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Chapter 10 Group Therapy for Treatment of Addictions
Laura R. Haddock
Walden University
Donna S. Sheperis
Lamar University
One very common treatment modality for substance use disorders is group counseling. Within the last
decade, studies have indicated approximately 94% of treatment facilities within the United States
utilize group counseling for treatment of substance abuse (Weiss, Jaffee, de Menil, & Cogley, 2004
2004), and
it has replaced individual counseling as the treatment approach of choice (Johnson, 2004
2004; Ruis &
Strain, 2011
2011). In addition to the low cost of group counseling, the popularity of this approach has
evolved from peer-based self-help groups such as Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA) to include psychoeducational and psychotherapeutic approaches (Behavioral Health
Treatment, 1997
1997; Center for Substance Abuse Treatment, 2005a
2005a).
Groups have a number of important functions in substance abuse treatment, including education,
therapy, and support. This chapter will address the theory behind utilizing a group counseling
approach as well as examine common types of groups employed for treatment of addictions.
Additionally, ethical and legal issues, managing diversity in group settings, and group therapy with
family members will be discussed.
THEORY BEHIND GROUP WORK
The research supporting the use of group work in the treatment of a variety of concerns is well
established. Essentially, group counseling is an interpersonal treatment approach that emphasizes an
expression of thoughts and feelings geared toward insight and behavioral change. Yalom and Lesczc
(2005
2005) proposed that groups offer a number of advantages over individual or other counseling
methods including creating a sense of universality or the understanding that clients are not alone in
their struggles. The empathy and support provided through group work creates the necessary
atmosphere for the counseling process. Participants can explore relationship styles, try on new
behaviors, and participate in rehearsal for change using the medium of the group (Corey, 2011
2011).
Ideally, through interpersonal learning and group cohesiveness, members develop a greater
understanding of themselves and can capitalize on this insight by making necessary changes in the
way they live their lives (Yalom & Lesczc, 2005
2005).
Group counseling can be used for many purposes, both preventative and remedial in nature (Corey,
2011).
2011
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Preventative groups are those that members participate in to avoid using substances. They
take place in schools, agencies, and communities. Remedial groups address unhealthy behaviors that
currently exist and have resulted in negative consequences for the client. In addictions counseling,
aftercare groups that offer treatment in an outpatient setting following an inpatient treatment stay
would be considered remedial.
The content of the group may be preset or determined by the membership (Corey, 2011
2011). Advantages of
group counseling include using a collective mind-set to gain perspective on an individual counseling
issue. Concepts related to interpersonal skills and trust are inherently worked through in a group
environment. However, group counseling is not for everyone. The dynamics and interpersonal risks
involved may prove to be too overwhelming for some clients, and some counseling issues are not best
treated through the group process.
GROUP TREATMENT OF ADDICTION
When treating addiction, there are specific dynamics that make group counseling the approach of
choice. Although the design of a group may vary, there are certain benefits that contribute to the
behavior change process. While many evidence-based interventions are individualized, addictions
counselors disproportionately conduct treatment clients in groups (Sanders & Mayeda, 2009
2009).
The influence of group members who have similar experiences is helpful in breaking down the denial
frequently associated with addiction (Sadler, 2003
2003; Washton & Zweben, 2008
2008). Because individuals who
participate in long-term substance abuse typically exhibit poor communication skills and the inability
to perpetuate healthy interpersonal relationships, group therapy affords an opportunity to interact
with others, promoting effective social skills and self-disclosure; explore new behaviors in a safe
environment; and emotionally invest in others and in education about addiction (Campbell & Page,
1993; Johnson, 2004
1993
2004).
Joan has been a problem drinker for a number of years. She and her husband, Michael,
have experienced a decline in their relationship over the last 5 years. Michael says he cannot talk to
Joan, that she shuts him out, and that all she does is blame him for their troubles. How might group
treatment for Joan’s alcohol abuse facilitate a different style of communication in her marriage? Is
Joan’s behavior in group related to how she interacts with her husband, or are these unrelated
concepts? What impact might feedback from other group members have on Joan? Is it possible she
might be able to hear the observations of other group members or a group facilitator in spite of the
fact that she rejects her husband’s observations or perceptions about her relating style?
