Group Treatments in Behavioral Health Programs

This is the first column that will focus on issues related to group leaders and group treatments since this modality is often the main form of treatment in programs for substance use (SUD) or co-occurring disorders (CODs). In this column I provide a brief summary of types, goals, and formats of group treatments, a summary of research, and common challenges in groups and how to manage these. Future columns will address interventions of group leaders to review clinical strategies for use in groups. In my experience, which includes conducting up to thirteen groups a week for several years, a challenge facing group leaders and patients is boredom with the materials and problems reviewed in groups. Many patients have a history of multiple relapses and have participated in numerous programs, so the topics discussed in groups are familiar to them. Clinicians provide the same curriculum numerous times, making it a challenge to maintain a high level of interest. These columns will provide ideas that help clinicians conducting treatment groups.

Interventions depend on the type and goals of the group, and number of participants. For example, an educational group with a group of over fifty attendees will be conducted differently than a group with ten attendees. Similarly, a therapy group focusing on specific issues of members will be conducted differently than a curriculum-based session on relapse in which the leader conveys specific information to patients about relapse issues. Group interventions include, but are not limited to:

• Providing education and facilitating group discussions
• Using stories or guest presenters to educate, motivate or inspire patients
• Reviewing readings, journals, workbooks or homework assignments
• Practicing interpersonal skills with the use of behavioral rehearsals or role-plays
• Learning healthy ways to manage emotions and moods
• Challenging faulty, negative, depressed, anxious or addictive thinking
• Learning to reach out for help and support from peers, family or supportive friends
• Using monodramas to raise awareness of attitudes, behaviors or coping strategies used
• Integrating creative media in group sessions 

I have conducted, observed or rated videotapes of many group sessions, developed and managed group programs, and provided consultation and supervision to group leaders. I have written group protocols, including several used in clinical trials. Thus, I have an understanding of the challenges faced by group leaders and participants in group sessions.

I conducted a survey of 444 readers of Counselor related to groups and topics to address in groups, and three surveys with 432 community treatment providers (CTPs) involved in the NIDA Clinical Trials Network (CTN), two of which were specific to group interventions. The CTN is a national research project involving NIDA, thirteen centers in the U.S., a data and hundreds of providers. The mission is to improve clinical care using science as the vehicle by conducting multisite trials in diverse clinical settings with a broad range of patients, and disseminating findings to providers, patients, and families in publications, Blending Products, and educational and training activities.

A majority of the 444 respondents of Counselor survey were “very interested” in strategies or techniques to use in group sessions. Other topics of interest that can be addressed in groups include: 

• Motivation
• Relapse
• Recovery
• Medications for addiction, managing emotions or moods (including positive emotions)
• Relationship issues
• SUDs combined with psychiatric disorders
• The impact of disorders on the family and members, including children, and family recovery 

Many models of group treatment provide manual-based curriculum to address specific topics related to substance use, psychiatric or co-occurring disorders (see suggested readings). Integrating a structured curriculum into a group program can insure programs use evidenced-based interventions. Patients in our programs report benefits from a combination of structured recovery groups and therapy groups, in which personal problems are discussed.

In a survey of eighty-nine CTN providers specific to experiences conducting groups, it was found that areas of greatest interest among group leaders include managing conflict in group and disruptive members, engaging all members in the group discussions, dealing with group members who “do not work” in the sessions, facilitating self-disclosure of members so they share problems and feelings, getting members to give each other feedback when appropriate, and using “action” or “experiential” techniques in sessions.  The use of action techniques in groups will be addressed in a future column.

Types of groups include milieu groups such as check-in, goal review, end of day review; structured or curriculum based; coping skills, social skills or illness management; therapy, problem solving, process or counseling; relapse prevention; Twelve Step facilitation; and family groups. Groups are used for specific populations (e.g., adolescents, women, criminal justice clients) and to address common problems (e.g., anger, trauma, motivation, relapse), specific addictions, psychiatric disorders or combinations of these.  

Goals may include any of the following: 

• Provide education on symptoms, causes, effects, and treatment for substance use, psychiatric or co-occurring disorders, and recovery resources
• Introduce members to recovery, illness management, and relapse prevention strategies
• Teach coping skills to manage the disorder or disorders. This may involve practicing skills with peers (e.g., asking for help and support, resisting social pressures to use substances, resolving relationship problems) or challenging depressed or addictive thinking
• Provide an opportunity to give and receive feedback from peers on attitudes and behaviors
• Create an environment in which feelings, thoughts, and conflicts can be explored in a safe and supportive environment
• Prepare patients for involvement in recovery following treatment

These last from sixty to ninety minutes. Groups can be limited to a specific number of sessions in which all participants start and end together, or be open-ended, so that new patients can be added at any time. Programs involving multiple groups during each treatment day expose patients to a variety of interventions and clinical staff; although some programs use the same staff to conduct all groups. Structured groups have a curriculum that includes a topic (problem/issue), objectives or goals, and methods to cover the material such as discussions, role-plays or other techniques.  This keeps the group focused on a specific topic. Therapy groups focus on the problems and concerns of current members. The goal is to enhance awareness and help patients learn ways to cope with their problems and manage their disorder(s).

