produce therapists who are well qualified to lead therapy groups composed primarily of individuals who are chemically dependent. Groups and Substance Abuse Treatment A second major improvement needed if people who have addictions are to benefit from group therapy is a clear answer to the question, “Why is group therapy so effective for people with addictions?” We already have part of the answer, and it lies in the individual with addiction, a person whose character style often involves a defensive posture commonly referred to as denial. Addiction is, in fact, frequently referred to as a disease of denial. The individual who is chemically dependent usually comes into treatment with an uncommonly complex Groups instill set of defenses and character pathology. hope, a sense that Any group leader who intends to help people “If he can make it, who have addictions benefit from treatment should have a so can I.” clear understanding of each group member’s defensive process and character dynamics. More than 20 years ago, John Wallace (1978) wrote about this important issue in an informative essay on the defensive style of the individual who is addicted to alcohol. He referred to these character- related defensive features as the preferred defense system of the individual addicted to alcohol. A third major modification needed is the adaptation of the group therapy model to the treatment of substance abuse. The principles of group therapy need to be tailored to meet the realities of treating clients with substance use disorders. For the most part, group therapy has been based on a model derived from outpatient therapy for clients whose problems may or may not include substance abuse. The theoretical underpinnings and practical applications of general group therapy are not always applicable to individuals who abuse substances. Substance abuse treatment sometimes is implemented as a grab bag of strategies, approaches, and techniques that were not tailored for people with substance use disorders. Further, the common characteristics and typical dynamics seen in this population have not always been evaluated adequately, and this lapse has inhibited the development of effective methods of treatment for these clients. This model suitability problem is further complicated by the fact that clients with substance use disorders, and even staff members, often become confused about the different types of group treatment modalities. For instance, in the course of their treatment, clients may engage in AA, Narcotics Anonymous, other 12-Step groups, discussion groups, educational groups, continuing care groups, and support groups. Given this mix, clients often become confused about the purpose of group therapy, and the treatment staff some- This TIP will help times underestimates the impact that counselors expand group therapy can make on an individtheir awareness ual’s recovery. The upshot of these and comprehen problems has been partial or complete sion of dynamics failure; that is, the techniques andoccurring in their strategies that usually work with the gen treatment groups. eral psychiatric population often do not work with people abusing substances. A further negative result is that the clients who have addictions may be unfairly viewed as poor treatment risks—people resistant to treatment and unmotivated to change. Time also is an important factor in a person’s recovery. What a group leader does in group therapy with clients in an inpatient setting in a hospital during the first few days or weeks of recovery will differ dramatically from what that same group therapist will do with the same recovering person in a continuing care group 6 months into abstinence with the expectation that the person will remain in the group at least another 6 to 12 months. Approach of This TIP While this TIP does not provide the training needed to become an interpersonal process group therapist, the point of view, attitudes, and considerations of these group therapists infuse the discussions throughout this TIP. The panel hopes that this TIP will help counselors expand their awareness and comprehension of dynamics that might be going on in their current substance abuse treatment groups. These insights will help counselors become better prepared to manage their groups and their individual members, inform group members’ individual therapists of possible issues that need resolution, record dynamics and issues for use in treatment during later stages of recovery, and improve retention by appropriately acknowledging issues that are outside the scope of the group. The TIP will achieve its purpose to the extent that it assists counselors as they juggle immediate client needs, interactions in groups, tasks leading to recovery, and sheer human complexity. Groups and Substance Abuse Treatment In This Chapter… Five Group Models Psychoeducational Groups Skills Development Groups Cognitive–Behavioral Groups Support Groups Interpersonal Process Group Psychotherapy Specialized Groups in Substance Abuse Treatment Relapse Prevention Communal and Culturally Specific Groups Expressive Groups Groups Focused on Specific Problems 2 Types of Groups Commonly Used in Substance Abuse Treatment Overview This chapter presents five models of groups used in substance abuse treatment, followed by three representative types of groups that do not fit neatly into categories, but that, nonetheless, have special significance in 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, and typical techniques for these groups are described. Introduction Substance abuse treatment professionals employ a variety of group treatment models to meet client needs during the multiphase process of recovery. A combination of group goals and methodology is the primary way to define the types of groups used. This TIP describes five group therapy models that are effective for substance abuse treatment: • Psychoeducational groups • Skills development groups • Cognitive–behavioral/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 therapeutic experiences for group members. A model, however, has to be matched with the needs of the particular population being treated; the goals of a particular group’s treatment also are an important determinant of the model that is chosen. This chapter describes the group’s purpose, principal characteristics, leadership requisites, and appropriate techniques for each type of group. Also discussed are three specialized types of groups that do not fit into the five model categories, but that function as unique entities in the substance abuse treatment field: •Relapse prevention treatment groups •Communal and culturally specific treatment groups •Expressive groups (including art therapy, dance, psychodrama) Figure 2-1 lists some groups commonly used in substance abuse treatment and classifies them into the five-model framework used in this TIP. This list of groups is by no means exhaustive, but it demonstrates the variety of groups found in substance abuse treatment settings. Occasionally, discussions in this TIP refer to the stages of change delineated by