Group therapy also offers an opportunity for positive interpersonal exchange to replace isolated selfinvolvement. Group members presented with an opportunity to identify and relay needs and emotions
may result in their identifying and confronting maladaptive patterns of behavior (Weiss et al., 2004
2004).
According to Campbell and Page (1993
1993), “Any effective therapeutic intervention must target not only
drug use, but also a means by which meaningful communication can occur” (p. 34). Additionally, many
individuals with addictions have blind spots for their own defenses but not necessarily those of others.
Thus, the members may assist one another in confronting defense mechanisms and blind spots,
resulting in accomplishment of treatment goals. Finally, group treatment uses peer influence and
motivation to enhance individual commitment to recovery (Johnson, 2004
2004).
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AN OVERVIEW OF TYPES OF GROUPS
The general purposes of a therapeutic group are to assist members in determining the issues they are
most interested in addressing while increasing members’ awareness and understanding of themselves
and others in their lives, and providing participants with the support needed to make these changes
(Corey, Corey, & Corey, 2013
2013). Essentially, members get an opportunity to “try on” new behaviors in a
setting that is safe and receive honest feedback from others concerning these behaviors. Often it is the
first time individuals have an opportunity to learn how others perceive them.
The Association for Specialists in Group Work (ASGW, 2000
2000) developed a four-category
system for classifying types of group work. ASGW standards identify standards of competence for the
leaders and identifies particular areas of group work, including (1) task groups, (2) psychoeducational
groups, (3) counseling groups, and (4) psychotherapy groups. As counseling groups are not aimed at
major personality changes and not concerned with the treatment of severe behavioral disorders, they
are not frequently implemented for addictions work.
Psychoeducational Groups
A variety of issues common to recovery from addiction require specific planned treatment
interventions. Because the focus of treatment combines educating members with fostering selfunderstanding through the dynamics of the group, these groups are sometimes referred to as
psychoeducational treatment groups. Psychoeducational groups are an increasingly popular and
important source of help for many clients. Perhaps their greatest asset is that they provide a planned
framework that can be replicated, modified, and/or adapted to fit different types of client groups.
In structured psychoeducational groups, it is not unusual for the agenda to be established before the
group session. Compared to less structured, process-centered approaches, structured group
approaches give the counselor greater responsibility for group goals and the way the group conducts
its work. Although in psychotherapeutic approaches members are encouraged to take informal
leadership roles and develop their own goals, agendas, and contracts, in psychoeducational groups the
members’ input is generally limited to modifying goals, agendas, and contracts the counselor has
already developed. The interventions are planned and focus on specific learning outcomes. Integrating
behavioral therapies with experiential learning is common practice. The group can aim to help
members translate what they learn into specific action.
There are a variety of time-limited, structured groups that focus on transferring information about
drugs and the consequences of use. Meetings usually contain a combination of educational material,
exercises, role-play, and simulations to help members process discussion of the material and the
problems they are experiencing outside the group.
It is not uncommon for school counselors to implement time-limited structured groups that
are preventative in nature. For example, elementary school counselors might utilize programming
that examines the reasons that children use drugs and offer alternatives to drug use. Parents may also
be included in the process through the use of homework.
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In a series of studies on the efficacy of group work, members of groups with specific purposes,
homogeneous concerns, clear agendas, and structured group meetings demonstrated greater success
with treatment outcome than members of groups with less structure (Martin, Giannandrea, Rogers, &
Johnson, 1996
1996; Toseland & Rivas, 2001
2001). Members report that they appreciate the leader providing
specific information and effective strategies to help with their concerns. Thus, in a group program for
individuals recovering from substance abuse, the leader can provide information about addiction,
communication skills, assertiveness/social skills training, and other topics deemed appropriate. Studies
have shown that even spiritual concerns can be successfully addressed within this format, allowing
participants to examine beliefs and gain increased understanding of their feelings, problems, and
questions within this domain (Phillips, Lakin, & Pargament, 2002
2002). Psychoeducational designs also
provide members with an opportunity to discuss specific concerns and learn stress reduction and
other coping techniques.
