Group therapy has been the most commonly employed treatment modality for adolescents with substance use disorders (SUD). Evidence has been accumulating in support for the efficacy of diverse forms of group therapy that have been utilized with adolescents, such as 12-step (Winters et al., 2000), psychoeducation (Kaminer et al., 2002) and cognitive behavioral therapy (Dennis et al., 2004; Kaminer et al., 1998; 2002; Waldron et al., 2001). However, it has been argued that aggregation of youths who display problem behavior in group interventions may, under some conditions, produce clinically induced negative effects on all participants (Dishion et al., 1999).

The highly influential publication entitled, When Interventions Harm: Peer Groups and Problem Behavior, suggests that “high-risk youth are particularly vulnerable to peer aggregation, compared with low-risk youth. Association with deviant peers in early adolescence, under some circumstances, inadvertently reinforces problem behavior” (Dishion et al., 1999, P. 755). This publication — that was based on prevention research with individuals at a developmental stage between pre-to-early adolescence — created a barrier to progress in the treatment and research of group therapy for adolescents with SUD because many generalizations applied Dishion’s conclusions to all settings that employ group therapy, without examining the differences between different group settings and treatment modalities.

Nevertheless, Dishion’s publication has raised the need for examining the extent to which deviant peer behavior in group interferes with the efficacy of group treatment for adolescents with SUD. The objective of this review is, therefore, to address challenges and opportunities associated with group therapy treatment for adolescents with SUD. Suggestions also are made as to optimizing group intervention while considering the management of potential clinically induced negative effects associated with the aggregation of antisocial youths in heterogeneous groups.

Evidence for group intervention that “Do harm” for youth
The finding that affiliation with deviant peers is associated with increased delinquent behavior is supported in much of the literature on juvenile delinquency (Gifford-Smith et al., 2005). There is a growing consensus regarding the negative impact of treating homogenous groups of youths manifesting antisocial or delinquent behavior (Hoag & Burlingame, 1997). There have been several reports in the literature supporting the potential harmfulness of group intervention for youth manifesting antisocial behavior.

The Cambridge-Somerville Youth study, conducted in the 1940s, used a comprehensive approach to crime prevention. The investigators assigned “delinquency prone” and “average” boys to both the experimental treatment and control groups. Treatment consisted of counseling and social services for five years. An evaluation conducted shortly after the completion of the program failed to find differences between the treated and untreated boys (Powers & Witmer, 1951).

However, 30 years later, further examination of the data indicated statistically significant negative effects reported in boys in the treatment group (McCord, 1978). These findings of clinically induced negative effects associated with peer aggregation were interpreted as causal and not merely correlational (Dishion et al., 2002). Ang and Hughes (2001) performed a meta-analysis of studies of social skills training with antisocial youth. Groups comprised only of antisocial peers produced smaller benefits compared to groups comprised of a mixture of prosocial and antisocial youth. Delinquent youths are reluctant to replace their belief system and behavior with a pro-social set, which creates a therapeutic challenge.

Ang and Hughes (2001) emphasized the higher reinforcement generated by antisocial behavior as compared to prosocial behavior for homogenous groups of antisocial youths. These results might also be partially explained by other findings. Dodge and colleagues (1995) reported that youths who lack social skills fail to identify and attend to social cues from others (i.e., social-information processing theory). It also has been noted that boys who have disruptive behavior disorders often manifest difficulties encoding social cues, generating appropriate responses, and more often, selected aggressive responses to social problem-solving. Another reason for these findings might be attributed to the reinforcing effects of a process referred to as “deviancy training” characterized by positive affective reactions to rule-break talk (Dishion et al., 1999). These investigators focused on preventive interventions for pre- and early adolescence aged youth who were at risk for substance use but had not yet developed SUD. They reported an increase in negative behavior and outcomes in groups for adolescents compared to the control conditions or with a condition that targeted parents only (Dishion et al., 2002; Poulin et al., 2001). Direct observations of deviancy training were associated with escalation in substance use, delinquency, and violent behavior in adolescence (Dishion et al., 1995; Poulin et al., 1999).

Finally, Mahoney and colleagues (2004) support the assertion that aggregating antisocial peers is likely to promote the antisocial behavior of new attendees in activities that are lacking structure and skill building aims. Collectively, this body of research suggests that groups with a higher percentage of youth with conduct problems will display greater antisocial behavior in groups (Macgowan & Wagner, 2005).

Evidence that group therapy is not unequivocally “harmful” but beneficial for youth
Although most recently Dishion and Dodge (2005, pp.395) have reviewed their earlier assertion, they still opine that “the positive effects of the content of an intervention might be offset by processes of peer influence that occur when deviant youth are allowed to interact with each other.”

Sukhodolsky and colleagues (2004) conducted a meta-analysis of cognitive-behavioral therapy for anger in children and adolescents. They reported that skills training and multimodal treatments were more effective in reducing aggressive behavior and improving social skills. Problem-solving treatments were more effective in reducing subjective anger experiences. In addition, overall effect sizes did not differ significantly between group and individual treatments.

Petrocelli (2002) addressed additional issues pertaining to group therapy utilizing cognitive behavioral therapy (CBT). CBT may be defined as therapy that uses the dynamics of the group format, in addition to common CBT techniques: to change distorted, maladaptive, and dysfunctional beliefs, interpretations, behaviors, and attitudes. A core principle that separates CBT from individual CBT is the social force of cohesiveness (i.e., the degree to which group members are interested in relating to each other). This is the equivalence of their alliance.