Prochaska and DiClemente (1984). They examined 18 psychological and behavioral theories of how change occurs, including the components of a biopsychosocial framework for understanding substance abuse. Their result was a continuum of six categories for understanding client motivation for changing substance abuse behavior. The six stages are: •Precontemplation. Clients are not thinking about changing substance abuse behavior and may not consider their substance abuse to be a problem. •Contemplation. Clients still use substances, but they begin to think about cutting back or quitting substance use. •Preparation. Clients still use substances, but intend to stop since they have recognized the advantages of quitting and the undesirable consequences of continued use. Planning for change begins. •Action. Clients choose a strategy for discontinuing substance use and begin to make the changes needed to carry out their plan. This period generally lasts 3–6 months. •Maintenance. Clients work to sustain abstinence and evade relapse. From this stage, some clients may exit substance use permanently. •Recurrence. Many clients will relapse and return to an earlier stage, but they may move quickly through the stages of change and may have gained new insights into problems that defeated their former attempts to quit substance abuse (such as unrealistic goals or frequenting places that trigger relapse). For a detailed description of the stages of change, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] 1999b). The client’s stage of change will dictate which group models and methods are appropriate at a particular time. If the group is composed of members in the action stage who have clearly identified themselves as substance dependent, the group will be conducted far differently from one composed of people who are in the precontemplative stage. Priorities change with time and experience, too. For example, a group of people with substance use disorders on their second day of abstinence is very different from a group with 1 or 2 years of sobriety. Theoretical orientations also have a strong impact on the tasks the group is trying to accomplish, what the group leader observes and responds to in a group, and the types of interventions that the group leader will initiate. Before a group model is applied in treatment, the group leader and the treating institution should decide on the theoretical frameworks to be used, because each group model requires different actions on the part of the group leader. Since most treatment programs offer a variety of groups for substance abuse treatment, it is important that these models be consistent with clearly defined theoretical approaches. In practice, however, groups can, and usually do, use more than one model, as shown in Figure 2-1. For example, a therapy group in an intensive early recovery treatment setting might combine elements of psychoeducation (to show how drugs have ravaged the individual’s life), skills development (to help the client maintain abstinence), and support (to teach individuals how to relate to other group members in an honest and open fashion). Therefore, the Types of Groups Commonly Used in Substance Abuse Treatment Figure 2-1 Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models Group Types Group Model or Combination of Models Skills Development Cognitive– Behavioral Therapy InterpersonalProcess Support SpecializedGroup* Psychoeducational 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 • Cognitive–behavioral • • • Psychodrama • Adventure-based • Marathon • Humanistic/existential • • Source: Consensus Panel. *See “Specialized Groups in Substance Abuse Treatment” on p. 29. Types of Groups Commonly Used in Substance Abuse Treatment descriptions of the groups in this chapter are of ideal, pure forms that rarely stand alone in practice. It must be acknowledged, too, that the terms used to describe groups are not altogether clear-cut and consistent. In different treatment settings, programs, and regions of the country, a term like “support group” may be used to refer to different types of treatment groups, including a relapse prevention group. Despite such discrepancies between neat theory and untidy practice, little difficulty will arise if the group leader exercises sound clinical judgment regarding models and interventions to be used. One exception to this assurance, however, should be noted. Close adherence to the theory that dictates the way an interpersonal process group should be conducted has crucial implications for its success. Five Group Models Figure 2-2 summarizes the characteristics of five therapeutic group models used in substance abuse treatment. Variable factors include the focus of group attention, specificity of the group agenda, heterogeneity or homogeneity of group members, open-ended or determinate duration of treatment, level of facilitator or leader activity, training required for the group leader, length of sessions, and preferred arrangement of the room. Psychoeducational Groups Psychoeducational groups are designed to educate clients about substance abuse, and related behaviors and consequences. This type of group presents structured, group-specific content, often taught using videotapes, audiocassette, or lectures. Frequently, an experienced group leader will facilitate discussions of the material (Galanter et al. 1998). Psychoeducational groups provide information designed to have a direct application to clients’ lives—to instill self-awareness, suggest options for growth and change, identify community resources that can assist clients in recovery, develop an understanding of the process of recovery, and prompt people using substances to take action on their own behalf, such as entering a treatment program. While psychoeducational groups may inform clients about psychological issues, they do not aim at intrapsychic change, though such individual changes in thinking and feeling often do occur. Purpose. The major purpose of psychoeducational groups is expansion of awareness about the behavioral, medical, and psychological consequences of substance abuse. Another prime goal is to motivate the client to enter the recovery- ready stage (Martin et al. 1996; Pfeiffer et al. 1991). Psychoeducational groups are provided to help clients incorporate information that will help them establish and maintain abstinence and guide them to more productive choices in their lives. These groups also can be used to counteract clients’ denial about their substance abuse, increase their sense of commitment to continued treatment, effect changes in maladaptive behaviors (such as associating with people who actively use drugs), and supporting behaviors conducive to recovery. Additionally, they are useful in helping families understand substance abuse, its treatment, and resources available for the recovery process of family members. Some of the contexts in which psychoeducational groups may be most useful are •Helping clients in the precontemplative or contemplative level of change to reframe the impact of drug use on their lives, develop an