Leaders of psychoeducational groups vary depending on the topics to be covered; they may be licensed
professional counselors or paraprofessionals trained in the treatment of addictions.
Group leaders should keep in mind that members’ concerns and needs are not always served by a
time-limited, structured-group approach. A flexible structure maximizing member input has been
found to be more effective in helping members to vent their concerns and give and receive help from
fellow group members (Toseland & Rivas, 2001
2001). Group counselors should be savvy enough to
determine the goals and specific agendas that will best meet the needs of members.
There are also psychoeducational groups designed to assist in the prevention of addiction. Drug Abuse
Resistance Education (D.A.R.E.) and similar programs are based on the theory that teaching children
about the harmful effects of alcohol and drugs while helping them build self-esteem will deter the
desire to abuse chemicals later in life (Doweiko, 2010
2010). The D.A.R.E. program is typically conducted by
local law enforcement and taught within a classroom setting. There is a great deal of testimonial
support for these programs, but very little empirical evidence that they are effective in reducing
substance abuse among children or adolescents (Doweiko, 2010
2010; Gorman, 2003
2003).
Psychotherapeutic Groups
Psychotherapeutic groups are commonly utilized in addictions treatment. Because group members
have serious impairments in functioning as a result of their substance abuse, these types of groups
explore the foundation of current behaviors, seeking to build insight and replace dysfunctional coping
patterns with healthy ones.
Group psychotherapy offers a number of advantages over individual counseling. Group members can
learn from and offer feedback to each other and provide behavioral models for each other; this is
useful for clients who do not trust the counselor. The group format provides an opportunity for clients
to work on many of the interpersonal deficits that contribute to their own addiction within the safety
of the group setting.
Counselors sometimes utilize experiential activities with members. For example,
genograms, or family maps, help counselors and clients see a family more clearly. A genogram is a
visual representation of a person’s family tree, created with lines, words, and geometric figures
(Gladding, 2010
2010). For addictions treatment, the genogram may reveal patterns of addiction,
codependence, or other problem behaviors in the client’s family system.
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Finally, because of the nature of group therapy, each individual might find other members who
provide a reflection of his or her family of origin, allowing the individual to work through problems
from earlier stages of growth.
Individuals may participate in group counseling as part of an inpatient treatment regimen or as an
adjunct to individual counseling in an outpatient setting. The majority of substance abuse
rehabilitation programs use counseling groups as the primary method of working with clients
(Doweiko, 2010
2010; Weiss et al., 2004
2004). For clients receiving inpatient treatment as a result of involuntary
commitment, a common difficulty is resistance to group work. Many members begin with attitudes of
resentment, blaming others, and operating under the conviction that they do not need counseling.
Techniques and strategies must be employed to address resistance.
Individuals who experience chronic substance dependence or usage exhibit behavioral characteristics
that can interfere with the ability to develop effective communication and to sustain healthy
interpersonal relationships. As use of substances persists, social, personal, and work-related activities
are negatively affected (Campbell & Page, 1993
1993). Social and psychological problems develop or are
exacerbated by the prominence of drugs in the user’s lifestyle. Psychosocial aspects of the individual’s
life become so impaired that interpersonal interactions develop with maladaptive behavioral patterns
(American Psychiatric Association, 2013
2013). In attempting to treat these issues, a variety of methods may
be employed, including methods intended to prompt reversion to past experiences, approaches to
work with unconscious dynamics, and techniques designed to assist members in processing traumatic
circumstances so that catharsis can occur (Corey et al., 2013
2013).
While psychotherapeutic groups typically do not have specific agendas for each session, the group
counselor may choose to offer specific topic areas for a session, encouraging the participants to
explore pertinent life issues. If group topics address real-life issues of the group members, they can
generate meaningful discussion (Corey et al., 2013
2013). The topics chosen should reflect the purpose of the
group. When working with participants suffering from addiction, topics could include identifying and
dealing with family-of-origin issues, painful affective states that may contribute to the urge to use
chemicals, and shame-based issues. Additionally, grief issues are a common focus of process groups as
newly sober members attempt to cope with loss of friends, loss of coping mechanisms, and in general,
loss of a way of life.
