A number of group therapists have developed models of group treatment helping members move from one phase to the next. One example is a treatment model for alcohol(Drug information on alcohol) dependence that involves four phases: crisis, abstinence, sobriety and recovery (Banys, 2002). Each phase calls for the completion of phase-specific tasks. These tasks include the maintenance of abstinence and the reparation of damaged interpersonal relationships. If relationships cannot be repaired, therapy then focuses on dealing with loss and its accompanying emotions. Issues dealt with in the group also include low self-esteem and tolerating affect. Each phase requires suitable techniques, and progression in treatment depends on completing the specific tasks of each phase. Phases begin with managing behavior and progress to reconstructing addicts' lives. As patients progress from one phase to the next, they become more able to deal with troubling affects and difficulties in relationships. Patients focus on reconstituting their lives and maintaining behavioral changes. "Achieving insight" in therapy is regarded as a risk factor for relapse, which is seen as a failure of treatment structure. Relapse can lead to more intense treatment in a more structured phase of treatment; patients who relapse are asked to return to earlier-phase groups and a greater focus on controlling behavior and maintaining abstinence.
In order to help patients achieve and maintain abstinence, the group therapist must assess patient behavior on an ongoing basis. What patients think is less important than how they change behaviors. Relapse-prevention techniques help patients identify risks for relapse and teach coping skills to bring about more constructive behaviors. Regular attendance is important; if group sessions are attended regularly, the group setting can be utilized as a safe place to interact with other people.Relapse-Prevention Groups
Formal relapse-prevention groups may focus on particular stages achieved by substance abusers as they progress toward recovery. Groups can include a motivational group to help participants move toward involvement with treatment and a readiness to change (Washton, 2002). The goals of this self-evaluation group (SEG) are to help members assess involvement with substance use, consequences of previous use, motivation for change and the development of a plan to begin to change. The group's purpose is to encourage each participant to begin self-evaluation, aided by the group leader's active involvement in providing feedback and helping members interact. The group is non-critical, but members are encouraged to use the group's observations of each other to assess their behaviors. The group is time-limited and uses a set of structured guidelines. At the end of the process, participants may choose to enter formal treatment.
The initial abstinence group (IAG) comprises substance abusers in the action stage who are ready to begin to make changes in their behavior in order to stop substance use (at least for a trial period) (Washton, 2002). The IAG's goal is to help patients progress through the action stage to the maintenance stage, at which point the focus is on remaining abstinent. Patients are expected to stop substance use as quickly as possible. A patient's stay in the IAG is time-limited and focuses on learning coping skills used to begin and maintain abstinence. Participants are required to attend self-help groups.
The next phase in achieving recovery from addictive behavior is entry into a relapse-prevention group (RPG). These groups are time-limited and focus on helping members to maintain abstinence through the development of coping skills and behavioral changes. They involve education, peer support, and therapy focused on coping with interpersonal difficulties and internal states more effectively. Patients enter an RPG after a period of abstinence. Participants share information about relapse and relapse prevention and focus on interventions designed to prevent relapse. Each group deals with a specific topic using a structured format. The group leader should adopt a relatively active stance in order to maintain the focus of the group. Members are also often urged to attend self-help groups. Designed around cognitive-behavioral principles, the Matrix Model also includes patient and family participation (Rawson and Obert, 2002). This model has been the subject of numerous publications and standardized treatment manuals.Therapeutic Communities
Group methods are also used in a variety of types of therapeutic communities. The therapeutic community (TC) approach is marked by the use of a community of peers in the TC to bring about behavioral and psychological changes in the community members. The method used to bring about change is participation in a variety of groups in the TC. These groups include community groups (e.g., encounter groups and marathon groups) and educational groups (e.g., seminars and tutorials). These groups often use specific techniques to bring about self-awareness and increase participation in the group process (De Leon, 2002). The TC approach may be used with many types of patient populations in a wide range of special settings.Network Therapy
Network therapy involves using the social network of the identified substance-abusing patient in a group format to provide support for behavioral change and relapse prevention, using a cognitive-behavioral approach (Galanter, 2002; 1993). The participation of individuals who are part of the patient's network of relationships can enhance the outcome of treatment. The use of a supportive network comprising significant others in the patient's life and therapist is focused on helping both patient and therapist work toward the achievement and maintenance of abstinence. Network therapy focuses strictly on the patient, and its use requires skill and sensitivity on the part of the therapist. Network therapy involves a time-limited approach, and the network requires skillful management for its effectiveimplementation.Other Group Therapies
Groups for specific homogeneous patient populations, such as female substance abusers, adolescents, gay men and lesbians, and elderly substance abusers, are also helpful. Groups for patients addicted to specific drugs (i.e., smoking cessation groups), and for substance abusers with medical illnesses or patients with comorbid mental illness and substance abuse are also useful.Summary
A wide variety of substance abuse groups are used to treat diverse patients in a range of treatment settings. Techniques are adapted to the needs of the patients and to the goals of treatment. Patients in different stages of treatment require different group techniques. Patients who are in group treatment in different settings also require treatment methods that are adapted to those specific settings. Group therapy can be made a part of treatment programs for substance abusers. Although treatment may also include medications and individual therapy, because of the importance of groups in people's lives--and in the development of substance abuse--group therapy has found widespread acceptance. In the future, research into group outcome and group process will provide further understanding and enhance our ability to use group therapy for the well-being of our substance-abusing patients.Acknowledgement
Dr. Brook is a psychiatrist and researcher and is professor of community and preventive medicine at the Mount Sinai School of Medicine in New York City.