internal need to seek help, and discover avenues for change. •Helping clients in early recovery learn more about their disorders, recognize roadblocks to recovery, and deepen understanding of the path they will follow toward recovery. •Helping families understand the behavior of a person with substance use disorder in a way that allows them to support the individual in recovery and learn about their own needs for change. •Helping clients learn about other resources that can be helpful in recovery, such as Types 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 focus Specificity of thegroup agenda Heterogeneousor homogeneous Open-ended/ determinate Level of facilitator activity Psycho- educational Leader focused Specific Either Either High Skills Leader Specific Either Either High development focused (depending on topic) Cognitive– behavioral Mixed/ balanced Either Either Either High Support Group focus Nonspecific Either Open Low to moderate Interpersonal process Group focus Nonspecific Heterogeneous Open Low to moderate Groupmodel Level of facilitator activity Duration of treatment Length ofsession Space and arrangement Leader training Psycho- educational High Limited by program requirements 15 to 90 minutes Horseshoe or circle Basic Skills High Variable 45 to 90 Horseshoe Basic with development minutes or circle some specialized training Cognitive– High Variable and 60 to 90 Circle Specialized behavioral open-ended minutes training Support Low to moderate Open-ended 45 to 90 minutes Circle Specialized training with process- oriented skills Interpersonal Low to Open-ended 1 to 2 hours Circle Specialized Process moderate training in interpersonal process groups meditation, relaxation training, anger management, spiritual development, and nutrition. Principal characteristics. Psychoeducational groups generally teach clients that they need to learn to identify, avoid, and eventually master the specific internal states and external circumstances associated with substance abuse. The Types of Groups Commonly Used in Substance Abuse Treatment coping skills (such as anger management or the use of “I” statements) normally taught in a skills development group often accompany this learning. Psychoeducational groups are considered a useful and necessary, but not sufficient, component of most treatment programs. For instance, psychoeducation might move clients in a precontemplative or perhaps contemplative stage to commit to treatment, including other forms of group therapy. For clients who enter treatment through a psychoeducational group, programs should have clear guidelines about when members of the group are ready for other types of group treatment. Often, a psychoeducational group integrates skills devel- Psychoeducational opment into its program. As part of a groups are highly larger program, psychoeducationalstructured and groups have been used to help clients often follow a reflect on their own behavior, learn new manual or a ways to confront problems, and increase their self preplanned esteem (La Salvia 1993). curriculum. Psychoeducational groups should work actively to engage participants in the group discussion and prompt them to relate what they are learning to their own substance abuse. To ignore group process issues will reduce the effectiveness of the psychoeducational component. Psychoeducational groups are highly structured and often follow a manual or a pre- planned curriculum. Group sessions generally are limited to set times, but need not be strictly limited. The instructor usually takes a very active role when leading the discussion. Even though psychoeducational groups have a format different from that of many of the other types of groups, they nevertheless should meet in a quiet and private place and take into account the same structural issues (for instance, seating arrangements) that matter in other groups. As with any type of group, accommodations may 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 be effective with clients with co-occurring mental disorders, including clients with schizophrenia (Addington and el-Guebaly 1998; Levy 1997; Pollack and Stuebben 1998). For more information on making accommodations for clients with disabilities, see TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998b). Leadership skills and styles. Leaders in psychoeducational groups primarily assume the roles of educator and facilitator. Still, they need to have the same core characteristics as other group therapy leaders: caring, warmth, genuineness, and positive regard for others. Leaders also should possess knowledge and skills in three primary areas. First, they should understand basic group process—how people interact within a group. Subsets of this knowledge include how groups form and develop, how group dynamics influence an individual’s behavior in group, and how a leader affects group functioning. Second, leaders should understand interpersonal relationship dynamics, including how people relate to one another in group settings, how one individual can influence the behavior of others in group and some basic understanding of how to handle problematic behaviors in group (such as being withdrawn). Finally, psychoeducational group leaders need to have basic teaching skills. Such skills include organizing the content to be taught, planning for participant involvement in the learning process, and delivering information in a culturally relevant and meaningful way. To help clients get the most out of psychoeducational sessions, leaders need basic counseling skills (such as active listening, clarifying, supporting, reflecting, attending) and a few advanced ones (such as confronting and terminating) (Brown 1998). It also helps to have leadership skills, such as helping the group get started in a session, managing (though not necessarily eliminating) conflict between group members, encouraging withdrawn group members to be more active, and making sure that Types of Groups Commonly Used in Substance Abuse Treatment all group members have a chance to participate. As the group unfolds, it is important that group leaders are nondogmatic in their dealings with group members. Finally, the group leader should have a firm grasp of material being communicated in the psychoeducational group. During a session, the group leader should be mindful both of the group’s need and the specific needs of each member. The group leader will need to understand group member roles and how to manage problem clients. Except in unusual circumstances, efforts should be made to increase members’ comfort and to reduce anxiety in the group. Leaders will use a variety of resources to impart knowledge to the group, so each session also requires preparation and familiarization with the content to be delivered. Group leaders should have ongoing training and formal supervision. Supervision benefits all group leaders of all levels of skill and training, as it helps to assure them that people in positions of authority are interested in their development and in their work. If direct supervision is not possible (as may be the case