Substance Abuse Treatment: Group Therapy
Substance abuse counselors come to the field from a variety of backgrounds, education, and experience. Many have not had specific training and supervision in the special skills needed to be an effective group therapist.
Counselors may be promoted to positions of supervision without the additional training in the skills needed to perform supervisory tasks, which are
This chapter describes the skills group therapy clinicians need, the purpose and value of clinical supervision, and how to get the training necessary to be a top -flight group clinician or supervisor of clinicians.
In a brief article, Geoffrey Greif lists "Ten Common Errors Beginning Substance Abuse Workers Make in Group Treatment." He contends that these errors are common because people who abuse substances are supremely adept at helping group leaders make mistakes.
Some of these are
Impatience with the clients' slow pace of dealing with change
Inability to drop the mask of professionalism
Failure to recognize countertransference issues
Not clarifying group rules
Conducting individual therapy rather than using the entire group effectively
Failure to integrate new members effectively into the group (Greif 1996)
Training and education for group therapists working in the substance abuse field can alleviate or eliminate such errors. Simultaneously, additional training is becoming even more critical because (1) the traditionally separate fields of mental health and substance abuse counseling increasingly overlap, requiring more and more cross -knowledge; and (2) an ever younger pool of clients is presenting with more cognitive deficits, abuse issues, and co -occurring disorders.
A group leader for people in substance abuse treatment requires competencies in both areas: group work and addiction. For example, facilitators should understand group process, group dynamics, and the stages of group development; they need to understand that group therapy is not individual therapy in a group setting.
Further, facilitators should be aware that although Alcoholics Anonymous (AA) or other 12 -Step programs are complementary to substance abuse treatment, these modalities are distinct from group therapy.
As trends move toward integrated mental and substance abuse treatment, counselors already adept at working with groups of clients with substance abuse problems may need specific training to manage mental disorders such as depression, which often co -occur with substance abuse.
Further, counselors in recovery may be familiar with the stages of addiction treatment but lack a background in group therapy.
On the other hand, group counselors who have treated clients without addictions may not always have sufficient skills to combat addiction and its effect on a group therapy situation. Therapists need to become well versed in the substance abuse treatment philosophy, its terminology, and techniques of recovery, including the self -help approaches (Kemker et al. 1993).
A group therapist with roots in the mental health field planning to become more competent in group work for the treatment of substance abuse will need to make a number of adjustments. First, the therapist working with clients with substance use disorders should be able to screen and assess for substance abuse problems.
On this subject, see TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases ( Center for Substance Abuse Treatment [CSAT] 1994b ); TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997a ); and TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999c ).
Second, the therapist will need to recognize the importance of abstinence. Third, the therapist will need to be sensitive to a client's anxiety and shame, especially in early stages of treatment for substance abuse.
In a modified interpersonal process group, for example, the group leader should create a safe, supportive environment free from the stigma of addiction while promoting a client's attachment to other group members, self -help groups, therapy, and the entire healing community of which the group is a part.
Group therapists who move into the treatment of clients who are chemically dependent typically need staff development in:
Theories and techniques. Theories may include traditional psychodynamic methods, cognitivebehavioral modes, and systems theory. From such theoretical bases are drawn applications that pertain to a wide variety of settings and particular client populations.
Observation. The observer can sit in on group therapy sessions, study videotapes of senior therapists leading group sessions (ordinarily followed by a discussion), or watch groups live through one -way mirrors as experienced therapists lead groups.
Experiential learning. With this approach, a therapist may participate in a training group offered by an agency, become a member of a personal therapy group (these are often process -oriented), or join in group experiences at conferences, such as those offered at the Institute of the American Group Psychotherapy Association's annual conference. (For more on experiential training, see the section on "Experiential Learning" later in this chapter.)
Supervision. A large part of this type of training is ongoing work with groups under the supervision of an experienced therapist. Supervision may be dyadic, that is, supervisor and supervisee, but while simple and easy, this setting does not allow opportunities for actual group work.
Supervision of group therapists ideally is conducted in a supervisory group format. Supervision in a group enables therapists to obtain first -hand experience and helps them better understand what is happening in groups that they will eventually lead.
Several other important benefits accrue as well. The supervisory group creates a safe place for trainees to reveal themselves and the skills they need to develop.
It provides support from peers and a chance to learn from their experience. It stimulates dialog around theory and technique and encourages a healthy kind of competition.
It expands the capacity for empathy (Alonso 1993).
Finally, this kind of supervision provides an opportunity for trainees to explore sensitive issues, such as child abuse, sexual abuse, and prostitution. (For more on supervisory groups, see the "Supervision" section later in this chapter.)
Before leaving the matter of what group leaders treating substance abuse should know, it is desirable to assess the importance of the group facilitator's being a person who is in recovery.
There is some tension around this issue. Culbreth (2000) reviewed 16 relevant studies and concluded that while clients do not perceive differences in treatment related to a therapist being in recovery or not, and no differences in treatment outcomes could be discerned, recovering and nonrecovering therapists do not perceive substance abuse problems the same way, use different methods to treat substance abuse, and differ in personality and attitudinal traits.
Some people dismiss the notion that all people with addictions prefer to work with a group leader who is in recovery. They insist that, on the contrary, some people with addictions prefer not to work with recovering leaders, fearing that leaders in recovery will share the issues and problems of people with addictions and thus will not be in a position to help them with these issues.
Others say that a staff of group leaders should include people in recovery. Those holding this point of view reason that people with addictions are highly skilled at manipulating people and situations. With both recovering and nonrecovering group leaders, a clinical team will be best positioned to see and treat the whole clientand not be duped by agreeable, but false, fa?ades.
In group therapy with clients with substance use disorders, it can be challenging to establish and maintain credibility with all group clients. Facilitators not in recovery will need to anticipate and respond to group members' questions about their experience with substances and will need skills to handle group dynamics focused on this issue.
On the other hand, leaders who are in recovery may tend to focus too much on themselves. Group leaders emotionally invested in acting as models of recovering perfection are easy marks for clients.
Of course, the main issue is not whether the leader is in recovery. What matters most is whether the counselor knows the fields of group therapy and addiction treatment and has good judgment and leadership skills (see Figure 7-1 ). Helping the group explore why the recovery status of the group leader is important can be discussed if and when the issue is raised.
Figure 7-1. How Important Is It for a Substance Abuse Group Leader To Be In Recovery?
For Figure, references, and rest of chapter, see source page
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 41. Substance Abuse Treatment: Group Therapy