Inpatient treatment providers frequently encounter grief issues. Group members may
struggle to say goodbye to a drug or behavior of choice, loss of power or money, or the social
relationships associated with their addiction (Bradley, Whiting, Hendricks, Parr, & Jones, 2008
2008). Group
leaders may suggest writing letters to say goodbye, designing eulogies, or even holding an actual
funeral service for the issue.
It has been posited that up to 50% of individuals receiving treatment for addiction also have cooccurring disorders (James & Gilliland, 2005
2005). Group counseling helps dually diagnosed clients develop
the insight they need to sustain recovery from chemical dependence while maintaining psychiatric
stability (Center for Substance Abuse Treatment, 2005b
2005b). The group process offers members the
opportunity to share experiences involving addiction and mental illness in an atmosphere of
acceptance and support while learning how their addictions influence their mental illness and how
their mental illness affects their addiction. The group format allows clients to challenge one another in
a climate that reinforces the reality and acceptance of both the addiction and the mental illness.
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A skilled counselor knowledgeable in both addictions and group therapy treatment is recommended to
facilitate group psychotherapy of addicted clients. The counselor should be educated about mental
illness and well versed in the jargon of self-help groups, such as AA, as clients may use self-help
language as a defense to keep them from getting into deeper issues. A skilled group counselor will be
able to balance the need to attend to substance abuse issues, while maintaining awareness about
mental illness, resistance, and behavior destructive to the group therapy process. The group counselor
must also be sensitive to the fact that not all addicted clients are compatible with group counseling.
Individuals with severe pathology may not be capable of making the affective connection necessary to
facilitate recovery (Behavioral Health Treatment, 1997
1997).
Unfortunately, there is limited evidence that group psychotherapy approaches are effective in the
treatment of substance disorders (Doweiko, 2010
2010). However, treatment approaches that incorporate a
larger proportion of group counseling to individual counseling are positively associated with increased
likelihood of treatment success (Panas, Caspi, Fournier, & McCarty, 2003
2003). Additionally, studies indicate
that substance-addicted clients participating in group counseling as part of a treatment regimen
improved significantly on depression, suicide risk, and trauma symptoms (Hunter, Witkiewitz,
Watkins, Paddock, & Hepner, 2012
2012; Sunich, 2013
2013).
Self-Help Groups
Instead of seeking help from a mental health professional, many individuals seek assistance from selfhelp, or mutual-help, groups. These voluntary groups have members that share a common problem
and meet for the purpose of exchanging social support. Most are self-governing, with members rather
than experts or mental health professionals determining activities. They also tend to stress the
importance of treating all members fairly and giving everyone an opportunity to express their
viewpoints. The members face common problems so they benefit from the universality of the other
members’ concerns. These groups stress the importance of reciprocal helping, because members are
expected to both give help to others and receive help from others. Self-help groups usually charge little
in the way of fees. AA is an example of a self-help or mutual-help group. AA is the “most frequently
consulted source of help for drinking problems” (Doweiko, 2010
2010, p. 446). In the years since its
development, AA has grown to an association of more than 114,000 groups with over 2 million
members in 150 countries (AA Services, 2013
2013). There is an enormous variety of self-help groups.
Why are AA and NA not considered group therapy? The primary difference is the role of the
leader. Recall that psychotherapeutic groups are led by counselors who facilitate the group. This
person is trained in group roles and dynamics and typically has experience in providing group
counseling. The group facilitator may or may not have personal experience in the topic under
discussion. In other words, a psychotherapeutic group counselor facilitating an addiction recovery
group may NOT be an addict him- or herself. Regardless of personal history, the group counselor in a
psychotherapeutic group is not a participant, but is exclusively a facilitator. AA and NA were
developed as self-help or mutual-help groups. As such, they are led by individuals with history and
experience in the topic under discussion. That is, the leader of an AA or NA group is in addiction
recovery and functions in both a leadership and member role within the group.