in remote, rural areas), then Internet discussions or regular telephone contact should be used. Techniques. Techniques to conduct psychoeducational groups are concerned with (1) how information is presented, and (2) how to assist clients to incorporate learning so that it leads to productive behavior, improved thinking, and emotional change. Adults in the midst of crises in their lives are much more likely to learn through interaction and active exploration than they are through passive listening. As a result, it is the responsibility of the group leader to design learning experiences that actively engage the participants in the learning process. Four elements of active learning can help. First, the leader should foster an environment that supports active participation in the group and discourages passive note taking. Accordingly, leader lecturing should be limited in duration and extent. The leader should concentrate instead on facilitating group discussion, especially among clients who are withdrawn and have little to say. They need support and under- Types of Groups Commonly Used in Substance Abuse Treatment standing of the content before expressing their views. Techniques such as role playing, group problemsolving exercises, and structured experiences all foster active learning. Second, the leader should encourage group participants to take responsibility for their learning rather than passing on that responsibility to the group leader. From the outset of the group, the leader can emphasize group self- ownership by allowing members to participate in setting agreements and other group boundaries. The leader can emphasize member responsibility for honest, respectful interaction among all members and can de-emphasize the leader role in determining group life. Third, because many people have pronounced preferences for learning through a particular sense (hearing, sight, touch/movement), it is essential to use a variety of learning methods that call for different kinds of sensory experience. Excellent material on adapting instruction to learning styles is available through the Association for Supervision and Curriculum Development Web site, http://www.ASCD.org. To access the many articles and book chapters, enter “learning styles” into the search function and click the “Go” button. Most people, at one time or another, have had unpleasant experiences in traditional, formal classroom environments. The resulting shame, rejection, and self-deprecation strongly motivate people to avoid situations where these experiences might be brought back into awareness. Therefore it is critically important for the group leader to be sensitive to the anxiety that can be aroused if the client is placed in an environment that replicates a disturbing scene from the past. To allay some of these concerns, leaders can acknowledge the anxieties of participants, prevent all group participants from mocking others’ comments or ideas, and show sensitivity to the meaning of a participant’s withdrawal in the group. Overall, leaders should create an environment where participants who are having difficulty with the psychoeducational group process can express their concerns and receive support. Fourth, people with alcoholism and other addictive disorders are known to have subtle, neuropsychological impairments in the early stage of abstinence. Verbal skills learned long ago (that is, crystallized intelligence) are not affected, but fluid intelligence, needed to learn some kinds of new information, is impaired. As a result, clients may seem more able to learn than they actually are. Therapists who are teaching new skills should be mindful of this difficulty. Skills Development Groups Most skills development groups operate from a cognitive–behavioral orientation, although counselors and therapists from a variety of orientations apply skills development techniques in their practice. Many skills development groups incorporate psychoeducational elements into the group process, though skills development may remain the primary goal of the group. Purpose. Coping skills training groups (the most common type of skills development group) attempt to cultivate the skills people need to achieve and maintain abstinence. These skills may either be directly related to substance use (such as ways to refuse offers of drugs, avoid triggers for use, or cope with urges to use) or may apply to broader areas relevant to a client’s continued sobriety (such as ways to manage anger, solve problems, or relax). Skills development groups typically emerge from a cognitive–behavioral theoretical approach that assumes that people with substance use disorders lack needed life skills. Clients who rely on substances of abuse as a method of coping with the world may never have learned important skills that others have, or they may have lost these abilities as the result of their substance abuse. Thus, the capacity to build new skills or relearn old ones is essential for recovery. Since many of the skills that people with substance abuse problems need to develop are interpersonal in nature, group therapy becomes a natural treatment of choice for skills development. Members can practice with each other, see how different people use the same skills, and feel the positive reinforcement of a peer group (rather than that of a single professional) when they use skills effectively. Principal characteristics. Because of the degree of individual variation in client needs, the particular skills taught to a client should depend on an assessment that takes into account individual characteristics, abilities, and background. The suitability of a client for a skills development group will depend on the unique needs of the individual along with the skills being taught. Most clients can benefit from developing or enhancing certain general skills, such as controlling powerful emotions or improving refusal skills when around people using alcohol or illicit drugs. Skills might also be highly specific to certain clients, such as relaxation training. Skills development groups usually run for a limited number of sessions. The size of the group needs to be limited, with an ideal range of 8 to 10 participants (perhaps more, if a cofacilitator is present). The group has to be small enough for members to practice the skills being taught. While skills development groups often incorporate elements of psychoeducation and support, the primary goal is on building or strengthening behavioral or cognitive resources to cope better in the environment. Psychoeducational groups tend to focus on developing an information base on which decisions can be made and action taken. Support groups, to be discussed later in this chapter, focus on providing the internal and environmental supports to sustain change. All are appropriate in substance abuse treatment. While a specific group may incorporate elements of two or more of these models, it is important to maintain focus on the overall goal of the group and link methodology to that goal. Leadership skills and styles. In skills development groups, as in