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Groups are important throughout the course of a patient's therapy, especially for patients who have substance use disorders. Group therapy's clinical and cost benefit is evaluated for its efficacy in preventing and treating substance abuse.
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.
Phase Models of Treatment
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 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.
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.
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 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.
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.
Dr. Brook's research has been supported in part by grants from the National Institute on Drug Abuse of the National Institutes of Health.
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.
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