CHAPTER 8: Applying Group Theory in the Treatment of Substance Abuse and Addiction

1. CHAPTER 8: Applying Group Theory in the Treatment of Substance Abuse and Addiction Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory First Edition Todd F. Lewis Developed by Katie A. Wachtel, University of North Carolina at Greensboro

2. Introduction • Poor relationships, isolation and difficulty connecting with others are common themes among individuals who use substances • Group therapy provides many advantages to assist clients in confronting issues related to interpersonal relationships • Group therapy is NOT the same as support groups (i.e., AA) • The goals of this chapter are to outline the major tenets of group therapy, discuss the application of group therapy in working with substance abuse, discuss support groups, explain the implications of diversity in group therapy, and provide a case example.

3. Inpatient vs. Outpatient Addictions Group Counseling • Outpatient • Allows clients to live at home, work, and lead normal lives • Typically occur 1 or more times per week • Focus on processing feelings and managing triggers outside of the group • Inpatient • Brief, intense, with frequent meetings • Group members tend to have more severe problems • Sessions occur throughout the day to provide continuity

4. Therapeutic Factors • Instillation of hope • Universality • Imparting information • Altruism • Corrective recapitulation of the primary family group • Socializing techniques • Imitative behavior • Interpersonal learning • Group cohesion • Catharsis • Existential factors

5. Stages of Group Therapy • Stage 1: Initial stage—orientation and exploration • Stage 2: Transition stage—dealing with resistance • Stage 3: Working stage—cohesion and productivity • Stage 4: Final stage—consolidation and termination • Note, these stages may not be a linear process. It is possible for groups to move back and forth between stages or straddle two stages.

6. Application of Group Therapy with Substance Abuse Problems • Group members share language, experiences, and problems, which helps unify members • Groups allow clients to understand themselves in relation to others, offer and receive feedback, and share goals • Group therapy differs from 12-Step programs in that they encourage boundaries, structure, higher levels of feeling expression and exploration of the past

7. Working with Client Defenses • Clients may experience anxiety regarding group participation and sobriety. • Common defense mechanisms for anxiety: • Compensation • Denial • Rationalization • Undoing • Displacement • It is important to effectively assist clients in recognizing these distortions

8. Recognizing Denial • Denial is one of the most commonly expressed defenses amongst substance abuse clients • Clients may be convinced and attempt to convince others they do not have a problem • Clinicians must be skilled at recognizing denial, as many clients can be convincing • It is more difficult for clients to maintain denial in a group environment because many of the other members can recognize and confront denial readily due to experience

9. Other Considerations in Substance Abuse Group Counseling • Setting group boundaries can help clients increase their sense of personal responsibility • Setting clear, measurable goals can increase client self-efficacy in setting goals throughout life • Role playing can help clients practicing new skills and learn from one another

10. Common Substance Abuse Group Formats • Psycho-educational group • Educate clients on substance abuse issues, consequences, use and related behaviors • Techniques: mini-lectures, videos, movie clips, podcasts, use of process and reflective questions, role playing, case studies, problem solving exercises, writing exercises • Skill-building groups • Help clients learn or relearn skills (managing emotions, practical skills, social skills, etc.) • Techniques: didactic instruction, group practice, role play, demonstration, processing, and feedback

11. Common Substance Abuse Group Formats Continued • Cognitive-behavioral groups • Can be the foundation for many skill building groups • Focus on deeper change • Use cognitive restructuring and behavioral application • Techniques: didactic instruction on the interconnectedness of thoughts, feelings, and behavior, problem solving and goal setting, helping clients monitor thoughts, feelings and behavior • Support groups • Come from the 12-step traditions • Members offer one another support • Less emphasis on technique because leaders play a more passive role

12. Common Substance Abuse Group Formats Continued • Interpersonal process groups • Focus on intrapersonal and interpersonal change through interpersonal dynamics • Focus on process rather than content • Techniques: interpret group dynamics and interpersonal functioning, focus on the here ad now • Other group therapy techniques • Linking • Blocking • Conveying focus and discipline

13. Substance Abuse Group Counseling Through the Lens of Theory • Many substance abuse theories can be adapted into group environments • It is important to consider theoretical orientation when forming groups in order to establish specific tasks and techniques • Incorporation of theory into group approaches can increase effectiveness of implementation and outcomes • Populations served should be identified when deciding upon theory

14. Mutual Support Groups • Members rely on each other in a reciprocal fashion for support, guidance, and fellowship • A supplement to group counseling, not a replacement • Can be connected to positive treatment outcomes, but may not be effective for everyone • 12-step groups (AA, NA, Al-Anon) are among the most well-known and focus on spiritual development and connecting with a higher power

15. Group Therapy in the Treatment of Diverse Populations • Cultural considerations should be addressed throughout the group counseling process • Acceptance amongst group members and leaders is key, especially in heterogeneous groups • Leaders must understand the impact of culture on substance use and group process • Universality plays an important role in multicultural groups

16. Using Group Therapy in the Case of Michael • Skill-building group: The clinician provided education about the relationship between stress and substance abuse. He then taught, modeled, encouraged practice, and processed a relaxation exercise • Supportive group: Clinician used a non-directive approach to assist members in supporting one another. Members offered suggestions and support to assist Michael in managing cravings • Interpersonal process group: The clinician focused attention on interactions between group members to facilitate intrapersonal and interpersonal change among members. Relationships and behaviors within groups can often mimic relationships problems outside of the group

17. Strengths, Limitations, and Ethical Issues Related to Group Therapy • Strengths • Considered standard care in substance abuse • Based on one theoretical research base • Cost effective • Provides a unique setting to share emotions, suggestions and support • Can be conducted using a variety of formats • Effective at treating problems associated with addictions

18. Strengths, Limitations, and Ethical Issues Related to Group Therapy Continued • Limitations • May not be suitable for clients who need one-on-one work • Additional training may be needed to effectively run groups • Leaders can become overwhelmed by the complex nature of group content and process • Ethical Issues • Considerable skill and understanding is necessary to effectively implement group therapy • Ethical issues (e.g. confidentiality) can arise within groups • Multicultural issues