psychoeducation, leaders need basic group therapy knowledge and skills, such as understanding the ways that groups Types of Groups Commonly Used in Substance Abuse Treatment grow and evolve, knowledge of the patterns that show how people relate to one another in group, skills in fostering interaction among members, managing conflict that inevitably arises among members in a group environment, and helping clients take ownership for the group. In addition, group leaders should know and be able to demonstrate the set of skills that the participants are trying to develop. Leaders also will need significant experience in modeling behavior and helping others learn discrete elements of behavior. Other general skills, such as sensitivity to what is going on in the room and cultural sensitivity to differences in the ways people approach issues like anger or assertiveness, also will be important. Depending on the skill being taught, there may be certain educational or certification requirements. For example, a nurse might be needed to teach specific health maintenance skills, or a trained facilitator may be needed to run certain meditation or relaxation groups. Techniques. The specific techniques used in a skills development group will vary greatly depending on the skills being taught. (For more information on the techniques used in cognitive– behavioral coping skills training see chapter 4 of TIP 34, Brief Interventions and Brief Therapies for Substance Abuse Treatment [CSAT 1999a].) It is useful to keep in mind that most skills, such as riding a bicycle or swimming, seem relatively simple, straightforward, and easy once incorporated into one’s repertoire of behavior. The process of learning and incorporating new skills, however, may be difficult, especially if the previous approach has been used for a long time. For instance, individuals who have been passive and nonassertive throughout life may have to struggle mightily to learn to stand up for themselves. As a consequence, it is crucial for leaders of skills development groups to be sensitive to the struggles of group participants, hold positive expectations for change, and not demean or shame individuals who seem overwhelmed by the task. Furthermore, many behavioral changes that seem straightforward on the surface Skills developmenthave powerful effects at deeper levels of groups typically psychological functioning. For instance, emerge from a cog- assertiveness may touch feelings of nitive–behavioral shame and unworthiness. Thus, new assertive competence approach. may be incompatible with and overwhelmed by deep feelings of inadequacy and low self-esteem. As a result, a client may learn a new behavior, but be unable to incorporate it into a repertoire of positive action. Counselors should not automatically assume, therefore, that a newly learned skill inevitably will translate into action. Feedback from participants on their progress since the last group is a good way to assess both learning and the incorporation of skills. An often unstated and underrecognized difficulty in leading skills groups is that a leader teaching the same material week after week can become bored with the content. In due course, the boredom will creep into the teaching. To retain energy and teaching effectiveness, leaders can switch topics, or one leader can teach different topics over time. When feasible, it also may help to provide feedback to leaders by making video or audio recordings of their presentations. Other specific techniques for skills development groups depend on the nature of the group, topic, and approach of the group leader. Before undertaking leadership of a skills development group, it is wise for the leader to have previously participated in the specific kind of skills development group to be led. Often special training programs are available for leaders of these kinds of groups. Types of Groups Commonly Used in Substance Abuse Treatment Cognitive–Behavioral Groups Cognitive–behavioral groups are a well- established part of the substance abuse treatment field and are particularly appropriate in early recovery. The term “cognitive–behavioral therapy group” covers a wide range of formats informed by a variety of theoretical frameworks, but the common thread is cognitive restructuring as the basic methodology of change. Purpose. Cognitive–behavioral groups conceptualize dependency as a learned behavior that is subject to modification through various interventions, including identification of conditioned stimuli associated with specific addictive behaviors, avoidance of such stimuli, development of enhanced contingency management strategies, and response-desensitization (McAuliffe and Ch’ien 1986). The etiologies of dependency include neurobehavioral factors (Rawson et al. 1990), biopsychosocial (Nunes- Dinis and Barth 1993; Wallace 1990), and the disease model (Miller and Chappel 1991), in which the key etiological determinants of dependency are genetic and physiological factors, ones that the person with dependency cannot control. Cognitive–behavioral therapy groups work to change learned behavior by changing thinking patterns, beliefs, and perceptions. The groups also work to develop social networks that support continued abstinence so the person with depen- Cognitive– dency becomes aware of behaviors behavioral groups that may lead to relapse and develops strategies to contin are particularly ue in recovery (Matano et al. appropriate in 1997). early recovery. Cognitive processes include a number of different psychological elements, such as thoughts, beliefs, decisions, opinions, and assumptions. A number of thoughts and beliefs are affected by an individual’s substance abuse and addiction. Some common errant beliefs of individuals entering recovery are •“I’m a failure.” •“I’m different.” •“I’m not strong enough to quit.” •“I’m unlovable.” •“I’m a (morally) bad person.” The word “morally” carries the implication of a “shame script” and feeling defective as a person. “Bad” alone refers more to behavior, or doing “bad things.” Changing such cognitions and beliefs may lead to greater opportunities to maintain sobriety and live more productively. Principal characteristics. In cognitive– behavioral groups for people who abuse substances, the group leader focuses on providing a structured environment within which group members can examine the behaviors, thoughts, and beliefs that lead to their maladaptive behavior. Treatment manuals— providing specific protocols for intervention techniques—may be helpful in some, though not all, cognitive–behavioral groups. In any case, most cognitive–behavioral groups emphasize structure, goal orientation, and a focus on immediate problems. Problem solving groups often have a specific protocol that systematically builds problemsolving skills and resources. One example is a model cognitive–behavioral group for women with posttraumatic stress disorder (PTSD) and substance abuse designed to •Educate clients about the two disorders •Promote self-control skills to manage overwhelming emotions •Teach functional behaviors that may have deteriorated