Many groups based on the 12 steps of AA have emerged, including NA for the treatment of drug
addiction and Gamblers Anonymous (GA) for the treatment of compulsive gambling. Other groups
based on the 12-step model have also emerged in response to the needs of family members requiring
support, including Adult Children of Alcoholics (ACOA), Al-Anon, and Nar-Anon. These groups are
covered in more detail in Chapter 12.
12
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TABLE 10.1 Comparison of Types of Groups Commonly Used in
Addictions Counseling
Type
Basic Goal
Leader
Examples
Educating members
on specific areas while
providing emotional
support
Both licensed mental
health professionals
and trained
paraprofessionals
Addiction education
group, anger
management group,
communication skills
group
Psychotherapeutic
Group
Mental health
professional,
Improve psychological psychologist, clinical
functioning and
social worker, or
adjustment of
certified alcohol and
individual members
drug counselor
Interpersonal or
cognitive-behavioral
group counseling,
psychodrama groups,
interpersonal groups
Self-Help Group
Help members cope
with or overcome
specific problems
while providing
support to one
another
Alcoholics
Anonymous, Narcotics
Anonymous, Al-Anon,
SMART Recovery
Psychoeducational
Group
Typically led by a
volunteer participant
and may not include a
leadership position
While the most prominent self-help groups are based on the 12-step model, SMART Recovery® (n.d.) is
a group based on a cognitive behavioral model. It assists persons with substance or behavioral
addictions through a four-point program. This four-point program includes enhancing and
maintaining motivation to abstain, coping with urges, problem solving, and lifestyle balance
(smartrecovery.org
smartrecovery.org). SMART Recovery® states on its website that its purpose is offering assistance to
persons choosing to abstain or considering abstinence from addictive behaviors by instruction in
making changes in self-defeating cognitions, affect, or behaviors, and working toward satisfaction with
life circumstances.
SMART Recovery® offers face-to-face meetings, online meetings, and an online message board for
members to offer support to one another. Meetings are educational in nature and involve open
discussions and treatment based on scientific knowledge, including the use of psychotropic medication
and psychological treatment. Topics include teaching self-empowerment and self-reliance, teaching
tools and techniques for self-directive change, and advocating for the appropriate use of medications
(smartrecovery.org
smartrecovery.org).
When determining the most appropriate group treatment method for clients, consideration of the
group format, general goals, and types of leadership is critical. Table 10.1 provides a visual comparison
of typical group types and lists examples of each.
ETHICAL AND LEGAL ISSUES WITH GROUPS
The efficacy of group work within the field of addictions is well established. Addictions counselors face
additional considerations when they undertake group treatment methods. The ethical and legal
aspects of conducting group counseling are numerous. Counselors are best served by having a
thorough understanding of how the ACA Code of Ethics (American Counseling Association [ACA], 2005
2005)
as well as state and federal laws affect the services they provide. While many of the ethical and legal
aspects of addictions work was covered in Chapter 4,
4 the following section provides a view of group
work in the field of addictions through the lens of the inherent legal and ethical components.
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Competence of the Leader
Addictions groups may be facilitated by leaders who vary in formal training and personal experience
with the recovery model. For example, addictions groups may be run by academically trained
counselors in recovery, formally educated counselors with no personal history of addiction, or
individuals in recovery with no formal academic training but much experience in the arena of
recovery. For the purposes of this chapter, we will focus on counselors who have pursued formal
academic training in counseling. Despite having a master’s degree or higher, counselors may lead
groups with limited training in the theory and techniques specific to group counseling (Gazda, Ginter,
& Horne, 2001
2001). Counselors who lead groups are called to practice within the scope of competence. The
ACA Code of Ethics (2005
2005) states that counselors may only practice within areas in which they have
received the necessary education, training, experience, and supervision. The ethical code further
indicates a need for counselors to commit to ongoing education and training in any field of practice
(ACA, 2005
2005). While the code explicitly addresses competence, it remains somewhat vague and open to
interpretation as to what constitutes necessary and sufficient education, training, experience, and
supervision. Consequently, group counselors would do well to consult the ASGW “Professional
Standards for the Training of Group Workers” (2000) for further clarification regarding leader
competence.