Common obstacles in groups and strategies to manage these include the following.

Implement a policy in which members are not admitted to group after a period of lateness (e.g., our ambulatory programs use a ten-minute rule based on patient and staff input), missed sessions are discussed when a patient returns to group, and excessive absenteeism leads to offering other treatment options.

Outpatient programs typically have a policy that patients cannot attend group if under the influence of substances. The use of breathalyzers or urinalysis is one way to monitor this. Intoxicated members can be asked not to stay for group and assessed to determine what to do (e.g., call a friend or relative to pick them up, have themselves assessed for detoxification, etc.).

Group leaders can use active strategies to engage members, such as “Brad, what do you think of what Beth’s belief that weed helps her depression?” or “Let’s end by each of you stating one strategy you learned that you can use in recovery.”

The leader can thank the member for sharing then ask others to share. Members will always have issues they want to discuss in groups, but curriculum-based groups need to focus on the topics as much as possible. For example, the leader can say, “I’m going to ask that we come back and focus on today’s topic, which is how to deal with anger.”  

The leader can prompt the member to share more specifics. For example, “So Matt, what was it like for you when your wife questioned your commitment to recovery?” or “Cele, you admitted your behavior after drinking heavily hurt your kids. Can you give us examples of your specific behaviors, and how these affected your kids?”

The group leader can point this out discussed why is occurring. The members who offered help and support can be asked to talk about what this feels like so that the member who rejects their help is aware of the impact this behavior has on peers.

For example, if a session focuses on understanding and challenging depressed or addictive thinking, the leader should insure enough time is used to review ways to challenge this type of thinking. Or, if the group topic is using social support, sufficient time should be allotted to talking and practicing ways to ask others for help or support.    

There are many other challenges and obstacles. Orienting patients to groups and how to use groups can help reduce these obstacles. Another strategy is to regularly ask groups of patients to evaluate how the group is going, focusing on what they like and find helpful, and what they do not like or think should be changed. If the group session gets bogged down, the leader can switch from the “content” of the group to the “process” and comment on the group.  

Randomized controlled trials of group interventions with SUDs are limited. Sobell and Sobell (2011) found only five studies comparing the same intervention in both an individual and group format. All studies found both types of treatment to be effective, but none showed a significant difference in outcomes of patients receiving individual versus group treatment, suggesting that group treatment is as effective as individual treatment. Weiss, Jaffee, de Menil, and Cogley reviewed twenty-four studies comparing group therapy with one or more treatment conditions (2004). The findings showed that additional specialized group therapy can enhance the effectiveness of “treatment as usual,” no differences were found between group and individual modalities, and no single type of group therapy demonstrated any consistent superiority in efficacy. The authors noted the paucity of research on this topic, although groups remain one of the principal modalities of treatment.

While group treatments play a critical role with SUDs and CODs, a combination of group and individual treatment is recommended. Many patients want and need individual counseling. Integrated group therapy that focuses on both substance use and psychiatric issues is the preferred approach for patients with CODs. Staff training and ongoing supervision can enhance the effectiveness of groups. A challenge for clinicians is to use a variety of strategies when they conduct groups. The next section lists many treatment manuals that can help counselors develop and implement group programs for SUDs and CODs.

Daley, D. C., & Douaihy, A. (2011). Group treatments of addiction: Counseling strategies for recovery and therapy groups. Murrysville, PA: Daley Publications.

Daley, D. C., Douaihy, A., Weiss, R. D., & Mercer, D. E. (2014). Group therapies. In R. K. Ries, D. A.  Fiellin, S. C. Miller, & R. Saitz (Eds), The ASAM principles of addiction medicine (5th ed.) (pp. 845–57). New York, NY: Wolters Kluwer. 

Daley, D. C., & Thase, M. E. (2004). Dual disorders recovery counseling: Integrated treatment for substance use and mental health disorders (3rd ed.). Independence, MO: Herald House/Independence Press.

Gingerich, S., & Mueser, K. T. (2011). Illness management and recovery: Personalized skills and strategies for those with mental illness. Center City, MN: Hazelden.

Linehan, M. M. (2014). DBT skills training manual (2nd ed.). New York, NY: Guilford Press.

Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: Guilford Press.

Sobell, L. C., & Sobell, M. B. (2011). Group therapy for substance use disorders: A motivational cognitive-behavioral approach. New York, NY: Guilford Press.

Weiss, R. D., & Connery, H. S. (2011). Integrated group therapy for bipolar disorder and substance abuse. New York, NY: Guilford Press.

Weiss, R. D., Jaffee, W. B., de Menil, V. P., Cogley, C. B. (2004). Group therapy for substance use disorders: What do we know? Harvard Review of Psychiatry, 12(6), 339–50.