as a result of the disorders •Provide relapse prevention training (Najavits et al. 1996) Types of Groups Commonly Used in Substance Abuse Treatment The group format is an important element of the model, given the importance of social support for PTSD and substance use disorders. In addition, group treatment is a well-established, relatively low-cost modality, so it can successfully reach a large number of clients. Some key characteristics of this program are that it •Uses a model designed for 24 sessions, in which 3–10 members meeting twice each week for 3 months in 90-minute group meetings •Is early-recovery–oriented, with a strong focus on coping skills to gain control over symptoms •Has homogeneous membership (for example, all women) •Includes a six-session unit on relationships and themes, such as Safety and Self- protection and Reaching Out for Help •Uses educational devices to promote rapid and sustained learning of material, such as visual aids, role preparation, memory improvement techniques, written summaries, review sessions, homework, and audiotapes of each session •Focuses on both disorders, with instruction on stages of recovery to motivate members to achieve abstinence and control over PTSD symptoms (Najavits et al. 1996) Another cognitive–behavioral model was employed to reduce the anger that can trigger renewed use of cocaine among 59 men and 32 women diagnosed with cocaine dependence. The model assumed that angry responses are learned behavior that can be changed. Clients in the pilot program were taught to gauge their anger levels and to use anger management strategies like time-outs and conflict resolution. During the 12 weeks of treatment, participants were able to reduce and control their anger more effectively than they had in the past, and these gains held at the follow-up 3 months after treatment. Violent behavior also decreased significantly (Reilly and Shopshire 2000). Leadership skills and styles. Cognitive–behavioral therapies encompass a variety of methodological approaches, all focused on changing Types of Groups Commonly Used in Substance Abuse Treatment cognition (beliefs, judgments, and perceptions) and the behavior that flows from it. Some approaches focus more on behavior, others on core beliefs, still others on developing problem- solving capabilities. Regardless of the particular focus, the group therapist conducting cognitive– behavioral groups should have a solid grounding in the broader theory of cognitive–behavioral therapy. This basis is the framework from which specific interventions can be drawn and implemented. Training in cognitive–behavioral theory is available in many workshops on counseling skills and in many alcohol and drug training programs for counselors. For instance, over a 2-week period in 2002, the Rutgers Summer Schools of Alcohol and Drug Studies offered seven week- long courses that concentrated specifically on cognitive counseling theory and methods. Many books are available on the theory of cognitive– behavioral therapy (Beck 1976; Ellis and MacLaren 1998; Glasser 2000; Leahy 1996) as well as self-help manuals with a cognitive– behavioral focus (Burns 1999; Greenberger and Padesky 1995). See chapter 7 for more information about training sources. The level of interaction by the therapist in cognitive– behavioral groups can vary from very directive and active to relatively nondirective and inactive. It also can vary from highly confrontational with group members to relatively nonconfrontational demeanor. Perhaps the most common leadership style in cognitive– behavioral groups is active engagement and a consistently directive orientation. A cautionary note: In cognitive–behavioral groups, the leader may be tempted to become the expert in how to think, how to express that thinking behaviorally, and how to solve problems. It is important not to yield to such a temptation, but instead to allow group members to use the power of the group to develop their own capabilities in these areas. Techniques. Specific techniques may vary based on the particular orientation of the leader, but in general, techniques include those which (1) teach group members about self destructive behavior and thinking that leads to maladaptive behavior, (2) focus on problem- solving and short- and long-term goal setting, and (3) help clients monitor feelings and behavior, particularly those associated with drug use. More experienced leaders will have a wider range of specific techniques to engage participants and more comfort with a wider range of client needs and expectations. An important element of conducting cognitive– behavioral groups is recognizing that behavioral change and intellectual insight gained in the group can be provocative and upsetting for clients with a poor sense of self, low self- esteem, and fear of emotional and interpersonal inadequacy. As a result, resistance to change inevitably will occur as the group evolves and behavioral changes begin to become routine. Experienced leaders learn to recognize, respect, and work with the resistance instead of simply confronting it. Clinical supervision is quite beneficial in learning a variety of styles of working with resistance generated by growth and change. Many specific approaches to cognitive–behavioral therapy, including rational emotive therapy (Ellis 1997), reality therapy (Glasser 1965) and the work of Aaron Beck and colleagues (1993), incorporate various techniques specific to each approach. Substance abuse treatment counselors may find it useful to explore these approaches for techniques appropriate to their specific client populations. Support Groups The widespread use of support groups in the substance abuse treatment field originated in the self-help tradition in the field. These groups also have roots in the realization that significant lifestyle change is the long-term goal in treatment and that support groups can play a major role in such life transitions. Self-help groups share many of the tenets of support groups—unconditional acceptance, inward reflection, open and honest interpersonal interaction, and commitment to change. These groups attempt to help people with dependen cies sustain abstinence without necessarily understanding the determinants of their dependence (Cooper 1987). The focus of support groups can range from strong leader-directed, problem-focused groups in early recovery, which focus on achieving abstinence and managing day-to-day living, to group-directed, emotionally and interpersonally focused groups in middle and later stages of recovery. Purpose. Support groups bolster members’ efforts to develop and strengthen the ability to manage their thinking and emotions and to develop better interpersonal skills as they recover from substance abuse. Support group members also help each other with pragmatic concerns, such as maintaining abstinence and managing day-to-day living. These groups are also used to improve members’ general self- esteem and self-confidence. The group—or more often, the group leader—provides specific kinds of support, such as being sure to help