Group Psychotherapy and Substance Use Disorder
• Close to 9 million Americans have problems with substance use; the
large majority of those with substance use problems do not seek
treatment.
• The prevalence of underage drinking, drinking and driving, cocaine
and tobacco use has declined slightly over the last ten years (NIH, 2013),
while the use and abuse of marijuana has increased (NIH, 2013).
• Group psychotherapy is the most common treatment approach for
helping individuals with substance use disorders and it offers unique
opportunities for individuals to engage, learn, grow, and change (SAMSHA
2013; Washton, 2014).
• While not everyone recovers, group psychotherapy appears to be an
effective and powerful model of addressing these challenges (Broekaert,
Autrique, Vanderplasschen, & Clopaert, 2012; Burlingame, Strauss, &
Joyce, 2013; White, 2012; Witkiewitz, Steckler, Gavrishova, Jensen, &
Wilder, 2012).
• Clients who commit to long-term aftercare relapse prevention
programs, such as relapse prevention group psychotherapy, appear to
have a much better chance of sustained recovery (NIH, 2013; SAMSHA,
2013).
While the majority of the Substance Use Disorder (SUD) research examines individual psychotherapy and psychiatric interventions, group psychotherapy is the most often utilized treatment in confronting these challenges (Washton, 2014). Treatment costs and waiting lists have been identified as obstacles for substance abuse treatment. Group therapy provides opportunities for clinicians to work with many individuals at reduced costs to the client and other funding sources. Group treatment for SUDs also provides many benefits that make it potentially superior to individual treatment: (1) peer support from others with similar challenges; (2) peer encouragement, problem solving, and guidance; (3) skill building and in vitro practice; (4) instillation of hope by experiencing the success of others; (5) universality and reduced isolation by helping to combat shame about addiction (Flores, 2011).
A variety of group approaches have been used and shown to be effective with substance abusing individuals, including models of cognitive-behavioral, psychoeducation, interpersonal process, and experiential (e.g., psychodrama, expressive art therapies, outdoor adventure) group treatment (Burlingame, Strauss, & Joyce, 2013). Preliminary research also shows very favorable outcomes for the newer mindfulness-based group approaches such as Dialectical Behavior Therapy (Dimeff & Linehan, 2008), Mindfulness-Based Relapse Prevention (Bowen, Chawla, & Marlatt, 2010) and Harm Reduction (Denning & Little, 2011).
Overall success rates for SUD treatment remain moderate. While some reports estimate close to 50 percent success rate in multiple studies, others criticize previous studies for lack of longitudinal data and questionable rigor (White, 2011), and suggest success rates are likely to be lower. Outcome research is challenging to interpret because of differences in treatment goals, such as reduced or less dangerous use versus sustained sobriety.
From a general perspective, Cognitive-Behavioral Therapy (CBT) delivered in the group psychotherapy format has the strongest evidence of success. The theory is that CBT works to help clients build self control though learning new coping strategies to deal with cravings and triggers, analyzing the benefits and detriments of substance abuse, and building positive behavior patterns to support healthy life choices (McHugh, Hearon, & Otto, 2010). Many contemporary CBT group models include increasing amounts of interpersonal process elements, particularly in the later stages of treatment. Group dynamic elements that appear to impact positive outcome including a sense of group cohesion, clear group structure, learning from others’ experience, and interpersonal feedback (Flores, 2011).
Contemporary SUD group treatment research has increasingly moved towards more specificity. Studies examine the specific drug of abuse (e.g., alcohol, cocaine), specific populations (e.g., adolescents, college athletes, Asian-Americans, Afghan refugees), the presence of co-morbid medical or mental health challenges (e.g., depression, chronic pain, borderline personality disorder), and other demographic variables (gender, race, social economic status). However, this specificity is important as a “one size fits all” perspective does not fully address the complexity of each individual’s unique path to recovery. Bringing multicultural awareness and adapting group theory to each client’s cultural history, needs, and values has also been shown to increase treatment success (SAMSHA, 2013; Washton, 2014).
In actual clinical practice, many group leaders serve individuals with a variety of demographic backgrounds and diagnoses within a single group. Most leaders also incorporate methods and exercises from multiple perspectives. Often, the SUD group focus and approach depends upon the stage of recovery. In the early stages of treatment, most leaders work with cognitive and behavioral interventions, but later clients are encouraged to examine more distal thoughts and relational patterns that can further enhance feelings of self understanding and self mastery (Hopper, Kaklauskas, & Greene, 2008). Regardless of treatment approach, several key client factors have been associated with successful outcomes, including client motivation for change, severity of dependence or withdrawal, medical or psychiatric co-morbidity, negative affective states, cognitive strengths or limitations, and economic and social factors (Ciraulo, Piechniczek-Buczek, & Iscan, 2003; NIH, 2103).
For the contemporary, evidence-based group clinician working with substance use disorders, several suggestions can be made. The completion of an extensive intake appears to help guide treatment. Collecting information about each client’s life and substance use history, current and historic social supports and challenges, co-morbid conditions, motivation level, cultural worldview, and personal goals is essential. These data help frame a treatment strategy geared to the specific needs of each client (Kleber,et al., 2006; Witkiewitz, Steckler, Gavrishova, Jensen, & Wilder, 2012). As in any group, helping clients understand how to best use the group process through honest self-disclosures, providing and receiving feedback, and other ways of being engaged is essential for positive outcome. Clinicians should review the summative literature to incorporate general ideas and techniques, and also consult recent articles about specific populations to best treat each individual in what are often heterogeneous groups in clinical settings.