The major assumption of CBT is that self-destructive behaviors and thoughts will subside when distorted core beliefs are confronted and reconstructed. CBT may provide a practical forum for such change because of the immediate consensual validation that can be afforded by a group atmosphere.

Hoag and Burlingame (1997) evaluated the effectiveness of child and adolescent group treatment by conducting a meta-analytic review. These eight meta-analyses that included the group format in assessing the outcome literature provide evidence that psychotherapy with children and adolescents is effective and that group and individual therapies do not differ in their overall effectiveness. Furthermore, group treatment improved significantly more than wait-list or placebo.

Additional data indicate that peer intervention groups may result in beneficial effects, especially when the group also includes prosocial youth (Hudley & Graham, 1993; Tremblay et al., 1995). A meta-analytic study by Lipsey (in press) concluded that there was no evidence for reduced effectiveness associated with peer aggregation in studies of the treatment of delinquent behavior in adolescence. Moderating factors have been addressed as well. Gilford-Smith et al., (2005) stated, “These effects appear to be moderated by three factors, including: age of participants (i.e., being younger appear to be less susceptible to clinically induced negative effects); leader characteristics (i.e., more experience can mitigate the clinically induced negative effect), and composition of group (i.e., introducing non-deviant peers mitigates the clinically induced negative effect).”

Given these most recent findings, Dishion and Dodge modified their position and concluded: “The deviancy training dynamic is a process, and may or may not occur depending on the characteristics of the participants, the skill of the group leader, and the context of the intervention” (Dishion & Dodge, 2005).

Group therapy for adolescent substance use disorders
Most behavioral treatments for SUD in community settings, such as 12-Step, CBT, or psychoeducation, are delivered via group format. Yet, relatively few systematic studies of group therapy have been conducted. No studies comparing group versus individual interventions for adolescent SUD have been published. In studies of group versus individual CBT conducted with adults, both conditions were equally successful in reducing drinking and drug use at 12-month follow-up (Graham et al., 1996; Marques & Formigoni, 2001). Furthermore, Graham and colleagues reported that the group condition demonstrated its superiority in improving social skills that are deemed important for relapse prevention in many patients, including adolescents.

Because teens typically use alcohol or drugs when in the company of other users, and because they are easily influenced in group settings, group treatment has the benefit of mirroring their daily experience. Brown and D’Amico (2001) reported that when given a choice for voluntarily selecting a method of secondary prevention of alcohol use, 80 percent of adolescents selected the group format over an individual, or even a web site activity. Brown and D’Amico (2001) also noted that adolescents who stop drinking without formal treatment use a variety of strategies to reduce or stop drinking, including social resources as support groups and friends. Thus, in certain circumstances group involvement may facilitate reductions in drinking, whereas other group contexts may socialize youth toward greater deviance.

A number of features associated with group approaches to treatment may also facilitate affective, behavioral, and cognitive changes (Myers & Brown, 1996). These factors include: the realization that others share similar problems; the development of socializing techniques; role modeling; rehearsal; and peer/therapist feedback. The opportunity to try out new behaviors in a social environment, and the development and enhancement of interpersonal learning and trust may also be influential.

Group interventions have been doing as well as individual and family interventions. Furthermore, in the Cannabis Youth Treatment (CYT) study they were among the more cost effective approaches (French et al., 2002). McDermutt (2001) reported in a meta-analysis of depression, that from an economic analysis standpoint, a session-by-session fiscal analysis shows group therapy is less costly than individual therapy. Furthermore, there is consistent empirical support of the efficacy of manualized CBT in group format for adolescents with SUD (Dennis et al., 2004; Kaminer et al., 1998; 2002; Waldron et al., 2001). The favorable results of the Minnesota 12-Step model for youth (Winters et al., 2000); recent report that group-based treatment program for adolescents who were mild-to-moderate substance abusers produced significant reduction in marijuana use at six and 12 months (Battjes et al., 2004); and lack of reports of adverse effects all stand in contrast to the potential clinically induced negative effects for youth who exhibit antisocial behavior.

Conclusions and recommendations
It is imperative to optimize group intervention while considering how to prevent, reduce and control, potential clinically induced negative effects associated with the aggregation of antisocial youths in heterogeneous groups. The management of peer contagion processes and adolescent problem behavior in group by the therapist or counselor is of utmost importance (Feldman et al., 1993).

Recommendations include: Recruit-ment of adolescents from diverse referral sources, maintaining group heterogeneity by including: prosocial kids; employing competent and well-trained therapists; maintaining an effective supervision apparatus; conducting manualized interventions that include clear “trouble shooting” protocols (e.g., how to prevent war stories, negative and verbally offensive reference toward group members and leaders); and examining processes and mechanisms of change will assure minimization of “harmful” adverse effects. There is a need to empirically support this assertion by continued advancement for research and dissemination of adolescent SUD treatment.

Eccles and Gootman (2002) summarize eight contextual features that promote positive outcomes for youth: physical and psychological safety, appropriate structure, supportive relationships, opportunities for belonging, positive social norms, support for efficacy and mattering, opportunities for skill building, and integration of family, school, and community. Seven of these features can be directly implemented in group therapy.

An unbalanced approach that may unconditionally generalize “deviancy training” for heterogeneous groups of youth with SUD might impede the progress made in researching group therapy for adolescent SUD, as well as the progress made in sharing the benefit of efficacious treatment technology with service providers and the community.

Yifrah Kaminer, MD, MBA, is a Professor of Psychiatry and Co-Director of Research at the University of Connecticut’s Health Center, Division of Child & Adolescent Psychiatry.

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This article is published in Counselor,The Magazine for Addiction Professionals, April 2006, v.7, n.2, pp.38-42.

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