clients avoid isolation and finding something positive to say about each participant’s contribution. In some programs, support groups might be considered process (therapy) groups, but the main interest of support groups is not in the intrapsychic world, and the goal is not character change. Process issues may be involved, but support groups are less complex, more direct, and narrower in focus than process groups. Principal characteristics. Many people with substance use disorders avoid treatment because the treatment itself threatens to increase their anxiety. Because of support groups’ emphasis on emotional sustenance providing a safe environment, these groups are especially useful for apprehensive clients, indeed, for any client new to abstinence. The adjective “support” itself may be a way of destigmatizing the activity. For this reason, a “support” group may be more attractive to someone less committed to recovery than a “therapy” group. Not all support groups, however, are intended just for clients new to recovery. Support groups Types of Groups Commonly Used in Substance Abuse Treatment can be found for all stages of treatment in all sorts of settings (inpatient, outpatient, continuing care, etc.). While a support group always will have a clearly stated purpose, the purpose varies according to its members’ motivation and stage of recovery. Many of these groups are open-ended, with a changing population of members. As new clients move into a particular stage of recovery, they may join a support group appropriate for that stage until they are ready to move on again. Groups may continue indefinitely, with new members coming in and old members leaving, and occasionally, returning. Program differences will also alter how this type of group is used. A support group will be different in a 4- to 6-week daily treatment program from the way it is used in a 1-year treatment community. In a support group, members typically talk about their current situation and recent problems that have arisen. Discussion usually focuses on the practical matters of staying abstinent; for example, ways to deal with legal issues or avoid places that tempt people to use substances. Group members are encouraged to share and discuss their common experiences. Issues that do not specifically relate to the focus of the group are often considered extraneous, so discussion of them is limited. Support groups provide guidance through peer feedback, and group members generally require accountability from each other. The group leader, however, will try to minimize confrontation within the group so as to keep anxiety levels low. In cohesive, highly functioning support groups, member-to-member or leader-to-member confrontation does occur. Support groups can work from a variety of theoretical positions. Many reflect the 12-Step tradition in the substance abuse field, but other recovery tools, such as relapse prevention, can form the basis of a support group. Some support groups are based on theoretical frameworks such as cognitive therapies or spiritual paths. Programs may even design a support group by combining theories or philosophies. Leadership skills and styles. Some support groups may be peer-generated or peer-led, but Types of Groups Commonly Used in Substance Abuse Treatment this TIP is mainly concerned with groups led by a trained, professional group leader. Support group leaders need a solid grounding in how groups grow and evolve and the ways in which people interact and change in groups. It is also critical that group leaders have a theoretical framework for counseling (such as cognitive–behavioral therapy) that informs their approach to support group development, the therapeutic goals for group members, the guidance of group members’ interactions, and the leader’s implementation of specific intervention methods. In a support Since the leader should help build connections between group, members members and emphasize what they have in typically talk common, it is useful for the leader to have about their cur- participated in a support group and to rent situation and have been supervised in support group problems that work before undertaking leadership of have recently such a group. Training and supervi arisen. sion focused on how individuals develop psychologically, typical psychological conflicts, and the way these conflicts may appear in group therapy settings also may help the support group leader function more effectively, since such considerations help the leader understand individual members’ behavior in the group. The leadership style for someone running a support group typically will be less directive than for psychoeducational, skills development, or cognitive–behavioral groups because the support group is generally group-focused rather than leader-focused. The leader’s primary role is to facilitate group discussion, helping group members share their experiences, grapple with their problems, and overcome difficult challenges. The group leader also pro vides positive reinforcement for group members, models appropriate interactions between individuals in the group, respects individual and group boundaries, and fosters open and honest communication in the group setting. In a most general way, the leader is active but not directive. Techniques. The techniques of leading support groups vary with group goals and member needs. In general, leaders need to actively facilitate discussion among members, maintain appropriate group boundaries, help the group work though obstacles and conflicts, and provide acceptance of and regard for members. In a support group, the leader exercises the role of modeler of appropriate behaviors. In this way, the leader helps members grow and change. Specific group techniques may appear to be less important for the leader of a support group, since the leader is usually less active in group direction and leadership. The techniques used in support groups, however, are simply less obvious. Interventions, for example, are likely to be more interpretive and observational and less directive than in many other groups. The observations are generally limited to support for the progress of the group and facilitating supportive interaction among Process-oriented group members. The goal is not to provide insight to group group therapy members, but to facilitate the evolu uses the process of tion of support within the group. the group as the The support group primary change leader is also responsible for monitoring each individual’s mechanism. progress in group and ensuring that individuals are participating (in their own way) and benefiting from the group experience. Understanding some of the history of each person in the group, the leader also watches to see whether the group is providing each individual with emotional and interpersonal experiences that build success and skills that apply to life arenas outside the group. In addition to monitoring individuals in the group, the leader also monitors the progress of the group as a whole, making sure that group development proceeds through its predictable stages