There has been great progress in the treatment of substance abuse over the past 20 years. The use of a multidisciplinary approach in a biopsychosocial framework has resulted in innovations in treatment in areas such as cognitive-behavioral therapy, relapse prevention, family therapy, group therapy and psychopharmacological treatments. This article comprises a review of published approaches to group therapy, which has been found to be clinically effective and cost-effective for the prevention and treatment of substance abuse, particularly in its effects on behavioral risk factors. Psychosocial and cultural risk factors (as well as protective factors) described by the family interactional theory include the parent-child and spouse/significant other attachment relationships, peer interactions, and personality/attitude/behavioral and cultural factors (Brook et al., 1990).
Because of the importance of groups over the course of a patient's development, especially in the development of substance use disorders, group therapy is of particular importance in the prevention and treatment of these disorders. There are many kinds of group treatments now available, and group therapy has come to fill a significant role as the psychosocial therapy of choice for substance abuse patients and for patients suffering from concurrent comorbid disorders. Group therapy can play a major role in treatment programs in inpatient, outpatient and partial hospitalization settings. Group members can offer one another mutual support and understanding. This support and understanding can have an important impact on the lives of substance abusers in parent-child interactions, child and adolescent development, peer relationships, the maintenance of health, and the prevention of HIV transmission. Groups can be time-limited or long-term, and the reduced cost of group treatment is particularly important in managed care environments.
Types of Groups
Self-help groups. The most widely used form of group treatment is probably the self-help group--a large group treatment typified by Alcoholics Anonymous (AA). Self-help groups are composed of members sharing a common condition and a common goal. They are self-run, without professional leaders, and in a variety of group formats, including large group and smaller group meetings. Meetings are free, and contacts made in the group are continued outside of the group setting. Twelve-step programs focus on mutual support, characterological change and achievement of abstinence. Attendance often continues over a person's lifetime, either intermittently or continuously. Although AA has a spiritual element, other self-help groups do not. Regular AA attendance has been found to be helpful in reducing drinking and increasing members' ability to function (Emrick et al., 1993).
Interpersonal group psychotherapy. Interpersonal group psychotherapy (IGP) is based on the understanding that interpersonal relations are necessary to regulate all aspects of living. Greatly influenced by Yalom's model of interactional group psychotherapy and other contributions (Flores, 1997; Ormont, 1992; Yalom, 1995), IGP focuses on the here-and-now in the group, an establishment of group cohesion and therapeutic norms, and the interaction between members--with an active approach taken by the group leader and a decreased emphasis on the group-as-a-whole perspective. It also helps members focus on abstinence and encourages involvement in complementary 12-step programs. Addiction is viewed as an attachment disorder caused by genetic and early developmental failures that lead to defective attempts at self-repair. The substance abuser attempts to substitute drugs and alcohol for satisfactory interpersonal relationships. Physical dependence results in further deterioration and increased difficulty in affect regulation, self-care, interpersonal relationships, the ability to verbalize feelings, experience pleasure and develop a capacity for empathy.
The methods and goals of early IGP treatment must be differentiated from the methods and goals of later-stage treatment. In early treatment, the group leader should be active without being charismatic and must develop an empathic relationship with the members--helping them to communicate feelings and to develop interpersonal relationships in the group. In later-stage treatment, the group leader helps members learn to cope with internal deficits. Here-and-now exchanges in the group allow members to focus on the development of interpersonal skills and the alleviation of shame. Members become able to relate successfully to people outside of the group without the need to turn to substances of abuse through the development of healthy relationships in the group.
Cognitive therapy addiction groups. An increasingly important form of group therapy for addiction is based on the principles of cognitive therapy. Cognitive therapy addiction groups (CTAGs) address understanding and changing cognitive processes about addiction (Liese et al., 2002). Cognitive-behavioral theories like Marlatt's (1985) discussion on relapse prevention and harm reduction have influenced the development of CTAGs. Cognitive processes include myriad mental activities, which interact with affective, environmental, physiological and developmental processes resulting in addictive behavior. The working of the cognitive model is reviewed in each group session by the group facilitator focusing on its relationship to the difficulties and addictive processes of members. Group facilitators take an active role in modeling or suggesting goals for members. Group members learn how maladaptive thinking leads to addiction; in CTAGs, the focus is on helping members control their thought processes and addictive behaviors.
Helping members refrain from addictive behavior and cope more effectively are the goals of CTAGs. Group members are taught specific coping skills in areas such as affect regulation, the development of relationships and crisis management by carrying out homework assignments to achieve specific goals. With assistance, members visualize the future and identify resources. It is suggested that members attend sessions at least weekly and are encouraged to attend even after extended periods of abstinence (Liese and Najavits, 1997). Members of CTAGs vary in their readiness to change; therefore, a familiarity with the transtheoretical model of change (Prochaska and DiClemente, 1992) and the principles of motivational interviewing (Miller and Rollnick, 1991) is helpful. A harm-reduction approach may be necessary on the road to achieving abstinence even though that may be the long-term goal of CTAGs.
Modified dynamic group therapy. The formulation of the self-medication hypothesis to explain substance abuse as a self-regulation disorder later led to the development of modified dynamic group therapy (MDGT). This type of group therapy addresses the self-regulatory ego deficits of substance abusers and addicts (Khantzian, 1997). Using an interpersonal approach, MDGT focuses on deficits in self-regulation and resulting characterological difficulties. It allows members to examine shared issues to overcome feelings of isolation and shame, as well as establish a safe environment with the goal of self-control and abstinence. The group leader serves as a model for members--maintaining a nonjudgmental, flexible approach. The leader helps the members develop shared responsibility and mutual respect and gently examine painful affects and self-destructive behaviors. The leader encourages members to observe each other and share difficulties in the regulation of affect, self-esteem, peer interactions and self-care. The group provides structure, shared goals and a shared commitment to talking about feelings to progress to abstinence. In addition to safety, MDGT encourages an understanding of feelings and an acceptance of responsibility in a supportive framework. The duration of MDGT can be short-term or can be used for long-term group therapy. The ultimate goals of MDGT are to help patients develop nondestructive methods of self-regulation and the ability to give up substances of abuse.
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