The ASGW outlines the specific minimum training guidelines recommended by leading
psychoeducational and psychotherapeutic groups. In addition to one graduate course in group
counseling and 10 or more hours of group experience, the ASGW recommends specific advanced
coursework and 45–60 clock hours of supervised experience in order to specialize in group
psychoeducation, counseling, or psychotherapy (ASGW, 1998
1998). Demonstration and evaluation of core
competencies are required, and the ASGW (1998
1998) recommends practica and internship experiences
that correspond with the Council for Accreditation of Counseling and Related Educational Programs
(CACREP). It is important to note that the competencies set forth by both ASGW and CACREP require
the future group leader to participate in a personal group experience, the rationale being that such
participation enhances the leader’s understanding of the practical application of group theory.
Does meeting minimum standards ensure competence? Ethical group leaders do more than meet
minimal requirements for training and experience. Being a competent and ethical group practitioner
“[i]mplies functioning at a level of consciousness geared toward doing whatever it takes to function at
the highest level, both personally and professionally” (Corey, Williams, & Moline, 1995
1995, pp. 161–162).
The group counselor is, after all, a human being prone to the same mishaps and errors of judgments as
his or her clients. Group practitioners bring their personal lives to the profession of counseling, and
their experiences, characteristics, and values play a part in the efficacy of their leadership style (Corey
et al., 2013
2013). Consistent and persistent evaluation of the effectiveness of counseling activities is the
responsibility of all group leaders desirous of maintaining ethical standards and competence.
Screening of Participant
Group therapy is often the treatment of choice in addictions work. Whether agency structure,
managed care influences, or treatment efficacy is behind the decision, many clients find themselves
participating in groups. Group counselors are skilled at managing a diverse dynamic in a group setting
and have an ethical responsibility to both the individual client and the group as a whole. In Section
A.8.a., the ACA Code of Ethics (2005
2005) specifically calls counselors to screen members for compatibility
with group goals and membership. Ultimately, it is the group
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counselor’s responsibility to maximize treatment outcome and minimize any adverse effects on
individual clients throughout group treatment while maintaining the integrity of the group process.
Once properly screened and determined to be suitable for placement in a group, the client is entitled
to the process of informed consent.
Informed Consent
Group leaders educate and engage clients through the use of informed consent, which communicates
basic rights and responsibilities to the prospective group member. Because clients have the right to
choose whether or not to enter into a particular counseling relationship (ACA, 2005
2005), a thorough
informed consent is part of the screening process to ensure that client and group treatment method
are a good fit. The informed consent should cover what the client should know before joining the
group, as well as his or her rights and responsibilities during the group process (Corey et al., 2013
2013).
Ethically, group counselors inform prospective clients of the nature of the group process; benefits and
limitations to such counseling; education training and credentials of the group counselor; expectations
of the client within the group; the right to terminate the counseling relationship; and other concerns
relevant to receiving services in a group environment (Corey et al., 2013
2013). Finally, because of the
nature of addiction, specifically illegal drug use, it is important for informed consent to address
potential legal ramifications of disclosures made throughout the group counseling process.
Confidentiality
Confidentiality is of primary concern in the group treatment of addictions. Several decades ago,
Congress took interest in the fact that addicts and alcoholics were avoiding treatment because of
confidentiality concerns. To address this stigma, the federal government enacted a law commonly
referred to as 42CFR Part 2 that defines limits of confidentiality for substance abuse programs in the
United States (Substance Abuse and Mental Health Services Administration, 2010
2010). Because of 42 CFR
Part 2,
2 a client’s mere presence in a chemical dependency facility is considered a diagnosis and cannot
be revealed without a written consent, nor can it be denied if someone inquires. However, in addition
to confidentiality at the facility level, the group counselor is responsible for establishing the limits of
confidentiality within the treatment group.
Informed consent is critical in conveying information and expe