and does not become blocked at any stage of its evolution. Finally the leader is responsible for recognizing interpersonal blocks or struggles between group members. It is not necessarily the responsibility of the leader to resolve these blocks, or even to point them out to group members, but to ensure that such struggles do not hinder the development of the group or any member of the group. Interpersonal Process Group Psychotherapy The interpersonal process group model for substance abuse treatment is grounded in an extensive body of theory (Brown 1985; Brown and Yalom 1977; Flores 1988; Flores and Mahon 1993; Khantzian et al. 1990; Matano and Yalom 1991; Vannicelli 1992; Washton 1992). Even this sharply defined area of process- oriented group therapies is widely diverse. Psychodynamic group therapies can be thought of as a generic name encompassing several ways of looking at the dynamics that take place in groups. Originally, these dynamics were considered in Freudian psychoanalytic terms that placed a heavy emphasis on sexual and aggressive drives, and conflicts and attachments between parents and children. Over the past half century many researchers, such as Jung, Adler, Bion, Noreno, Rogers, Perls, Yalom, and others, expanded or changed the Freudian emphasis. As a result, current dynamic conceptualizations include heavy emphasis on the social nature of human attachment, rivalry and social hierarchies, and cultural and spiritual Types of Groups Commonly Used in Substance Abuse Treatment concerns (i.e., existential issues and questions of faith). This therapeutic approach focuses on healing by changing basic intrapsychic (within a person) or interpersonal (between people) psychological dynamics. Thus, a student of process-oriented group therapy, a group treatment approach that uses the process of the group as the primary change mechanism, soon learns that the way Bion (1961) taught group therapy will be far different from the way other recognized authorities, such as Wolf and Schwartz (1962), taught. These theorists in turn differ from the process- orientation exemplified by Durkin (1964) or Glatzer (1969). The many theoretical variants differ in what they pay most of their attention to as group members interact. Purpose. Interpersonal process groups use psychodynamics, or knowledge of the way people function psychologically, to promote change and healing. The psychodynamic approach recognizes that conflicting forces in the mind, some of which may be outside one’s awareness, determine a person’s behavior, whether healthy or unhealthy. Attachment to others is one of the contending forces. From a psychodynamic point of view, starting in early childhood, developmental issues are a key concern, as are environmental influences, to which certain people are particularly vulnerable because of their genetic and other biological characteristics. For those people who have been drawn to substance abuse, the interpersonal process group raises and re-examines fundamental developmental issues. As faulty relationship patterns are perceived and identified, the group participant can begin to change dysfunctional, destructive patterns. The group member becomes increasingly able to form mutually satisfying relationships with other people, so alcohol and drugs lose much of their power and appeal. Basic tenets of the psychodynamic approach include the following •Early experience affects later experience. Individuals bring their histories—personal, Types of Groups Commonly Used in Substance Abuse Treatment cultural, psychological, and spiritual—to therapy. •Sometimes perceptions distort reality. People often draw generalizations from their life experiences and apply the generalizations to the current environment, even when doing so is inappropriate or counterproductive. These “cognitive distortions” may serve to maintain habits people would otherwise like to change. •Psychological and cognitive processes outside awareness influence behavior. As clients become conscious of some formerly subconscious processes supporting a behavior they want to change, this information can be used to alter dysfunctional relationships. •Behaviors are chosen to adapt to situations and protect people from harm. A specific behavior is a person’s best effort to adapt to a particular situation given individual makeup, environment, and personal history. In a sense, people come to therapy because of their solutions, not their problems. Within the interpersonal process model, the objects of interest are the here-and-now interactions among members. Of less importance is what happens outside the group or in the past. All therapists using a “process-oriented group therapy” model continually monitor three dynamics: •The psychological functioning of each group member (intrapsychic dynamics) •The way people are relating to one another in the group setting (interpersonal dynamics) •How the group as a whole is functioning (group-as-a-whole dynamics) A group leader conducting an interpersonal process group, however, will tend to pay more attention to the interpersonal dynamics and concentrate less on each member’s individual psychological dynamics and the workings of the group as a whole. The section that follows includes illustrations (Figures 2-3 to 2-6) of how groups might differ according to their focus on intrapsychic, interpersonal, and group-as-awhole dynamics. The experienced group leader knows that the intervention chosen at any moment in the group will have an impact on all three dynamics and that a delicate balance must be struck in the attention given to each. A too-intense focus on group members’ interaction, to the exclusion of attention to individual psychological needs or the needs of the group as a whole, blunts the effectiveness and relevance of group development. Principal characteristics. Interpersonal process group therapy delves into major developmental issues, searching for patterns that contribute to addiction or interfere with recovery. The group becomes a microcosm of the way group members relate to people in their daily lives. The Interpersonal Process Group Psychotherapy (IPGP) model links the abstinence-based treatment approach with current psychological principles of treatment, while still remaining compatible with 12-Step theory and practice. IPGP and substance abuse treatment both recognize that a person’s capacity for healthy interpersonal relationships supports solid recovery from substance abuse. IPGP is easy to understand and adapt because it is •Pragmatic. IPGP is a practical, nuts and bolts, hands-on type of group treatment. It focuses on results, not abstract concepts and all-encompassing theories, and its results-oriented nature is especially satisfying to a population that needs some swift, positive outcomes. This feature is especially important during the early phases of treatment, when the window of opportunity for influencing clients is small and open only briefly. •Applicable. IPGP is a very adaptable model. Because it can so readily be modified, it can be applied in diverse sets of difficulties and under