Also strongly recommended is continual supervision, and even personal therapy, as this population presents challenges to success that can affect a clinicians’ confidence, can elicit strong countertransference feelings, and will expose the clinician to stories of trauma, relational failures, and despondent feelings (Forrest, 2001; Yerks, 2012). The substance use disorder clinician needs to stay realistic and positive.
References:
Bowen, S., Chawla, N., & Marlett, G. A. (2011). Mindfulness-based relapse prevention for addictive behaviors: A clinician’s guide. New York: Guilford. http://dx.doi.org/10.1080/1533256x.2012.703917
Broekaert, E., Autrique, M., Vanderplasschen, W. & Clopaert, K. (2010). “The human prerogative”: A critical analysis of evidence-‐based and other paradigms of care in substance abuse treatment. Psychiatric Quarterly, 81, 227-238. http://dx.doi.org/10.1007/s11126-010-9132-4
Burke, B. L., Arkonwitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, Vol 71(5), 843-861. http://dx.doi.org/10.1037/0022-006x.71.5.843
Burlingame, G. M., Strauss, B., & Joyce A; (2013). Change mechanisms and effectiveness of small group treatments. In M. Lambert (Ed.) Bergin & Garfield handbook of psychotherapy and behavior change. (6th ed. 640-689). New York: Wiley & Sons.
Ciraulo D. A., Piechniczek-Buczek J., & Iscan E. N. (2003). Outcome predictors in substance use disorders. Psychiatric Clinics of North America 26(2), 381-409. http://dx.doi.org/10.1016/s0193-953x(02)00106-5
Dimeff, L. A. & Linehan, M. M. (2008). Dialectical behavior therapy for substance abusers. Addiction Science and Clinical Practice. 4(2), 39–47. http://dx.doi.org/10.1151/ascp084239
Dutra L, Stathopoulou G, , Basden S. L., Leyro T. M,, Powers M. B,, & Otto M. W. (2008). A meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry 165, 179–187. http://dx.doi.org/10.1176/appi.ajp.2007.06111851
Flores, P. J. (2011). Addiction as an Attachment Disorder. Lanham, MD: Jason Arronson. http://dx.doi.org/10.1002/9780470713549.ch1
Forrest, G. G. (2002). Countertransference in chemical dependency counseling. Boca Raton, FL: CRC Press.
Hopper, S. J., Kaklauskas, F. J., & Greene, L. S. (2008). Group psychotherapy. In M. Herson & A. Gross (eds.), Handbook of clinical psychology (pp. 647-662). Hoboken :Wiley.
Kleber, H.D., Weiss, R.D., Anton, R.F., Rounsaville, B.J., George, T.P., Strain, E.C., Regier, D. (2006). Treatment of patients with substance use disorders, (2nd Ed.). American Journal of Psychiatry. 163(8):5-82, 2006. http://dx.doi.org/10.1176/appi.books.9780890423363.149073
McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive-behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33, 511-525. http://dx.doi.org/10.1016/j.psc.2010.04.012
Moos R. H., Finney J. W., Ouimette P. C., & Suchinsky R. T. (1999). A comparative evaluation of substance abuse treatment: Treatment orientation, amount of care, and 1-year outcomes. Alcoholism: Clinical and Experimental Research, 23, 529—536. http://dx.doi.org/10.1111/j.1530-0277.1999.tb04149.x
National Institute of Health. National Institute of Drug Abuse. (2013). Drug Facts: National Trends. http://dx.doi.org/10.1037/e313552004-006
Ouimette, P. C., Finney J. W., Gima K., & Moos R. H. (1999) A comparative evaluation of substance abuse treatment: Examining mechanisms underlying patient-treatment matching hypotheses for 12-step and cognitive behavioral treatments for substance abuse. Alcoholism: Clinical and Experimental Research, 23,545—551. http://dx.doi.org/10.1111/j.1530-0277.1999.tb04151.x
Simpson, D. D., Joe G. W., Fletcher B. W., Hubbard R. L., & Anglin M. D. (1999). A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry, 56:507—514. http://dx.doi.org/10.1001/archpsyc.56.6.507
Substance Abuse and Mental Health Service Administration. (2013). 2013 National Survey on Drug Use and Health. http://dx.doi.org/10.1037/e438122005-001
Washton, A. M. (2014). Group Therapy for Substance Use Disorders. In G. Gabbard (Ed.), Gabbard's treatments of psychiatric disorders, 5th Ed. (pgs. 893-906) Washington DC: American Psychiatric Association.
Weiss, R. D., Jaffee, W. B., de Menil V. P. & Cogley, C. B. (2004). Harvard Review of Psychiatry. 12(6), 330-350. http://dx.doi.org/10.1080/10673220490905723
White, W. L. (2012). Recovery/Remission from substance use disorders: An analysis of reported outcomes in 415 scientific reports, 1868-2011. Philadelphia: Philadelphia Department of Behavioral Health and Intellectual disAbility Services. http://www.attcnetwork.org/learn/topics/rosc/docs/RecoveryRemissionWW.pdf
Witkiewitz, K., Steckler, G., Gavrishova, A., Jensen, B., & Wilder, M. (2012). Psychotherapies for addiction: Empirically supported interventions for the addiction syndrome. In H. Shaffer, D. A. LaPlante, & Nelson, S. E. (Eds). APA addiction syndrome handbook, Vol. 2: Recovery, prevention, and other issues. (pp. 87-103). Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/13750-004
Yerks, S. (2012) Countertransference Knowledge and Substance Abuse Treatment. Master of Social Work Clinical Research Papers. http://sophia.stkate.edu/msw_papers/106